The U.S. Center for Disease Control and Prevention’s (CDC) Sept. 2 weekly update on COVID-19 mortality in the U.S., which is published by the National Center for Health Statistics (NCHS), reported 170,566 deaths “involving COVID-19” that occurred between Feb. 1, 2020 and Aug. 29, 2020.1 During the same time period there were 1,841,678 deaths from all causes. About 94 percent of the death cases confirmed to be COVID-19-related involved other coinciding infections or underlying poor health conditions, including influenza, pneumonia, hypertension, diabetes, and heart disease.
Child Deaths from COVID-19 Rare
Of the deaths involving COVID-19, 79 percent were over age 65 and 31 percent were over age 85. Children under age 14 accounted for 0.00035 percent of deaths.
Fifty four percent of all deaths involving COVID-19 were male. Provisional death reports for COVID-19 peaked on Mar. 18, 2020, which also coincides with the peak for deaths from all causes in the United States.2 Hispanic and non-Hispanic black residents experienced disproportionate deaths involving COVID-19.3
Most COVID-19 Deaths in Nursing Hospitals, Inpatient Facilities
Almost 65 percent of deaths involving COVID-19 occurred in a nursing home or other inpatient healthcare facility, whereas 29 percent of all-cause deaths during the same period occurred in an inpatient setting. Roughly 21 percent of COVID-19 deaths occurred in nursing homes, while approximately 18 percent of all-cause deaths occurred in nursing homes.
Home is the most common location (33.6 percent) for people who die of all causes in the U.S.4
94 Percent of COVID-19 Death Cases Had Other Underlying Health Problems
For six percent of the coronavirus-associated deaths, COVID-19 was the only cause mentioned. For COVID-19-related death cases in persons who had other infections or conditions in addition to COVID-19, on average, there were 2.6 additional conditions or causes per COVID-related death. The most common respiratory conditions included influenza, pneumonia, respiratory failure, and adult respiratory distress syndrome.
Comorbid circulatory diseases included hypertension, cardiac arrest, ischemic heart disease, heart failure, and cardiac arrhythmia. Approximately 16 percent of the death certificates listed diabetes, and 11 percent stated that vascular and unspecified dementia contributed or was the cause of death. Three percent had intentional or unintentional injury, poisoning or other type of adverse event listed.5
Reports of COVID-19 Deaths Based on Provisional Data
The NCHS uses incoming data from death certificates to produce provisional COVID-19 death counts.6 These include deaths occurring within the 50 states and the District of Columbia.
When COVID-19 is reported as a cause of death—or when it is listed as a “probable” or “presumed” cause—the death is coded using a new ICD-10 code, and this code can include cases with or without laboratory confirmation.
Provisional death counts may not match counts from other sources, such as media reports or numbers from county health departments. Counts by NCHS often track 1–2 weeks behind other data, and may be delayed for the following reasons:
- Death certificates take time to be completed. There are many steps to filling out and submitting a death certificate. Waiting for test results can create additional delays.
- States report at different rates. Currently, 63 percent of all U.S. deaths are reported within 10 days of the date of death, but there is significant variation between states.
- It takes extra time to code COVID-19 deaths. While 80 percent of deaths are electronically processed and coded by NCHS within minutes, most deaths from COVID-19 must be coded by a person, which takes an average of seven days.
- Other reporting systems use different definitions or methods for counting deaths.
Provisional counts are not final and are subject to change. Counts from previous weeks are continually revised as more records are received and processed. Counts do not include all deaths that occurred during a given time period, especially for more recent periods.
However, NCHS estimates how complete their numbers are by looking at the average number of deaths reported in previous years. Death counts should not be compared across states since some states report deaths on a daily basis, while other states report deaths weekly or monthly. State vital record reporting may also be affected or delayed by COVID-19 related response activities.
CDC Guidelines for Certifying Coronavirus Deaths
Death certificates contain two parts. Part I is for reporting the sequence of conditions that led directly to death. The immediate cause of death, which is the disease or condition that directly preceded death and is not necessarily the underlying cause of death (UCOD), are reported first and the conditions that led to the immediate cause of death should be reported in a logical sequence in terms of time and etiology below it. The UCOD, which is “the disease or injury which initiated the train of morbid events leading directly to death or… the circumstances of the accident or violence which produced the fatal injury,” should be reported on the lowest line used in Part I.7
Other significant conditions that contributed to the death, but are not a part of the sequence in Part I, should be reported in Part II. Not all conditions present at the time of death have to be reported—only those conditions that actually contributed to death.8
In cases where a definite diagnosis of COVID-19 cannot be made, but it is suspected or likely (e.g., the circumstances are compelling within a reasonable degree of certainty), CDC reporting guidelines state:
It is acceptable to report COVID-19 on a death certificate as “probable” or “presumed.” In these instances, certifiers should use their best clinical judgement in determining if a COVID–19 infection was likely. However, please note that testing for COVID-19 should be conducted whenever possible.9
Jeff Lancashire, acting associate director for communications at the NCHS, said that, while 94 percent of death certificates that mention COVID-19 also listed other conditions, the underlying cause of death was COVID-19 in almost all of them. “ The underlying cause of death is the condition that began the chain of events that ultimately led to the person’s death,” he said. “In 92 percent of all deaths that mention COVID-19, COVID-19 is listed as the underlying cause of death.”10
Are CDC guidelines used to “pad” COVID-19 numbers?
Scott Jensen, MD, a family physician and Minnesota state senator, has publicly challenged the CDC’s guidelines for permitting presumed or probable cases of COVID to be listed on death certificates, saying they are “ridiculous” and could be misleading the public. Dr. Jensen states that the CDC’s death certificate manual tells physicians to focus on “precision and specificity,” but the coronavirus death certification guidance runs completely counter to that axiom.11
Dr. Jensen also reacted to Dr. Anthony Fauci’s response to a question about the potential for the number of coronavirus deaths being “padded,” in which the NIAID director described the prevalence of “conspiracy theories” during “challenging” times in public health. Dr. Jensen said:
I would remind him that anytime health care intersects with dollars it gets awkward. Right now Medicare has determined that if you have a COVID-19 admission to the hospital you’ll get paid $13,000. If that COVID-19 patient goes on a ventilator, you get $39,000; three times as much. Nobody can tell me, after 35 years in the world of medicine, that sometimes those kinds of things [don’t have] impact on what we do.
Most Americans Live with Chronic Disease
That so many COVID-19 deaths are associated with chronic disease highlights the risk factor inherent in underlying poor health conditions. The CDC reports that six in ten Americans lives with a chronic disease, and four in ten have two or more. These chronic diseases—heart, lung and kidney disease, cancer, diabetes, and Alzheimer’s disease—are the leading cause of death and disability, and are the leading drivers in the nation’s $3.5 trillion in annual health care costs,12 as well as raise the risk of severe illness from the SARS-CoV-2 coronavirus infection.13
Obesity is one of the most common underlying conditions increasing one’s risk for severe illness and about 40 percent of U.S. adults are obese. The more underlying medical conditions people have, the higher their risk.14
1 U.S. Centers for Disease Control and Prevention. Weekly Updates by Select Demographic and Geographic Characteristics. Sept 2, 2020
3 CDC. Health Disparities: Race and Hispanic Origin. Sept 2, 2020.
4 See Footnote 1.
7 CDC. Guidelines for Certifying Deaths Due to Coronavirus Disease 2019 (COVID-19) National Vital Statistics Service April 2020.
10 Funke D Fact check: Did the CDC ‘quietly’ adjust US coronavirus death tally? MSN Sept. 2, 2020.
11 Creitz C Minnesota doctor blasts “ridiculous” CDC coronavirus death count guidelines Fox News Apr. 9, 2020.
12 CDC. Chronic Diseases in America. Oct. 23, 2019.
13 CDC. CDC updates, expands list of people at risk of severe COVID-19 illness. June 25, 2020.