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How are COVID-19 deaths counted?

Trucks used as temporary morgues sit outside the New York City Chief Medical Examiner's office on May 12, 2020.
Trucks used as temporary morgues sit outside the New York City Chief Medical Examiner's office on May 12, 2020.
(Image: © Eduardo Munoz Alvarez/Getty Images)

As coronavirus has swept through the United States, finding the true number of people who have been infected has been stymied due to lack of testing. Now, official counts of coronavirus deaths are being challenged, too.

In Colorado, for example, a Republican state legislator has accused the state's public health department of falsely inflating COVID-19 deaths; in Florida, local media have objected to the State Department of Health's refusal to release medical examiner data to the public, alleging that the state may be underreporting deaths.

The reality is that assigning a cause of death is not always straightforward, even pre-pandemic, and a patchwork of local rules and regulations makes getting valid national data challenging. However, data on excess deaths in the United States over the past several months suggest that COVID-19 deaths are probably being undercounted rather than overcounted.

Cause of death

Death certificates can be signed by a physician who was responsible for a patient who died in a hospital, which accounts for many COVID-19 deaths. They can also be signed by medical examiners or coroners, who are independent officials who work for individual counties or cities. Many COVID-19 death certificates are being handled by physicians unless the death occurred outside of the hospital, in which case a medical examiner or coroner would step in, said Dr. Sally Aiken, the president of the National Association of Medical Examiners (NAME). In some jurisdictions, including cities such as Chicago and Milwaukee, medical examiners are involved in determining the cause of death for every suspected COVID-19 case. In those jurisdictions, medical examiners review medical records even of patients who die in hospitals to ensure that the symptoms and any testing indicate that the patient did indeed die of COVID-19.

Having medical examiners confirm COVID-19 deaths can create more uniformity and clearer documentation, Aiken told Live Science. On a death certificate, there are spaces to list an immediate cause of death, as well as the chain of events that led to that final disease or incident. There are also spaces for adding contributing factors.

Related: 20 of the worst epidemics and pandemics in history

For COVID-19, the immediate cause of death might be listed as respiratory distress, with the second line reading "due to COVID-19." Contributing factors such as heart disease, diabetes or high blood pressure would then be listed further down. This has led to some confusion by people arguing that the "real" cause of death was heart disease or diabetes, Aiken said, but that's not the case.

"Without the COVID19 being the last straw or the thing that led to the chain of events that led to death, they probably wouldn't have died," she said.

Detecting COVID-19

How hard it is to accurately determine whether COVID-19 was truly that last straw depends on the situation. Most COVID-19 deaths seen at Mount Sinai Health System in New York are in people who have comorbid (or co-occurring) conditions such as coronary artery disease or kidney disease, said Dr. Mary Fowkes, the chief of autopsy services at Mount Sinai. But it's not typically difficult to tell what killed them.

Related: Why COVID-19 kills some people and spares others. Here's what scientists are finding.

"Most of the cases are pretty straightforward," Fowkes told Live Science. "The lungs are usually so severely involved with pathology, so they are two to three times or more the normal weight of a normal lung."

(The excess weight is due to fluid and cell detritus from damaged lung tissues.)

In some cases, particularly those where someone dies at home or quickly perishes after entering an emergency room, the determination can be a little more fuzzy, said Dr. Jeremy Faust, an emergency physician at Brigham and Women's Hospital in Massachusetts.

"The challenge is knowing who died of COVID-19 versus who died with the virus that causes COVID-19," Faust told Live Science.

Autopsies can help answer that question, but autopsy rates were low even pre-pandemic, Fowkes said. Even at Mount Sinai, a rare medical system that offers every family a chance to have their loved one autopsied for free, the rate of autopsy was only about 20% prior to the pandemic. According to NAME, there is an ongoing shortage of forensic pathologists working in the United States, with about 500 currently employed and a need for 1,200. Autopsies for COVID-19 can also be dangerous due to the infectious nature of the disease and ongoing shortages of personal protective equipment for pathologists. 

Another complication for assigning a cause of death for COVID-19 is that some younger people have died of strokes and heart attacks and then tested positive for COVID-19 without any history of respiratory symptoms. The virus is now known to cause blood clots, suggesting that COVID-19 was the killer in these cases, too. Fowkes and her colleagues conducted a microscopic inspection of the brains of 20 COVID-19 victims in her hospital system and found that six of them contained tiny blood clots that had caused small strokes before death.

"We're seeing it in younger patients than you would expect, and we're seeing it in a distribution that you wouldn't expect, so we think it's related to the COVID," Fowkes said.

The Centers for Disease Control and Prevention (CDC) has issued guidelines for how to attribute a death to COVID-19. The guidelines urge using information from COVID-19 testing, where possible, but also allow for deaths to be listed as "presumed" or "probable" COVID-19 based on symptoms and the best clinical judgment of the person filling out the death certificate. A medical examiner trying to determine a cause of death in the absence of testing would comb medical records and query family and loved ones about the person's symptoms before they died, Aiken said. Postmortem COVID-19 tests may be possible, depending on the jurisdiction.

Underreporting or overreporting?

All of the inconsistencies of cause-of-death reporting precede the COVID-19 pandemic, says Jay Wolfson, a professor of public health at the University of South Florida (USF). But getting good data about deaths is now extremely pressing, he told Live Science. Death certificates are often used by epidemiologists and public health officials to detect strange clusters of deaths or to link certain risk factors to certain causes of death. But because different states and localities have different rules about recording and reporting causes of death, the cumulative data is always messy.

Related: 13 coronavirus myths busted by science

"I think some states are reluctant to open their databases up, knowing they have validity problems or knowing the data might be misused," Wolfson said. But public health officials need access, he said, and they need to figure out ways to dig into the data and standardize them. Wolfson and other researchers at USF are already working with state officials to see what kind of data the state can legally release, he said.

Meanwhile, as the political debate over the response to the virus heats up, some have argued that death reports are being deliberately skewed. Aiken rejected the notion of a vast conspiracy by medical examiners; medical examiners are designed to be independent entities, she said, and they run the political gamut from conservative to liberal.

"It always cracks me up," she said. "Medical examiners and coroners aren't organized enough to have a conspiracy."

In Colorado, the discrepancy over people dying with COVID-19 versus of COVID-19 is due to federal reporting guidelines requiring the health department to report any COVID-positive death to the CDC, even if COVID-19 wasn't thought to cause the death, Gov. Jared Polis said in a news conference Friday (May 15). The health department has been instructed not to report those deaths as being caused by COVID-19 to the public, Polis said. 

In Florida, state law prevents the release of death certificate data, Wolfson said, but it may be possible to get public release of death certificates with identifying information removed, or of cumulative datasets. 

Both undercounts and overcounts of COVID-19 deaths are possible, Wolfson said, but it's not yet clear which is more likely, or whether they might simply balance each other out. Fowkes said that based on her experience, it's more likely that COVID-19 deaths are being missed than overcounted. That's because New York is among several cities that show spikes in deaths at home, and these anomalous spikes could be due to untested, untreated COVID-19. 

Perhaps, the best clue as to whether COVID-19 deaths have been undercounted or overcounted is excess mortality data. Excess mortality is deaths above and beyond what would normally be expected in a given population in a given year. CDC data shows a spike of excess mortality in early 2020, adding up to tens of thousands of deaths.

Some argue that many of these excess deaths are related to COVID-19 lockdowns, not COVID-19 themselves, Faust said, because people fear catching the disease if they go to the hospital for other reasons. A study in the Journal of the American College of Cardiology did find that nine major hospitals saw a 38% drop in emergency visits for a particular kind of heart attack in March. That suggests that people really are delaying or avoiding medical care, which could mean that some of them die of preventable causes. 

But non-COVID conditions probably don't explain most excess deaths, Faust said. Only a portion of heart attack visits would have represented lives saved, he said, because doctors must treat perhaps 10 patients to save one life. And other causes of death — such as motor vehicle accidents — are down.

This could change with time, Faust cautioned. For example, if cancer patients forego their treatments for a year, rather than a few months, the impact on their death rates is much more likely to be noticeable in the population-wide data. But for now, he said, "it's unlikely that the coronavirus deaths are being overcounted by a magnitude that explains our observation that something very unusual is going on."

(Image credit: Nicholas Forder)

Originally published on Live Science.

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  • DS in Bellaire
    The real problem with this overcount/undercount/whatever is that decisions to open or close the economy, various classes of business, church services, etc., are being made based on what are provably squishy numbers. The supposed metric "14 days of decreasing (cases, deaths, or whatever)" has become the criteria for granting more (already constitutionally guaranteed) freedoms. But the weekend reporting lag seen in the data cause a spike on Mondays, resetting the clock. Unfortunately, these criteria have been accepted by empowered people who have no statistical background, and no real inclination to look at the details behind the numbers...
    Reply
  • LivingMan
    Ok, so a guy catches the flu but dies of pneumonia. Nobody gives a crap but his death is counted as caused by pneumonia. Another guy catches corona but dies of a heart attack. His is counted as corona. Another guy had underlying issues that he died of but because the government is handing out tax money like candy and all you have to do is check the cause of death as corona, and hey, cha-ching! CBS does a special on all the huge numbers of people getting tested which is "flooding" a hospital and the hospital obliges by pulling nurses and techs from their jobs taking care of patients and making them go through a line pretending they are getting tested, thus inflating the numbers. Dr. Deborah Birx said 'there is nothing from the CDC that I can trust'. I call BS on the way they counted the deaths! America, you've been scammed so bad and all you can say is "Thank you, Sir, may I have another!"? Wake up you simple doofuses while your children still have a free(ish) country to call home!
    Reply
  • Quantum
    I really do not like "conspiracy theories," but this Coronavirus scare has clearly indicated nefarious activity from the Democratic Party. Governors in Blue States are easily sacrificing YOUR civil liberties. And, for what? For poorly reported and poorly researched so called scientific reasons. The disease is situated primarily in northeastern blue states. A person is sick with an underlying disease. If he/she would get almost any disease, the likelihood of death is high. This person happens to get the coronavirus, or what they think is the coronavirus. What did this person die of? The underlying disease, or the coronavirus. Clearly, the underlying disease is the cause. People should be classified correctly. Also, if you have underlying conditions, you need to engage in social distancing. Meanwhile, our Civil Liberties have been taken away. This is a serious problem in what is conceived to be a free society. Men and Women have gone off to wars, and sacrificed their lives, in order to preserve my and your civil liberties.
    Reply
  • kaiserdr
    Florida Governor Ron DeSantis has made it impossible to trust ANY of the state's statistics or the special panel he appointed.

    Florida's "statistics" mean absolutely nothing. In April, DeSantis directed ALL Florida's county coroners to STOP releasing cause-of-death statistics involving Corona virus. Citrus County, where I live, shares one coroner with several counties, it often takes a long time for the coroner to come here to determine the cause of death!

    The same month, the governor set up a committee of "experts" to determine how to respond to the virus. The only medical representative on that committee is an administrator and does not know anything at all about virology, its treatment or control.

    The decision to open Florida is totally political and is ignoring the potential of hundreds or even thousands of Floridians and tourists dying from the virus in Florida. Committee members have no idea what the medical consequences of opening up the state will be!

    As seen in Miami Beach this weekend, no one kept their distance, many people at the beach probably were exposed to the virus and quite possibly spread it to everyone they later associated with. No one will show symptoms for two or tree weeks and will end up in more casualties.

    Due to DeSantis muzzling coroners, those deaths will not be registered as due to Corona Virus and thousands of Floridians and any tourist who visits Florida could increase the number of deaths, while none of them will be recorded.

    Committee members on such panels should be medical experts, not businessmen whose only concern is THEIR bottom line.
    Reply
  • Ratwrangler
    Considering the nature of this new virus, overreporting of deaths may be better than underreporting, with some caveats. One, if the death is reported as COVID-19-related, the patient must have tested positive for the disease. We should not have doctors just able to say, "fever and congestion, must be coronavirus," and write that down. Show proof of infection first. Two, if the patient has the virus, but dies of something the virus cannot cause, the virus cannot be listed as a cause. That would leave out trauma due to car accidents, firearms incidents, or ingesting aquarium supplies. The biggest problem with the numbers is that they are horribly inaccurate and will remain so until we test a much larger percentage of the population. As it is now, if you catch it, you have a 6.5% chance of dying, and a 19% chance of getting over it, based on present published numbers.
    Reply
  • Quantum
    kaiserdr said:
    Florida Governor Ron DeSantis has made it impossible to trust ANY of the state's statistics or the special panel he appointed.

    Florida's "statistics" mean absolutely nothing. In April, DeSantis directed ALL Florida's county coroners to STOP releasing cause-of-death statistics involving Corona virus. Citrus County, where I live, shares one coroner with several counties, it often takes a long time for the coroner to come here to determine the cause of death!

    The same month, the governor set up a committee of "experts" to determine how to respond to the virus. The only medical representative on that committee is an administrator and does not know anything at all about virology, its treatment or control.

    The decision to open Florida is totally political and is ignoring the potential of hundreds or even thousands of Floridians and tourists dying from the virus in Florida. Committee members have no idea what the medical consequences of opening up the state will be!

    As seen in Miami Beach this weekend, no one kept their distance, many people at the beach probably were exposed to the virus and quite possibly spread it to everyone they later associated with. No one will show symptoms for two or tree weeks and will end up in more casualties.

    Due to DeSantis muzzling coroners, those deaths will not be registered as due to Corona Virus and thousands of Floridians and any tourist who visits Florida could increase the number of deaths, while none of them will be recorded.

    Committee members on such panels should be medical experts, not businessmen whose only concern is THEIR bottom line.
    The above post is so political as to be very suspicious. You see a lot of invective and Democratic Party talking points. The author makes no mention of the fact that the number of patients has been low, and the hospitals have not been over-run. The dire predictions have not come true. Yet, the author just throws out talking points, with no data or reasons, just political talking points. The author should be scrutinized, perhaps not a true scientist or commentator.
    Reply
  • Quantum
    The above post is so political as to be very suspicious. You see a lot of invective and Democratic Party talking points. The author makes no mention of the fact that the number of patients has been low, and the hospitals have not been over-run. The dire predictions have not come true. Yet, the author just throws out talking points, with no data or reasons, just political talking points. The author should be scrutinized, perhaps not a true scientist or commentator.
    Reply
  • DRH
    admin said:
    Most COVID-19 deaths are easy to diagnose, but sometimes the immediate cause of death is not so clear, leading to accusations of politically-motivated falsification of death certificates.

    How are COVID-19 deaths counted? : Read more
    The Covid19 death count is an utter mess. The CDC uses very antiquated systems and methodology and there is no truly uniform counting from State to State. The biggest issue is NOT whether or not deaths are attributed to Covid19 (even if not directly a result of the infection) BUT, deaths being counted as Covid19 when there is no actual infection of such. This was predicted to be a very bad Flu year - but amazingly the thousands of flu deaths reported in March fell to near zero for April. Gov Cuomo opened the door to the 'presumptive' Covid19 deaths in early April by dumping almost 4000 cases from the flu and bacterial pneumonia category into the Covid19 category of deaths. NYC is a special outlier in numbers of Covid19 deaths from any other locality in the world. And, it is looking suspiciously like what one would expect if you added the flu deaths to the Covid19 deaths as they had been materializing prior to the addition of the 'presumptives'.
    Doctors across the country have complained that they have been pressured into listing Covid19 as the cause of a death (whether direct or indirect cause) without proof of Covid19 infection even occurring. Corpses can be swabbed for Covid19 or influenza, but there has been pressure to simply list it as such. Usually it is a matter of 'follow the money', since States and localities see more Covid19 deaths as more Federal funding - and cities and counties competing for greater shares of the States' allotments. But, there are also those who are determined to construct as dire a landscape as possible to justify their policies.
    It was incumbent upon the CDC to get as accurate a count with any and all special factors for the deceased for a true picture, given a new pathogen and need for a better determination of lethality for the general populace and special sub groups . There are many in the CDC ranks who have their own preconceived ideas of what the landscape should look like with death counts, and their agendas work their way into the system. Ask Dr. Redding what the real 'flu' count is - and he cannot tell you. It was always an 'estimate'. Now, it is imperative that before a death is attributed to a Covid19 - it must be lab proven that the infection existed. This is a criteria that should have been demanded by the CDC, given the extreme ramifications this outbreak has exacted.
    Bottom line -- the count is highly inflated. The Covid19 death toll is conflated with flu and streptococcal pneumonia deaths. Even Dr Brix, whose judgement and paternalistic approach at times with which I've taken issue, says she cannot believe any of the statistics coming out of the CDC. She estimated that the count was inflated by 25%. By my 35 years of experience in this field - and what the flu and pneumonia count ought to have been - even conservatively - the Covid19 death count appears to be off by as much as 35%.
    Dr H
    Reply
  • The Fabulous Greenbean
    DRH said:
    The Covid19 death count is an utter mess. The CDC uses very antiquated systems and methodology and there is no truly uniform counting from State to State. The biggest issue is NOT whether or not deaths are attributed to Covid19 (even if not directly a result of the infection) BUT, deaths being counted as Covid19 when there is no actual infection of such. This was predicted to be a very bad Flu year - but amazingly the thousands of flu deaths reported in March fell to near zero for April. ..........

    Doctors across the country have complained that they have been pressured into listing Covid19 as the cause of a death (whether direct or indirect cause) without proof of Covid19 infection even occurring. Corpses can be swabbed for Covid19 or influenza, but there has been pressure to simply list it as such. Usually it is a matter of 'follow the money', since States and localities see more Covid19 deaths as more Federal funding - and cities and counties competing for greater shares of the States' allotments.
    First of all, flu deaths did not drop to near zero in April. (See latest CDC flu surveillance report.) Second: doctors "across the country" have not come out and said they were being pressured to put Covid on the death certificates. There are two doctors in California who made a vague accusation of this happening (with no details). It's fraud to falsify a death certificate. My guess is it may happen in isolated instances, in which the local people involved need to take their specific accusations to authorities. No one has done that with the exception of one case in Colorado recently.
    A lot of assumptions here, including that deaths are overcounted. Excess overall mortality rates indicate the opposite. In addition, Covid causes death in various ways, including heart attack (regardless of pre-existing condition). If Covid was in the US prior to March, there would have been no testing, but certainly deaths that would not have been counted as Covid deaths. Many states are not adding nursing home deaths and/or deaths at home, to their Covid death counts.
    If I have diabetes and pass away with lungs full of fluid and multiple organ failure, that's not going to be a diabetes death. That is a likely Covid death, and the doctor has to make that call. That's what they're trained to do. Blanket accusations of fraud are nothing but political posturing without specifics.
    Reply
  • DRH
    The Fabulous Greenbean said:
    First of all, flu deaths did not drop to near zero in April. (See latest CDC flu surveillance report.) Second: doctors "across the country" have not come out and said they were being pressured to put Covid on the death certificates. There are two doctors in California who made a vague accusation of this happening (with no details). It's fraud to falsify a death certificate. My guess is it may happen in isolated instances, in which the local people involved need to take their specific accusations to authorities. No one has done that with the exception of one case in Colorado recently.
    A lot of assumptions here, including that deaths are overcounted. Excess overall mortality rates indicate the opposite. In addition, Covid causes death in various ways, including heart attack (regardless of pre-existing condition). If Covid was in the US prior to March, there would have been no testing, but certainly deaths that would not have been counted as Covid deaths. Many states are not adding nursing home deaths and/or deaths at home, to their Covid death counts.
    If I have diabetes and pass away with lungs full of fluid and multiple organ failure, that's not going to be a diabetes death. That is a likely Covid death, and the doctor has to make that call. That's what they're trained to do. Blanket accusations of fraud are nothing but political posturing without specifics.

    I know only too well what doctors are trained to do. Respectfully Greenbean, you are mistaken. There was certainly NO accusation of fraud on the doctors' parts. And, I do not refer to the 2 CA doctors who complained, regarding incorrect death certificates - but to others who specifically note that they are willing to 'swab' a deceased to determine if a Covid19 infection actually existed. That their local officials were pressuring them to close out the 'call' strictly on a clinical 'presumption', which is not good enough for a new pathogen death tracking. A LIKELY death is just not good enough in gathering important data for a new pathogen. Pneumonia or other organ failure is just not 'specific' enough to be able to clinically rule a death due to Covid19. It is easy enough to swab a patient or deceased to 'prove' Covid19 was on board.

    As for influenza counts -- again, you are mistaken - look particularly at NY reporting. Coincidentally, it was after Cuomo announced in early Apr that his State would be adding about 4000 'presumptive' deaths to Covid19 (these were NOT proven to have even had the infection), NY's flu deaths fell from several thousand for Mar to less than 200 for April.

    Yes, a doctor may 'certify' the cause of death and contributing factors - BUT, the clinical and imaging picture alone is not enough for an accurate call. I have inherited a number of patients who were misdiagnosed both ways - some presumptively with Covid19 and others with another respiratory contagion - whose clinical and imaging presentations were NOT an absolute. Despite best efforts to determine unique clinical aspects to 'distinguish' influenza from Covid19 - there is too much overlap and variable presentation of flu to mimic Covid19 - unlike a case of smallpox that is unmistakable clinically.

    The major point is - that lab confirmed presence of the virus MUST be required for this new pathogen. Presumptive diagnosis and 'presumptive' cause of death as due to Covid19 is just not good enough for a new outbreak and should not be included, especially since it is easy enough to swab for lab confirmation.

    PS - I am also very well aware of how the CDC works, its antiquated systems and that we cannot count on it today for an accurate picture of Covid19 deaths. And, again for your edification -- the flu reports listed on the CDC Web site are 'estimates' not proven cases. This is just not good enough today. The estimate methodology was not great before, but okay when there was no competing predominately pneumonia viral pathogen. I have to side with Dr. Brix on her assessment of the CDC stats.

    DR H
    Reply