How Colorado tracks COVID-19 deaths
For months, confusion — and in many cases misinformation — has swirled about how deaths from the novel coronavirus are tallied.
COVID-19 deaths have become a political flashpoint as people, including politicians, have questioned whether the counts were overblown — much to the frustration of those responding to the crisis.
“Somehow you’ve trusted me for more than a decade to offer you the truth about why people are dying and now suddenly, me, the hospitals, the doctors, the nurses, the public health officials, all of us are in cahoots and lying to you about this?” said Dr. Leon Kelly, the El Paso County coroner.
The coronavirus pandemic is a mass casualty event. More than 260,000 Americans, including more than 3,000 people in Colorado, have died with COVID-19 in less than a year.
Now, the Colorado Department of Public Health and Environment estimates that the number of people to die with COVID-19 in Colorado could range between 4,900 deaths to 7,400 deaths by the end of December, depending on the level of transmission of the disease.
Not only does this mean that deaths are increasing at a rapid pace, but that the state’s third wave of infections is poised to become more deadly than the spring surge. Colorado recorded 2,000 deaths among people with COVID-19 in September and over the weekend — just two months later — that number surpassed 3,000 fatalities. In the spring, it took the state two months to record 1,000 deaths.
“The amount of disease transmission that we’ve seen in Colorado in the last several days is really the highest it’s been since the beginning of the pandemic,” said Dr. Rachel Herlihy, the state epidemiologist during news briefing last week. “At that high rate of disease transmission we are unfortunately going to see an increasing number of deaths occur.”
Understanding the death toll of the pandemic is complex and can be confusing. This is because when we talk about COVID-19 deaths, it’s not just about who died from the disease versus those who died with the disease. It also involves looking at deaths indirectly caused by the pandemic.
“It is always a bit politically charged because different people have different motivations,” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado. “But it has played out in spades with the COVID pandemic because there is such a lot of political motivation to say, ‘Oh, it’s not that many people. It’s not so dangerous.’”
How do we know a death is from the novel coronavirus?
The first thing to understand with COVID-19 data is that there is a lag in hospitalization and death information because of the progression of the disease. When someone becomes sick with the novel coronavirus, it can take up to two weeks for symptoms to become severe enough that they are hospitalized.
That’s why after a spike in new coronavirus cases statewide, there isn’t an immediate increase in hospitalizations.
It also takes time for a COVID-19 death to be recorded by the state health department, creating a lag between new cases and fatalities that ranges from about three weeks to a month.
It is also important to know that the process of investigating, determining and reporting a death has not changed during the pandemic. State and local officials said they are recording COVID-19 fatalities as they would any other death.
The cause of death written on a death certificate is determined by one of three people: a coroner, a medical examiner or a doctor.
When one of these three people fill out a death certificate, they are making a medical judgment on why they think a person has died, Kelly said.
Many people who die from COVID-19 do so in a hospital. Autopsies aren’t often performed on the patients after they die because by the time of the death they have already been diagnosed with the novel coronavirus. And not everybody who is autopsied is tested for the disease.
“(Physicians) have a very good idea based on their experience and their expertise about giving primary diagnoses about why patients passed and the comorbidities that play a role in that,” said Dr. Vernon Naake, chief medical officer at North Suburban Medical Center.
In determining the cause of a death, medical professionals use what they call the “but for” principle: if “but for (a certain event),” a person would not have died at this specific time and place.
There are multiple ways this could unfold when someone dies from COVID-19. Take a case in which the cause of death listed is septic shock, but the death certificate also says that the septic shock was caused by another condition that came from acute respiratory distress syndrome, or ARDS. And in this case, the acute respiratory distress syndrome was caused by the novel coronavirus.
All of these conditions are written on a death certificate. But the reason a death is ruled as a COVID-19 fatality in such a scenario is because “but for COVID-19, none of these other things happen,” Kelly said.
Other conditions that the person may have had, such as obesity or diabetes, are not direct complications of COVID-19. However, they do put a person at an increased risk for severe symptoms, he said.
How the state health department reports COVID-19 deaths
Earlier this year, questions were raised about the accuracy of how the state health department tracks deaths when the novel coronavirus is not related to the cause of death. This scrutiny led to the state Department of Public Health and Environment changing the way it publicly reports COVID-19 deaths in May.
The department now reports both the total number of deaths due to the novel coronavirus and the number of fatalities among people who had COVID-19 at the time of their death, including when the disease was not the leading cause.
While they are broken up into two categories, most of the deaths in the latter count are fatalities caused directly by the disease. That is why there is often a narrow gap between the tally of those who died with COVID-19 and those who died from the disease.
As of Monday, the state health department has recorded 3,037 deaths among those with COVID-19 and 2,656 deaths due to the disease.
The reason for the discrepancy in the two numbers is due to how the data is collected by the state health department. The “deaths due to COVID-19” category comes solely from death certificate data, which has a lag of several weeks, so the count is expected to increase.
The “deaths among cases” category is more of a real-time count of fatalities that comes from hospitals or through contact tracing, case investigations and other methods. At times, this data is collected before a death certificate is registered and processed.
This category of death data helps the state health department “to really understand the severity of the disease and if it is changing over time,” said Herlihy, the state epidemiologist. “Ultimately, these two different systems of counting deaths line up very closely.”
Kelly, the coroner, said he reviews a spreadsheet created by public health officials of people that have been reported to have died from COVID-19 in his area. He goes through each death certificate and checks that it matches the cause of death and any other contributing factors that are listed on the spreadsheet. If it doesn’t match, then the death is removed from the spreadsheet.
“We’re doing all of this in real time,” Kelly said. “And so what happens is a lot of times, we’re trying to balance getting as much information out as quickly as we can because it’s relevant to people but also making sure what’s going on is correct, clear, concise and usable information.”
There are various reasons why deaths have initially been flagged as due to the novel coronavirus and then removed. For example, if a person dies while in a nursing home where there is an outbreak of the disease, health department officials could label it a probable COVID-19 fatality during their investigation into the outbreak.
But the death certificate may not list COVID-19 when it makes its way to the county coroner. Instead, it lists similar symptoms, such as shortness of breath or respiratory failure — both of which could come from another illness.
One of the challenges with the novel coronavirus is that it affects people differently. While the lungs are often the first organs affected by COVID-19, it can also damage kidneys and cause blood clots.
“Far more often I end up with cases that aren’t on the list,” Kelly said. “It kind of works both ways.”
Calculating the true toll of the pandemic
Many medical and public health experts believe the number of deaths from COVID-19 is undercounted because it’s likely that limited testing at the start of the pandemic led to missed diagnoses. This is often the case with other diseases, including influenza, because not everyone gets tested or diagnosed before they die, Herlihy said.
“Every number is an estimation,” said Wynia, with the Center for Bioethics and Humanities. “Every number is an estimation because even if you are counting individuals you are going to end up missing some.”
Or vice versa, he said.
Public health experts believe that the true toll of the pandemic extends beyond just tracking who died from the disease. It is also important to look at deaths indirectly caused by the pandemic. Public health experts will ultimately look at whether and how deaths could have been mitigated by the government response.
“If you want to understand the total impact of a disaster, that total impact includes the response to the disaster,” Wynia said.
Overall, deaths from all causes increased 20% in Colorado during the first six months of the pandemic. This is largely due to COVID-19, but other causes — from Alzheimer’s to overdoses — also saw significant spikes.
Tracking deaths indirectly caused by the pandemic is complex. There are multiple reasons that deaths are up, but one that has concerned physicians is that people may have delayed getting care because they feared getting COVID-19.
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