[Herald Interview] When is a death linked to a COVID-19 vaccine?

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[Herald Interview] When is a death linked to a COVID-19 vaccine?
Dr. Lee Soo-kyoung, director of the National Forensic Service’s forensic medical examination division, poses during an interview with The Korea Herald at the government agency’s headquarters in Wonju, Gangwon Province. (Park Hyun-koo/The Korea Herald)WONJU, Gangwon Province — The challenge during the COVID-19 pandemic is to vaccinate as many people as possible. Concurrently with that campaign, postmortem examinations play a key role in determining whether a vaccine is to blame when a death takes places.

Because the COVID-19 vaccines are new, the science surrounding them is continually evolving, says Dr. Lee Soo-kyoung, director of the forensic medical examination division at the National Forensic Service.

At first, no one knew vaccination could cause blood clots with low platelets. And the task of staying up to date on related information was added to his day, about half of which is typically spent in the autopsy room and the rest writing reports and attending meetings.

“Cases involving a vaccinated individual require more work, in a sense,” he said. “Working with the possibility that an unknown mechanism may be going on can be stressful.”

As an increasing number of people got vaccinated, deaths that might not normally have stood out were getting noticed, he said. So many inquiries were pouring in from police stations all over the country that the forensic service was struggling to keep count of so-called “vaccine cases.”

“But abrupt deaths do happen in healthy people in the absence of vaccination,” he said. He says people who were apparently healthy are the ones usually referred to the service for autopsy. If they had obvious health problems when they were alive, “then they wouldn’t need to be here,” he said.

Often, there would be records of health checks showing they were not previously afflicted with any issues, making their untimely deaths even more of a shock for those left behind.

“It’s like that with nearly every case that gets an autopsy,” he said.

With post-vaccination deaths, getting the clear-cut answer that people expect isn’t always possible, said Lee, who is also part of the national health protection agency’s vaccine injury investigation unit. Since joining the unit in February, he’s sat in on more than 30 meetings.

Myocarditis, an inflammation of the heart muscle that is associated with the Pfizer and Moderna vaccines, was a regular screening in non-vaccine-relate cases, too.

Clinicians cannot confirm heart inflammation through a biopsy, but pathologists can.

“An autopsy can find out for certain if myocarditis was present, and where, and see if there might have been other contributing factors, like underlying conditions that health checkups could not pick up.”

Asked if an autopsy could reveal whether a condition was caused by a vaccine, Lee said it could not. There isn’t a marked difference between a vaccine-induced myocarditis and a naturally occurring one, for example.

“What autopsies achieve is look for injuries, diseases and other things that a clinical chart alone cannot demonstrate,” he said.

Assessing a causal relationship between a death and a vaccine was done over a spectrum of causality from “definitely not related” to “possibly or probably related” to “definitely related,” he said, so interpretations mattered as well.

“Determining whether the death is attributed to the vaccine, I think, is about how the criteria will apply.”

COVID-19 adds an extra layer of stress and peril to the job of a medical examiner.

“After an autopsy had already been done, if investigations reveal later on that the dead person had been in close contact with an infectious patient, the whole team has to get tested,” he said. “These are the kind of things that have become a routine occasion.”

Since the police carry out preliminary investigations of suspicious deaths, or deaths not from natural causes, the findings from their investigations, together with hospital records, if there are any, are handed over to the forensic service. “And then we work from there,” he said.

Testing the dead for COVID-19 is also done with the highly accurate PCR tests, using samples taken from the nasal airways all the way to the lungs.

South Korea’s custom of burying a person three days after death forces the examiners to work as expeditiously as possible. “Once the body gets here, it’s a matter of a day or two until everything is completed,” he said. Often, sections of organs and other samples that may hold important clues are kept for a microscopic inspection. The body is then sent back to the person’s loved ones. 

The state forensic service headquarters in Wonju is equipped with the only biocontainment laboratory in the country that meets the requirements for autopsies of patients with confirmed or suspected infection.

The biosafety Level 3 lab, like most national infectious disease infrastructure, was built in the aftermath of the 2015 outbreak of another coronavirus disease, Middle East respiratory syndrome.

Fewer than a dozen autopsies have taken place in the special lab since COVID-19’s onset, Lee said, because “there haven’t been a whole lot of requests.”

“The few cases conducted last year at the biosafety lab were of passengers from overseas who died shortly after arrival — all of them were found to be negative later on,” he said.

“So far just three were definitely positive,” he said. All three were done this year, to clarify the role COVID-19 played in their deaths.

Korea counts all deaths with a positive test, pre- or postmortem, as COVID-19 deaths, “probably out of statistical convenience,” he said. “But dying with COVID-19 is different from dying from it, and autopsies can help draw that distinction.”

In March last year, in a small city near Daegu, Korea’s initial epicenter of the pandemic, a 17-year-old died after developing pneumonia. Medics who treated him said he had COVID-19, which would have made him the country’s only teen fatality. The government, concluding that the result was a false positive, said no autopsy was necessary. Incomprehensibly, though, his family was still denied a proper funeral “out of caution.”

The teenager’s high-profile death is an example of a case where an autopsy would have helped elucidate the questions and put the controversy to rest, Lee said.

In Korea the forensic service has no authority to call for an autopsy — the court grants that permission, usually at the request of the police. The Korea Disease Control and Prevention Agency’s commissioner can also request the procedure, although to date no such request has ever been filed for a COVID-19 patient.

Lee cited the US system, where the medical examiner decides if an autopsy must be performed, as “ideal,” especially amid a complex web of challenges posed by the present pandemic that would not have been a problem in ordinary times.

“In investigations of deaths of COVID-19-vaccinated subjects, for instance, the public health agency can be considered a party of interest. For credibility, it’s better to put a third party in charge of making the related decisions and presenting the results to the public and so on,” he said.

Lee believes the reason that so few autopsies have taken place in Korea is twofold.

“One reason is people’s reluctance toward the idea of autopsies of their loved ones,” he said. “Another is the policy that mandates cremation for everyone who has had a positive test result for purposes of infection control.”

From the beginning of the pandemic, the Korean government has stated that people who have died with COVID-19 must be cremated — burial is not an option — despite the World Health Organization guidance that says cremation should be “a matter of choice.”

On a personal level, autopsies offer a final chance at finding out the truth in the face of an unexplained death. They can also provide crucial insights into the many mysteries of the new disease — which then could lead to lifesaving discoveries, like a treatment.

“The efforts are worthwhile, and beneficial to the families and society,” he said.

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