Change to death certificates could boost COVID-19 counts

An empty hospital room.
A hospital room with a negative air pressure setup sits ready for a COVID-19 patient at Bethesda Hospital in St. Paul, Minn., on Thursday, March 26, 2020. The negative air pressure setup pulls air outdoors, rather than filtering back into the hospital.
Evan Frost | MPR News

With rare exceptions, Minnesota officials have decided against postmortem testing to determine if undiagnosed people who died from severe respiratory problems were infected with COVID-19.

That has raised doubt about the accuracy of the fatality count, which officially stands at 22 in Minnesota. Infectious Disease Director Kris Ehresmann at the Minnesota Department of Health freely acknowledges it’s probably not a true reflection of the coronavirus toll.

“When we’re reporting deaths from COVID, we know there may be illnesses that aren’t diagnosed,” Ehresmann said in an interview Thursday. Of deaths where a test hadn’t been done, she said, “We wouldn’t necessarily count it in our data points because it is not confirmed.”

An example of an official death certificate
An example of a death certificate.
Courtesy of Minnesota Department of Health

But new guidelines from the National Center for Health Statistics, which Minnesota follows, will err on the side of pinning more deaths on COVID-19, at least provisionally.

An alert issued Thursday instructs those who fill out death certificates to categorize pneumonia deaths that can’t be traced to another underlying condition as presumptively COVID-19.

Steven Schwartz, director of the national vital statistics division, wrote in the alert that pneumonia deaths may have previously been misclassified if a test hadn’t been conducted prior to death.

“Increases in pneumonia deaths may be an indicator of excess COVID-19 related mortality,” he concluded.

Since early March, federal and state officials have revisited the way they classify deaths caused by pneumonia, acute bronchitis, acute respiratory distress and other airway problems. COVID-19 has been listed alongside those conditions on some death certificates but not all.

Doctors, medical examiners, funeral directors and others submit information for a person’s death certificate to the Minnesota Department of Health. The record includes information about where a person died, how old they were, what the cause was and who the primary caregiver was.

The state Health Department subsequently forwards the data to the U.S. Centers for Disease Control and Prevention for coding.

Molly Mulcahy Crawford, the state registrar in Minnesota’s Office of Vital Records, said the process and confirmation steps means that final information can be lagging. As of Thursday, her office had received only 10 of the 18 death certificates in the official state coronavirus count.

Some coronavirus tests were still pending at the time of death.

“We are seeing some of them registering before they have the results back and they put in words like ‘probable’ or ‘suspected’ and they have the opportunity to go back and update that once they get the results back,” Crawford said.

The CDC issued interim guidance last month that allowed for “probable” or “likely” COVID-19 designations if the disease was assumed to be a contributing cause.

The new instructions go further in pulling in potential coronavirus deaths.

“An accurate count of the number of deaths due to COVID-19 infection, which depends in part on proper death certification, is critical to ongoing public health surveillance and response,” the updated guidance reads. “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.”

Certificates involving deaths without a confirmed COVID-19 finding will be put into a separate category, however.

To date, Minnesota has left it up to local medical examiners to decide if someone who died while exhibiting coronavirus symptoms should be tested.

Ehresmann said the Health Department has been made aware of two such cases. In only one of them was a postmortem test conducted. She said that is because that person was a resident in a congregate care setting where others had also fallen ill.

“We certainly couldn’t do that in every situation,” Ehresmann said.

She said officials are reluctant to order postmortem testing in all cases because it consumes time of medical examiners and requires use of precious personal protective equipment.

“We have to be cognizant of how we’re using those resources,” she said.

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