A similar controversy cropped up in Colorado in May when the state's reporting of how many Coloradans have died from COVID-19 was called into question.
When Gov. Jared Polis found out that people who tested positive but may have died of something else were included in the state's death total, he said officials should report that total to the federal Centers for Disease Control and Prevention as is standard, but should also report to the public the lower number of deaths due directly to COVID-19, the governor said at a May 20 news conference.
In a May 15 news release, the Colorado Department of Public Health and Environment explained that its data included deaths among all people who had COVID-19 at the time of death.
That included deaths for which “the cause or causes may not have been attributed to COVID-19 on the death certificate,” the release said. “This is the standard way states report to the Centers for Disease Control and Prevention.”
“We know this virus can be deadly and can complicate other serious medical conditions and hasten death,” Eric France, chief medical officer at the state health department, said in the release. “As public health practitioners, we need to look at data that helps us understand disease transmission and protect people.”
A day earlier, a Douglas County state lawmaker requested that the area's district attorney investigate the state public-health department, accusing the agency of illegally changing death certificates.
State Rep. Mark Baisley, a Republican from Roxborough Park, made the request to 18th Judicial District Attorney George Brauchler in a letter dated May 14, after a family forwarded Baisley a letter from a Centennial senior living facility that raised the question.
In the health department's news release, the department “emphasized that it does not unilaterally change information on death certificates and does not question or try to change a physician's diagnosis or causes-of-death determination.”
It is not uncommon for state officials to use definitions that differ from death certificate coding, Rachel Herlihy, state epidemiologist, told reporters on a May 20 news conference call.
As of May 15, the state reported 1,150 deaths among people who have COVID-19. The number of deaths confirmed to have been caused by COVID-19 was 878 as of May 9, as reported by the CDC, according to the news release.
As of Sept. 9, deaths among cases had grown to 1,979, and deaths due to COVID-19 had risen to 1,889.
Neither method of counting deaths accounts for “people that we missed altogether, that probably died from COVID that aren't included in any number because they haven't been confirmed by a coroner or autopsy,” Polis said at a May 18 news conference.
Brauchler's office announced on June 9 that his office found no evidence of the state public-health department changing death certificates at the facility.
“If (Baisley) didn't ask this question and we didn't look around, you can imagine a conspiracy theory growing out of this,” he said. “If we didn't review this then it just fuels the idea that you can't trust the numbers, you can't trust CDPHE ... I can say that isn't going on in this case.”
The notion widely shared on social media that the federal Centers for Disease Control and Prevention reduced the U.S. COVID-19 death count by 94% — from nearly 154,000 down to just over 9,000 — is a misinterpretation of the data, a Denver metro epidemiologist explains.
Fact-checking reports from late August and early September focused on social media posts that used a misreading of a CDC data table to claim the agency had “admitted” its numbers were inaccurate. President Donald Trump was among those who tweeted the inaccuracy, which appeared to gain traction in late August.
“CDC just backpedaled (quietly) and adjusted the U.S. COVID deaths from 153,504 to 9,210. Admitting that their numbers are so (expletive) that they are off by a whopping 94%,” said a post that was shared on Facebook, the Associated Press reported.
The CDC data table in question — located on the agency's site — is based on an analysis of death certificates that mention COVID-19 as a cause. For 6% of the deaths, COVID-19 was the only cause mentioned, the CDC notes. The table showed 174,470 total COVID-19 deaths recorded as of its Sept. 9 update.
That regularly updated data table shows other health conditions that those who died of COVID-19 had, including Alzheimer's disease, diabetes and obesity, as well as problems that are caused by COVID-19 itself, such as respiratory failure and pneumonia, the AP reported. A death isn't excluded from the COVID-19 death count just because the person had other health conditions at the time.
The claim that COVID-19 deaths were over-reported “is an incorrect statement,” said Bernadette Albanese, a medical epidemiologist with the Tri-County Health Department.
The “CDC shares data on COVID-19 deaths for which the virus was the only identified cause of death (about 6% of all COVID-19 deaths) and deaths for which the virus infection was coupled with other underlying health problems that led to death (about 94% of all COVID-19 deaths),” Albanese wrote in a statement to Colorado Community Media. “Both are valid counts that add up to the totality of COVID-19 related deaths.”
The CDC runs through a “longstanding, well-established process” in gathering death data, said Albanese, whose department covers Adams, Arapahoe and Douglas counties.
“They do it for injuries, they do it for heart attacks, they do it for flu … and they do it now for COVID. They do it on behalf of states and every death in the United States,” Albanese said. She added: “There's nothing new about that process at all.”
The far majority of COVID-19 deaths occur among people 55 and older, who also often have other health conditions that make them more vulnerable to the severe impacts of COVID-19, such as pneumonia, Albanese noted. Public health officials have pointed to that trend for months.
“It is to be expected that those persons who die from COVID-19 also have other complicating health conditions contributing to death,” Albanese said.
For example, a person with an existing condition such as hypertension who dies due to COVID-19 would have COVID-19 listed as the underlying cause of death, according to the CDC's guidance for filling out death certificates. Hypertension would be listed in a separate section as a condition that contributed to, but did not directly cause, the death.
Death certificates are records that officials register for every death occurring in the United States, offering a complete picture of mortality nationwide, according to the CDC.
The CDC requires a physician, medical examiner or coroner to list a cause of death followed by other conditions that contributed to the death, according to Albanese.
The underlying cause of death is “the disease or injury which initiated the train of morbid events leading directly to death,” the CDC's guidance says.
“In many cases, it is likely that (COVID-19) will be the (underlying cause of death), as it can lead to various life-threatening conditions, such as pneumonia and acute respiratory distress syndrome,” the guidance says.
The CDC's guidance adds: “Ideally, testing for COVID-19 should be conducted, but it is acceptable to report COVID-19 on a death certificate without this confirmation if the circumstances are compelling within a reasonable degree of certainty.”
The agency gives an example of an elderly person who ends up pulseless before emergency medical workers could respond — a situation where, although no COVID-19 testing was done, the coroner determines that the likely underlying cause of death was COVID-19 given the patient's high fever and severe cough and exposure to a family member who was diagnosed with COVID-19.
In cases where a definite diagnosis cannot be made, but it is suspected or likely, it is acceptable to report COVID-19 on a death certificate as “probable” or “presumed,” the guidance says, while noting that COVID-19 testing should be conducted whenever possible.
It was unclear from the CDC data table what portion of COVID-19 deaths listed were those for which COVID-19 was listed as a “probable” or “presumed” cause.
As of Sept. 9, Colorado had seen 1,979 deaths among people with COVID-19, and 350, or 17.7%, were listed as “probable,” according to the state's online data.
The state had tallied 1,889 people who died due to COVID-19, as opposed to the total who died with COVID-19 but not necessarily due to it.
However, the true death toll from the virus is widely believed to be higher than what the official numbers show, as experts say many victims died of COVID-19 without ever being tested for it, the AP has reported.
Update November 2021: See an explainer by The Economist on "excess deaths" and COVID-19 death estimates here.
Other items that may interest you
We have noticed you are using an ad blocking plugin in your browser.
The revenue we receive from our advertisers helps make this site possible. We request you whitelist our site.