(Ned Oliver/ Virginia Mercury)

The Virginia Department of Health reported a total of three “probable” COVID-19 deaths on Tuesday — a number that many  funeral directors say is inconsistent with their experiences over the past few weeks. 

“It’s gotta be higher than that,” said Sammy Oakey, president of the Association of Independent Funeral Homes of Virginia and owner of Oakey’s Funeral Service & Crematory in Roanoke. “We’ve had three probable cases on our own. So, I can’t imagine, with all the funeral homes in the state, that the true numbers aren’t bigger.”

The new numbers — which include deaths that haven’t been confirmed by a laboratory test but are believed to be related to the virus —  are part of an effort to expand the available data on the department’s public COVID-19 dashboard. Officials are now reporting cases, hospitalizations and deaths by locality and providing the rate of cases per 100,000 residents.

One of the biggest changes involves the department’s decision to begin reporting probable COVID-19 cases and deaths, in addition to those confirmed by laboratory testing. In a state where testing rates are lagging — even as some private labs say they have unused testing capacity  — experts say that disclosing probable cases offers a better picture of how the SARS-CoV-2 virus, which causes COVID-19, is spreading across Virginia.

“It gives us the ability to better estimate the actual burden of COVID-19 in the community,” said Em Stephens, the respiratory disease coordinator for the department’s Office of Epidemiology. “We’re well aware that not everyone is being tested, and we’re well aware that we don’t have the capacity to test everyone. So, it enables us to get at the real truth of the situation.”

While Virginia previously developed its own suspect case definition for COVID-19, Stephens said the state was able to start reporting those numbers after the Council for State and Territorial Epidemiologists — a national organization responsible for drafting consistent reporting criteria — released its own probable case definition on April 5.

Under the new guidelines, probable deaths can be defined as “meeting vital records criteria with no confirmatory laboratory testing performed for COVID-19.” Even before Virginia began reporting those numbers, Stephens said the department was developing the capacity to search state death records for probable cases dating back to April 5.

“There’s a line where COVID-19 or SARS-CoV-2 can be listed as either a cause of or contributor to death,” she said. “We’ll be pulling those from our Vital Records data and reporting them publicly.”

But on the first day that probable death numbers were released, VDH reported a total of three across the entirety of Virginia — a drastic departure from areas like New York City, where death numbers surged by more than 3,700 after officials added probable deaths to their official count.

Virginia’s official case numbers are markedly lower than New York City. Even so, funeral directors across the state say the small probable death count is lower than the number of suspect cases they’ve handled at their own facilities.

Without a laboratory confirmed diagnosis, it’s up to physicians at hospitals and long-term care facilities to note COVID-19 as a cause or contributor to death based on clinical judgement. Dr. Joel Bundy, the vice president and chief quality and safety office for Sentara Healthcare, said doctors use a variety of benchmarks to designate a probable coronavirus death.

“Attending physicians may interpret symptoms and circumstances, such as dying in an ICU on a ventilator after displaying fever and shortness of breath, and fitting other criteria such as travel to known hot spots or exposure to someone diagnosed with COVID-19,” he wrote in a statement provided to the Mercury on Tuesday.

But Oakey said that information isn’t always included on a death certificate or relayed by facilities when they transfer bodies to a funeral home. One hospital in Roanoke has begun triple-bagging bodies to indicate there may be an elevated risk to his staff, he added. But on three separate occasions, Oakey’s funeral home has independently treated corpses as presumptive COVID-19 cases even when medical facilities have been reluctant to make the same designation.

“It helps us know to limit the number of people working on that case,” he said. It’s still unclear how long the virus can survive in the body after death, but there have been global cases — including what appears to be the first, in Thailand — of forensic workers catching COVID-19 after handling corpses.

“We take universal precautions for every body, but it really helps us in the mind to say, ‘Yes, it is,’ or ‘No, it isn’t,” Oakey added. In one case, the funeral home accepted a body from a nursing facility with a known outbreak of the disease. Oakey said the doctor who signed the death certificate told them it wasn’t COVID-19 — that the patient had pneumonia in a different part of the lung than was typical in cases of the virus. 

“We didn’t like that,” he said. “We appreciated them telling us that, but there were enough red flags that we treated it as a probable case.” In another instance, COVID-19 wasn’t mentioned as a cause of death, but the family mentioned that the deceased patient had been waiting on testing results from a private lab.

Larry Spiaggi, the owner and director of Morrissett Funeral & Cremation Service in Richmond, said he had a similar experience during a “trade work” assignment, when his staff received a body from a local hospital on behalf of another funeral home based farther away.

“They told us that the patient was being treated for COVID-19, but when we looked at the death certificate, there was no COVID listed,” he said. In that case, the patient was chronically ill, but Spiaggi thought it was “strange” that COVID-19 wasn’t listed as a contributing factor in the death. 

Robert Carmical, the owner of Money & King Funeral Home in Vienna, said that roughly two out of every six or seven COVID-19-related deaths brought to his facility — which made up 85 percent of his business last week — were presumed, rather than lab-confirmed, cases.

Current testing shortages, combined with long wait times for results from private labs, compounds the problem, said Brenda Clarkson, a certified hospice nurse who serves as the executive director for the Virginia Association for Hospices and Palliative Care. One of her members recently tried to test a hospice patient for COVID-19 to determine whether new symptoms were caused by the virus or another condition.

At the time, Virginia’s testing criteria — which were expanded late last week — didn’t allow for the patient to be tested at the state lab in Richmond. “By the time a private lab came back with results, the patient was already dead,” Clarkson added.

COVID-19 wasn’t listed as a cause or contributing factor to the death. It was the right call in that case, given that the patient’s results came back negative, she said. 

But the situation also highlights the difficulty of relying on clinical judgment to designate a probable COVID-19 result. Clarkson said that many physicians are reluctant to list the virus as a cause of death without strong proof, especially given the similarity of the symptoms to other diseases.

“Doctors are scientists,” she added. “They want evidence. And I think there will be that reluctance without confirmation from a test.” Bundy, too, wrote that Sentara hopes to “minimize presumption” by testing patients through its own in-house testing service.

Many funeral directors say they’re still left feeling vulnerable. In the first weeks of the pandemic, Spiaggi and Oakey said hospitals were reluctant to report confirmed or suspected COVID-19 deaths to funeral homes, saying that it would violate patient confidentiality. Spiaggi said he’s heard fewer of those reports, but the industry is still experiencing the same shortages of personal protective equipment as other frontline medical workers.

“We’re using N95 masks like they’re going out of style because we’re trying to protect our people,” Oakey added. His facility is now paying $4.65 apiece for respirator masks that formerly cost a dollar, while the funeral industry remains largely responsible for sourcing its own supplies. 

“We’ve reached out to [the health department in] Richmond, and they seem to think that the hospitals and first responders need to have them before the funeral homes,” Oakey said. “And I understand that. But there’s a lot of anxiety with funeral homes right now, and we’re the last responders in all of this.”

The headline and article have been updated for clarity.