Severe Acute Respiratory Syndrome Coronavirus 2 Antibody Seroprevalence in Decedents Undergoing Forensic Postmortem Examination: Feasibility for 
Real-Time Pandemic Surveillance

• Published in: Open forum infectious diseases Vol. 9; no. 5; p. ofac142
• Main Authors: Coburn, Sally B, Manabe, Yukari C, Laeyendecker, Oliver, Sherman, Susan G, Baker, Owen R, Quinn, Thomas C, Graham, Lindsey A, Dennis Thomas, F, Southall, Pamela, Weedn, Victor W, Ehsani, Johnathon, Klock, Ethan, Li, Rong, Shields, Wendy C, Michael, Jeffrey Paul, Li, Ling, Althoff, Keri N
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 01-05-2022
• Subjects: Major; seroprevalence; drug overdose; SARS-CoV-2 antibodies; decedents; motor vehicle crash
• ISSN: 2328-8957; 2328-8957
• DOI: 10.1093/ofid/ofac142

Abstract
Background
Population-based seroprevalence studies offer comprehensive characterization of coronavirus disease 2019 (COVID-19) spread, but barriers exist and marginalized populations may not be captured. We assessed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody seroprevalence among decedents in Maryland over 6 months in 2020.
Methods
Data were collected on decedents undergoing forensic postmortem examination in Maryland from 24 May through 30 November 2020 from whom a blood specimen could be collected. Those with available blood specimens were tested with the CoronaCHEK lateral flow antibody assay. We assessed monthly seroprevalence compared to the statewide estimated number of cases and proportion of positive test results (testing positivity). We used Poisson regression with robust variance to estimate adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) for associations of demographic characteristics, homelessness, and manner of death with SARS-CoV-2 antibodies.
Results
Among 1906 decedents, 305 (16%) were positive for SARS-CoV-2 antibodies. Monthly seroprevalence increased from 11% to 22% over time and was consistently higher than state-level estimates of testing positivity. Hispanic ethnicity was associated with 2- to 3.2-fold higher seropositivity (P < .05) irrespective of sex. Deaths due to motor vehicle crash were associated with 62% increased seropositivity (aPR, 1.62 [95% CI, 1.15–2.28]) vs natural manner of death. Though seroprevalence was lower in decedents of illicit drug overdose vs nonoverdose in early months, this shifted, and seroprevalence was comparable by November 2020.
Conclusions
Decedents undergoing forensic postmortem examination, especially those dying due to motor vehicle trauma, may be a sentinel population for COVID-19 spread in the general population and merits exploration in other states/regions.
SARS-CoV-2 antibody seroprevalence was 16% among Maryland decedents undergoing forensic postmortem examination (May–November 2020). Hispanic ethnicity and motor vehicle deaths were associated with seropositivity. Estimates in decedents exemplify feasible/real-time data for disease spread and potential sentinel surveillance meriting exploration.