Assigning cause of death is rarely as straightforward as it seems, especially when it comes to COVID-19.
In Nevada, patients who test positive for the virus and later die are added to the total state death count, said Shannon Litz, spokeswoman for the Nevada Department of Health and Human Services.
But that’s not how every state is counting its coronavirus deaths.
Colorado includes patients exhibiting COVID-19 symptoms — but not confirmed infected through a test — to its death count. Around 3% of deaths fell into this category, according to the Washington Post. Alabama determined last month that one in every 10 people who died with coronavirus didn’t necessarily die from coronavirus.
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“I don’t think any of those methods are wrong, they just tell us a slightly different thing,” said Dr. Brian Labus, an epidemiologist with the UNLV School of Public Health. He added that most deaths aren’t examined on a day-to-day basis the way COVID-19 deaths are.
The Centers for Disease Control and Prevention updated its website in April to say that cases that were not confirmed by a test can be added to the total death count.
But President Donald Trump and members of the White House Coronavirus Task Force are pressuring the CDC to alter the way it counts the dead, and to eliminate probable cases altogether. Trump has complained that the U.S. COVID-19 death count is overstated, according to reports.
Labus believes it’s more likely that there is an undercount of deaths than an overcount, noting that not everyone who dies from COVID-19 has been tested for it. Tests can also come back as false negatives, he added. In Nevada, 387 have died from the virus as of Friday.
“There’s a difference between what we can measure and what’s really happened,” he said.
Accurately deciphering the cause of death data in real time is a challenge that extends beyond the coronavirus and can be especially challenging for patients with pre-existing conditions, Labus said.
Take smoking, for example. A life-long smoker who later dies of emphysema or lung cancer wouldn’t have “smoking” listed as the cause of death on their death certificate.
“Smoking would be the underlying reason why these things happen, but the actual cause of death itself isn’t smoking, it’s lung cancer,” Labus said. “So if you’re trying to understand how bad smoking is, that presents some challenges. It’s the same thing with this disease. You have a lot of different things going on, but this virus plays a role.”
The CDC released specific guidelines in April on how officials should complete death certificates for COVID-19 patients. For example, a 77-year-old male with a history of hypertension and chronic obstructive pulmonary disease who comes to the hospital complaining of COVID-19 symptoms tests positive and dies three days later following respiratory acidosis and sustained cardiac arrest would have acute respiratory acidosis listed as his cause of death.
COVID-19 would be listed below as what precipitated the cause of death. Chronic obstructive pulmonary disease and hypertension would be listed as contributing causes of death.
In another scenario outlined by the CDC guidelines, an 86-year-old woman dies at home. Her husband reports that she was nonambulatory after suffering an ischemic stroke three years prior. He tells authorities that five days prior she developed a high fever and other COVID-19 symptoms.
They worsened until one morning he woke up to find her unresponsive. Upon EMS arrival, she is found pulseless and apneic. The coroner determines the immediate cause of death is acute respiratory illness, with the underlying cause being probable COVID-19.
In Clark County, around 15 COVID-19 deaths occurred at home. Each were positive cases, said Clark County Coroner John Fudenberg.
“We’ll ask the family if they exhibited the symptoms, and if there’s any reason to believe if they were exposed to someone with COVID,” he said. “If they have, what we’ll do is take a nasal swab (from the body) and test it for COVID.”
Labus said the final COVID-19 death toll will likely be reported differently than what’s coming out right now.
“People are watching these death numbers without understanding all the work that has to go into confirming them,” he said. “The trade-off for speed is some of that accuracy for right now.”