Death Certificates Tell Of Swine Flu's Wrath

Our friends at Neon Tommy have been busy tracking Los Angeles County health officials' handling of the swine flu pandemic. USC Annenberg student reporter Callie Schweitzer sums up some rather extensive team reporting with an overview of the individuals who succumbed to the virus and uncovers how some counties may be breaking the law by withholding death certificates from the public.

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Photo: Mike Lee/Daily TrojanFlu-shot seekers faced long lines and short supplies at a public clinic set up at the University of Southern California last week.

Anthony Rosario, a 28-year-old car salesman from North Hills, had no known health problems until he came down with swine flu in July and died 19 days later.

Sixth-grader Cristian Torres Rodriguez, a 12-year-old avid Dodgers fan with a history of chronic asthma, died in June of swine flu several days after he was admitted to Kaiser Permanente in Baldwin Park.

Twenty-three-year-old Lisa Yamashiro, a bank teller from Reseda with no preexisting conditions, died in August, weeks after contracting swine flu.

Their battles are among those documented on the 44 death certificates Neon Tommy obtained from the Los Angeles County Department of Public Health when we requested records of all swine flu-related deaths from the start of the outbreak in April. These records show the toll from swine flu through Oct. 9. Since then, 13 more deaths have been attributed to swine flu, bringing the countywide total to 57.

Neon Tommy analyzed the death records and interviewed family members, public health officials and doctors to see what the dozens of deaths suggest about the patterns of the illness and who remains most at risk. In several cases, the families we spoke with said they did not know their relatives had died of swine flu until we told them. In these cases, county officials said the diagnoses had been made after doctors filled out the death certificates, and that it is not the county's responsibility to notify family members. Nearly half of the death records do not list swine flu as a cause of death.

We undertook this project to tell the stories of victims of swine flu in Los Angeles County, from the first death in May to whenever the crisis ends. Our goal is to put a human face on the epidemic and help the public evaluate the performance of health officials in addressing it. Midway through the project, however, L.A. County health officials changed their legal position on releasing death certificates and said, in the future, they would only provide us with certificates that initially list swine flu as one of the causes of death. Neon Tommy has submitted a formal request to the California Department of Public Health for an ongoing and up-to-date list of all L.A. County victims, including those cases where swine flu is only identified as a cause of death by post-death examinations and tissue tests.

In the case of 12-year-old Cristian Torres Rodriguez of Baldwin Park, family members believe the boy would be alive today had doctors not sent him home the first time he showed up in the emergency room. The boy's parents said doctors finally admitted him five days later, on their fourth visit. "It never would have gone this far if they would have admitted him quicker," his mom, Susan Torres Rodriguez, said. Kaiser officials declined repeated requests for comment.

The initial batch of death records released by L.A. County shows why the deadly virus is so alarming to medical experts. Of the 44 County victims, nine were under age 20, 13 between the ages of 20 and 40, and 22 over age 40. There were two 1-year-olds and victims who were 3, 5, 7 and 8, only one of whom had preexisting conditions that would have made her vulnerable to a deadly flu strain.

The occupations of the victims—28 women and 16 men—varied from students to real estate agents to teachers to bakery owners. Many worked low-paying jobs as custodians, bus drivers, cooks, clerks and seamstresses; seven were homemakers; and four had never worked.

In a typical flu season, about 1,000 people usually die in Los Angeles County; 36,000, nationwide. But up to 70 percent of the victims usually suffer from preexisting conditions that put them at risk. Our study of the 44 swine flu victims showed this virus behaves differently—the number of people with such conditions was equal to those without such ailments; preexisting conditions included diabetes, renal failure, obesity, hypertension and lupus, among others.

Dr. Alonzo Plough, the director of the Emergency Preparedness and Response Program for the L.A. County Health Department, said officials are extremely concerned about the potential for a crisis in Los Angeles.

"We've had a large number of outbreaks each week—a lot of them school based—at a frequency we usually see much later in the flu season," he said. "It's troubling to see this number this early in the flu season."

Health officials in L.A. County and around the nation warn that the virulent flu strain could sicken and kill record numbers of people. "We have virtually half of our 4,000 member health department working exclusively on H1N1," Plough said. "It's a very large public health concern."

What We Found

Surprising trends and patterns emerged from an analysis of the certificates that rebuked and confirmed some of the information commonly associated with the H1N1 virus.

When the panic over the virus first began, people believed that as with seasonal influenza, the high-risk groups would be limited to the very young and very old. Now what worries health officials is the "disproportionate impact" of H1N1 on pregnant women and children ages 4 and younger, Plough said.

The 44 cases reviewed by Neon Tommy proved the message health officials have been trying to broadcast: H1N1 targets the young, including young adults. The Centers for Disease Control and Prevention has spoken loudly of the risk targeting an otherwise healthy population ages 19 through 24 and said the influenza "has caused greater disease burden in people younger than 25 years of age than older people."

A study of 272 swine flu patients published on Oct. 8 by the New England Journal of Medicine showed that 73 percent of all patients had at least one underlying medical condition—of which asthma was the most commonly seen, in 29 percent of children and 27 percent of adults. Additionally, 7 percent of the patients were pregnant.

But swine flu in L.A. County has not been predominantly killing people with troubled health histories. A closer look at the 44 certificates showed the contrary—the two categories were equal; 22 had preexisting conditions, and 22 had no preexisting conditions listed.

The L.A. County swine flu death toll shows the same age patterns noted by health officials across the nation. The CDC estimates that of the 36,000 people who die from seasonal flu each year, more than 90 percent are older patients. Swine flu has proved otherwise.

"Children and young adults are being hit at a rate that's disproportionate with the usual seasonal flu outbreaks," said Dr. Fred Lopez, a professor of medicine who specializes in infectious diseases at Louisiana State University Health Sciences Center.

The American College Health Association has noted a "significant risk among those in the college setting."

That risk may be even greater in Los Angeles, said Dr. Daniel Kantor, president-elect of the Florida Society of Neurology.

"In a place, like L.A. County, where there is overcrowding and people interact with many other people every day, the flu can be spread more quickly," he said. "College students live in groups, where there is a lot of intimate contact, and thus can more easily spread the flu virus."
But, Kantor said, it's not just L.A. feeling the effects of a flu season in full swing.

"We are seeing the highest rates of the flu everywhere," he said.

Lopez said older generations might have strains of immunity from similar flu outbreaks seen "decades ago," while younger people haven't been able to get the vaccine early enough to develop virus-fighting antibodies. Influenza pandemics in recent history struck in 1918, 1957 and 1968.

"We've got a virus that's never been seen before for which there's little immunity," Lopez said. "It's not too surprising that it's being spread so widely because most people are not immune."

Dr. Carole Lieberman, a Beverly Hills psychiatrist with a master's in public health, is on the clinical faculty of UCLA. She wonders whether the wavering media attention may be to blame for what she calls people's relaxed attitude toward the virus.

"Because the media has stopped warning L.A. residents to avoid being in crowded places and to avoid travel to Mexico, people are not being as cautious as they were initially," she said.

So Many Inaccurate Death Certificates

Many of the death certificates examined by Neon Tommy—20 of 44—do not identify swine flu or its variations as a cause of death. Twenty-one contain some variation of H1N1, Probable H1N1, Influenza or Influenza A as the cause of death, and three list them only as a contributing factor or preexisting condition.

Public health officials said the extensive testing process can take up to six to eight weeks of review. L.A. County's Plough speculated that it may take that long to determine what role H1N1 played in death because of anatomical, toxicological and chemical tests that take varying amounts of time to be returned.

"The death certificate is done as quickly as it can be done, but if there is a question about the cause of death then it may take a while to determine that information," Plough said.

Plough said the county has no role in preparing death certificates, but uses the information contained on them to "keep track of the number of deaths in the county," noting who has died, the age groups and the contributing factors. The county also provides a running tally of swine flu deaths to the state health department every month.

After review by hospitals or doctors, the remaining 20 deaths reviewed by Neon Tommy were blamed on H1N1.

Numerous phone calls to the doctors listed on the death certificates went unreturned. Of the three who did return the call or answer the phone, two declined comment and one said he hadn't handled the case that his name was on and referred a Neon Tommy reporter to a lung specialist.

Only a few cases involved the county coroner's office. Beatriz Estevez, a 28-year-old Canoga Park homemaker who had no preexisting conditions listed on her death certificate, died July 5th and her case was referred to the county coroner's office for determination of a cause of death. The coroner's office signed her death certificate on Aug. 19 when it deemed her cause of death to be H1N1 influenza pneumonia with staph sepsis.

"We've maybe had to handle one or two cases of swine flu," said John Kades, captain of the coroner's investigative division. "The rest of these were all signed by private doctors. They had an informed medical opinion as to the cause of death, and that was registered with the county health department."

Although Kades said he did not know specifics of the Estevez case, he speculated that the case was sent to the coroner's office after a doctor felt uncomfortable signing the death certificate of someone so young and diagnosing swine flu.

Kades said the coroner's office, which deals with about 20,000 cases per year, does not have the resources or time to notify each family.

"We notify the family via the death certificate," he said. "Sometimes death certificates are certified immediately, other times they take six to eight weeks until a cause of death is rendered. It's not something we keep a secret. It's just a matter of course, the death comes out on the death certificate."

Some families contacted by Neon Tommy did not believe swine flu was the cause of death. Fifty-year-old Olivia Cater developed what her husband, Darnell, thought was a cold after a crowded bus ride home from a dental appointment.

After a visit to a doctor and prescription medicine failed to alleviate Olivia's symptoms, she was admitted to Cedars Sinai Medical Center on May 17.

Doctors diagnosed Olivia with an infected lung, a complication of influenza, and on May 27, she died. Her death certificate also listed HIV infection, pneumonia and respiratory failure as causes of death.

Soon after she died, a television news report mentioned that the first African-American woman had died from swine flu. Darnell was swamped with calls asking if that person was Olivia. He maintained that she died of influenza.

Three days after Olivia's death, Darnell received word from her physician that she had died from swine flu.

Given the fast-moving and highly contagious nature of the virus, this case and the county's lack of communication with other families raise a public health question: Should people who came in contact with the victim be taking special precautions to prevent contracting swine flu?

Over the past week, reporters made numerous attempts to seek comment from Dr. Jonathan E. Fielding, L.A. County's director of public health, and find out whether he believes the process for notifying families of swine flu victims should be improved. On Nov. 3, we were told all Neon Tommy requests were being referred to the County Counsel's Office.

What's Ahead

Flu season normally begins in the cooler months of October and November, but swine flu has proved to be different—thriving in warmer temperatures, Lopez said.

"We have a virus that does very well in warmer months and is being transmitted pretty efficiently because of such low immunity," he said. "It's not very well understood that this virus has been able to sustain itself ever since it was introduced in April and May."

But as the weather cools down will the situation in L.A. get worse? It's possible, Lopez speculated.

"If the seasonal flu viruses begin to circulate along with the H1N1, we could have several more cases," he said, noting the widespread uncertainty that lies ahead in the medical field.

But if there's anything encouraging about this situation it's the proven effectiveness of the vaccine that's currently being seen, he said, adding that as long as the virus doesn't mutate, the vaccine's strain should be efficient at reducing the threat of the influenza.

President Obama declared the swine flu outbreak a national emergency on Oct. 24, saying that "the potential exists for the pandemic to overburden health care resources in some localities." The Obama administration was quick to note that the national emergency announcement was an administrative move and did not suggest an unexpected worsening of the outbreak. It will allow hospitals to set up space elsewhere for treatment of swine flu patients in the case of overcrowding.

The Influenza A (H1N1) virus, commonly referred to as swine flu, was first detected in April 2009. The World Health Organization declared it a pandemic on June 11.

The real challenge, Plough said, is building the vaccine supply.

The county health department has identified these groups as vaccination priorities: pregnant women, people who live with or care for infants under 6 months old, healthcare and emergency services personnel, people between the ages of six months and 24 years old and people ages 25 through 64 years old with preexisting conditions.

"Half the population in L.A. County would fall into those priority groups," Plough said, noting that counties outside L.A. are seeing similar results.

"L.A. County may be a little bit younger," he said. "Young people are more at risk and they fall into most of the categories for the risk. That makes us a little more vulnerable."

Plough said the department is trying to vaccinate 5.5 million people but had only received 300,000 doses for the whole county as of Oct. 28. While more doses are expected, it might be November or December before an "adequate supply" has been built up, he said.

"We have been predicting to get about 1.3 million by the end of the month," he said. "I'm not sure we'll get that target."

A two-day clinic at the University of Southern California Lyon Center that started Tuesday morning had an overwhelming turnout. Before the clinic's official opening at 8:30 a.m. Tuesday, families and community residents assembled in a line that spanned about a quarter of a mile. But many complained of the inefficiency of the county's system. No attention was paid to the order in which people arrived, and instead, county officials dealt with priority groups first, asking for all pregnant women to move to the front of the line, followed by children.

Brigitte Smith, 48, was the first to arrive at 5:10 a.m. At 9:45, she had yet to be vaccinated and said it would probably be another "50 hours" before she had her turn.

Smith, an L.A. resident, said she was getting the vaccine because she does home care for elderly people and knew it was an important precaution to take.

"I got here at 5 o'clock because I figured I'd be No. 1, and I'm not No. 1," she said. "I'm frustrated because I got here hours ago in the morning, and they're not organized."

Others waiting in line with Smith said they spoke with the person running the clinic and recommended setting times for different priority groups. One man who had arrived early was so upset with the change that security officials had to calm him down, Smith said.

"If you are used to giving these shots out, you should be better organized," she said.

Hector De La Cruz, the chief environmental health specialist with L.A. County's environmental health division, said he could understand people's frustration with waiting hours in line to be vaccinated.

"I can completely understand where they're coming from," he said. "With mass points of dispensing there are always going to be roadblocks and challenges. But I have had comments from a few people in line and I have made note of it."

For full coverage, including an interactive map, images of the death certificates and victim profiles, visit the series page at Neon Tommy. And be sure to tune in to our show Thursday night when Commentator Marcos Villatoro takes on the topic of swine flu.

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