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


WONJU, Gangwon Province – The challenge during the COVID-19 pandemic is to vaccinate as many people as possible. Along with this campaign, postmortem examinations play a key role in determining whether a vaccine is to blame when a death occurs.

Because COVID-19 vaccines are new, the science around them is continually evolving, says Dr Lee Soo-kyoung, director of the National Forensic Service’s forensic examinations division.

At first, no one knew that vaccination could cause blood clots with low platelet count. And the task of keeping up to date with related information was added to her day, about half of which usually 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 could occur can be stressful. “

As more and more people were getting vaccinated, deaths that might not normally have been noticed were being noticed, he said. So many inquiries poured in from police stations across the country that the forensic service was struggling to count so-called “vaccine cases.”

“But sudden deaths occur in healthy people without vaccination,” he said. He says the people who were apparently in good health are the ones who are usually referred to the department for autopsy. If they had obvious health problems during their lifetime, “then they wouldn’t need to be here,” he said.

Often there were records of health check-ups showing that they had no problems before, making their untimely death even more shocking to those who remain.

“It’s like that with almost every case that goes for an autopsy,” he said.

With post-vaccination deaths, it’s not always possible to get the clear answer people expect, said Lee, who is also part of the Vaccine Injury Investigation Unit. of the national health protection agency. Since joining the unit in February, he has attended over 30 meetings.

Myocarditis, an inflammation of the heart muscle associated with Pfizer and Moderna vaccines, was also screened regularly in cases unrelated to the vaccine.

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

“An autopsy can determine for sure if myocarditis was present and where, and see if there were other contributing factors, such as underlying conditions that check-ups could not detect.”

When asked if an autopsy could reveal whether a disease was caused by a vaccine, Lee said no. There is no marked difference between vaccine-induced myocarditis and natural myocarditis, for example.

“What autopsies do is look for injuries, illnesses and other things that a clinical record cannot demonstrate on their own,” he said.

The assessment of a causal relationship between a death and a vaccine was carried out on a spectrum of causality ranging from “definitely unrelated” 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, depends on how the criteria will apply.”

COVID-19 adds an extra layer of stress and peril to the work of a forensic pathologist.

“After an autopsy has already been done, if investigations subsequently reveal that the deceased had been in close contact with an infectious patient, the whole team should get tested,” he said. “These are the kinds of things that have become a routine occasion.”

As the police conduct preliminary investigations into suspicious or non-natural deaths, the results of their investigations, as well as hospital records, if any, are turned over to the forensic service. “And then we work from there,” he said.

The death test for COVID-19 is also carried out with very precise PCR tests, using samples taken from the nasal airways to the lungs.

South Korean custom to bury a person three days after death requires examiners to work as quickly as possible. “Once the body gets here, it’s a matter of a day or two until it’s all over,” he said. Often, sections of organs and other samples that may contain important clues are kept for microscopic inspection. The body is then returned to the person’s relatives.

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

The Biosafety Level 3 lab, like most national infectious disease infrastructure, was built following the 2015 outbreak of another coronavirus disease, Middle East Respiratory Syndrome.

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

“The few cases conducted last year at the biosecurity lab involved overseas passengers who died shortly after arrival – all tested negative later,” he said.

“So far only three have been 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 post-mortem, as deaths from COVID-19, “probably for statistical convenience,” he said. “But dying with COVID-19 is different from dying from it, and autopsies can help make that distinction. “

In March last year, in a small town near Daegu, the initial epicenter of the pandemic in Korea, a 17-year-old boy died of pneumonia. Doctors who treated him said he had COVID-19, which would have made him the only teenage death in the country. The government, concluding that the result was a false positive, said no autopsy was necessary. Incomprehensibly, however, his family has always been denied a proper funeral “out of caution”.

The teenager’s high-profile death is one example of where an autopsy helped clarify the issues and end the controversy, Lee said.

In Korea, the forensic service does not have the power to request an autopsy – the court grants this permission, usually at the request of the police. The commissioner of the Korea Disease Control and Prevention Agency may also request the procedure, although to date no such request has ever been made for a COVID-19 patient.

Lee cited the US system, where the medical examiner decides whether an autopsy should be performed, as “ideal,” particularly amid a complex web of challenges posed by the current pandemic that would not have been a problem in time. ordinary.

“In investigations into deaths of subjects vaccinated against COVID-19, for example, the public health agency can be considered a party of interest. For credibility, it is better to give a third party the responsibility of making the associated decisions and presenting the results to the public and so on, ”he said.

Lee thinks the reason why so few autopsies have taken place in Korea is twofold.

“One of the reasons is the reluctance of people to autopsy their loved ones,” he said. “Another is the policy that requires cremation for anyone who has tested positive for infection control purposes. “

Since the start of the pandemic, the Korean government has said that people who have died with COVID-19 must be cremated – burial is not an option – despite guidelines from the World Health Organization that say the incineration should be “a matter of choice”. “

On a personal level, autopsies offer one last chance to uncover the truth in the face of an unexplained death. They can also provide crucial information about the many mysteries behind the new disease – which could then lead to vital discoveries, like a cure.

“The efforts are worth it and benefit families and society,” he said.