BISMARCK — North Dakota has emerged as one of the nationwide leaders in COVID-19 testing since the pandemic began in March.

Gov. Doug Burgum and state health officials often describe testing as the key that unlocks a new sense of normalcy, in which some precautions are still necessary but life and commerce can go on. In their view, testing allows for the "tracing" of a positive case's contacts, and ultimately, the effective isolation of the deadly illness.

But even in North Dakota, not every sick person has been tested for COVID-19 over the last three months. There could be several reasons for this — perhaps a person chose not to get tested or maybe a COVID-19 diagnosis wouldn't change a hospice patient's grim outlook.

The state Department of Health now lists the number of deaths in people who were never tested but are presumed by medical professionals to have died from COVID-19.

There are nine North Dakotans who fall in this category, and their deaths are not included in the state's official COVID-19 deaths, which numbered 80 on Thursday, July 2.

Doctors, medical examiners and coroners can determine the cause of death to be COVID-19 for a person who was never tested if they showed symptoms of the illness or were likely to have been exposed, according to the Centers for Disease Control and Prevention. Tests for the illness can be performed after death, but some families opt not to test a deceased loved one because knowing the cause of death for certain may not be important at that point, Peske said.

Seven of those in North Dakota who are presumed to have died from COVID-19 are from Cass County, which encompasses Fargo and has accounted for more than 60% of the known cases in North Dakota. The health department lists 66 other COVID-19 deaths in the county in its official tally.

One of the victims lived in Walsh County, north of Grand Forks. Another lived in Stutsman County, which includes Jamestown.

Three of the nine residents presumed to have died of COVID-19 were in their 50s, while the other six were at least 70 years old. Six were women and three were men. Like for other victims of the illness, the department does not share any other information about the residents due to concerns for their medical privacy.

Health department spokeswoman Nicole Peske said the nine residents are not part of the official count because "in order for a person to be entered into our system, it all starts with a test.” Peske noted that the department decided to start listing the special classification in late May to be transparent.

Many other states and localities that provide regularly updated information about COVID-19 include a category for probable deaths in their state, county or city limits.

Minnesota classifies 37 fatalities as probable deaths, in which COVID-19 was listed on the death certificate but a positive test for the illness was never documented. It’s unclear if deaths are included as part of the state’s total death count, and Minnesota Department of Health spokespeople did not respond for comment in time for publication.

New York City, the hardest hit area in the country, began including probable deaths in its official count in mid-April. The more than 4,600 deaths in this category make up nearly 20% of the city's known victims of the illness.

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