Among death certificates from calendar year 2020 listing COVID-19 and at least one other co-occurring diagnosis, the documentation is consistent with these deaths being attributable to COVID-19, according to a Morbidity and Mortality Weekly report from the Centers for Disease Control and Prevention (CDC).
Specifically, in 97% of 357,133 death certificates with COVID-19 and at least one other diagnosis, the documented chain-of-event and significant contributing conditions were consistent with those reported in clinical and epidemiologic studies to occur among patients with severe COVID-19–associated outcomes.
Only 5.5% of death certificates had COVID-19 without any other conditions listed. Attributability of death to COVID-19 could not be evaluated for these death certificates and represents an opportunity for improvement in documentation.
A small proportion (2.5%) of death certificates documented conditions that have not currently been described to be associated with COVID-19 critical illness or death. This was noted more often among those who died at home, declared dead on arrival, and whose manner of death was not natural. In particular, a higher percentage of decedents aged <18 years (35.2%) and 18 to 29 years (10.2%) did not have a chain-of-event or significant contributing condition listed on the death certificate, even though their death certificates did have at least one other diagnosis code along with COVID-19 in Part I or II.
Although these age categories constituted a very small proportion of the entire decedent group, the information on the death certificate provides a starting point for identification of other conditions that might contribute to mortality in younger persons. Detailed evaluation of death certificates might provide insights into rare and lesser-known conditions that are not yet understood to be associated with or contribute to death from COVID-19.
Among 357,133 death certificates with at least one other condition, 97% had a co-occurring diagnosis of a plausible chain-of-event condition (e.g., pneumonia or respiratory failure), or a significant contributing condition (e.g., hypertension or diabetes), or both.
These findings support the accuracy of COVID-19 mortality surveillance in the United States using official death certificates. High-quality documentation of death certificate diagnoses is essential for an authoritative public record.
Concerns have been raised that some deaths are being improperly attributed to COVID-19. Analysis of International Classification of Diseases, Tenth Revision (ICD-10) diagnoses on official death certificates might provide an expedient and efficient method to demonstrate whether reported COVID-19 deaths are being overestimated.
Overall, 70% to 80% of death certificates had both a chain-of-event condition and a significant contributing condition or a chain-of-event condition only; this was noted for adults aged 18 to 84 years, both males and females, persons of all races and ethnicities, those who died in inpatient and outpatient or emergency department settings, and those whose manner of death was listed as natural.
These findings support the accuracy of COVID-19 mortality surveillance in the United States using official death certificates. High-quality documentation of co-occurring diagnoses on the death certificate is essential for a comprehensive and authoritative public record. Continued messaging and training for professionals who complete death certificates remains important as the pandemic progresses. Accurate mortality surveillance is critical for understanding the impact of variants of SARS-CoV-2, the virus that causes COVID-19, and of COVID-19 vaccination and for guiding public health action.
Nearly 18% of death certificates had a co-occurring significant contributing condition only. This finding was more frequent for death certificates indicating that the death occurred in the decedent’s home (38.3%), a nursing home or long-term care facility (38.5%), or hospice facility (23.2%).
