Medicine and Public Issues11 September 2020

Every Body Counts: Measuring Mortality From the COVID-19 Pandemic

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    As of mid-August 2020, more than 170 000 U.S. residents have died of coronavirus disease 2019 (COVID-19); however, the true number of deaths resulting from COVID-19, both directly and indirectly, is likely to be much higher. The proper attribution of deaths to this pandemic has a range of societal, legal, mortuary, and public health consequences. This article discusses the current difficulties of disaster death attribution and describes the strengths and limitations of relying on death counts from death certificates, estimations of indirect deaths, and estimations of excess mortality. Improving the tabulation of direct and indirect deaths on death certificates will require concerted efforts and consensus across medical institutions and public health agencies. In addition, actionable estimates of excess mortality will require timely access to standardized and structured vital registry data, which should be shared directly at the state level to ensure rapid response for local governments. Correct attribution of direct and indirect deaths and estimation of excess mortality are complementary goals that are critical to our understanding of the pandemic and its effect on human life.

    As of mid-August 2020, seven months after the first reported case in the United States, more than 170 000 U.S. residents have died of coronavirus disease 2019 (COVID-19) nationally (1). The true number of deaths resulting from COVID-19, both directly and indirectly, is likely to be much higher and is crucial to get right because the attribution of deaths to a disaster has a range of societal, legal, mortuary, and public health consequences (2, 3).

    Death certificates are the primary source of official mortality statistics in the United States (4). Deaths can occur directly from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or indirectly from the effects of socioeconomic disruptions and interrupted health care during the pandemic. Unlike short-term natural disasters, where longer-term indirect effects are often a result of physical destruction of infrastructure like power outages or road closures, the U.S. pandemic has resulted in prolonged disruptions to the health system, society, and the economy that will intersect in complex ways, making it harder to correctly attribute indirect deaths to the pandemic. Such challenges with mortality estimation during disasters are not new, and several national and global efforts have attempted to standardize methodology (5, 6).

    In this article, we propose ways to address the current difficulties in attributing disaster deaths and in accurately estimating pandemic-related mortality (the Table provides a summary) (7, 8).

    Table. Summary of Mortality Estimation Methods: Usefulness, Limitations, and Solutions
    Direct Deaths From COVID-19

    For a death to be attributed to a disaster, the name and type of the disaster must be listed on the death certificate. In April 2020, the Centers for Disease Control and Prevention (CDC) published guidance for certifying COVID-19 deaths, recommending that “COVID-19” be listed as an underlying cause of death in part I of the death certificate for all cases confirmed by laboratory testing or presumed to be COVID-19 on the basis of clinical suspicion and epidemiologic probability (3). Most jurisdictions require that deaths involving threats to public health be referred to a medical examiner or coroner, who in turn may modify the death certificate to include COVID-19 as an underlying cause of death on the basis of laboratory confirmation or clinical and epidemiologic reasoning (9).


    Early in the pandemic, when the understanding of the clinical presentation of COVID-19 was still developing and testing rates were very low, it is likely that practitioners in the United States and elsewhere did not attribute all deaths in patients infected with SARS-CoV-2 to COVID-19 (10). The Council of State and Territorial Epidemiologists did not finalize a standardized case definition for COVID-19 until 5 April 2020, more than 4 months after the first case (11). Deaths from COVID-19 are coded manually, resulting in reporting delays and frequent updates to the official death count, with substantial variation across states (12).


    To account for possible underestimation from underdiagnosis of deaths attributable to COVID-19, the CDC began counting all deaths from pneumonia, influenza-like illness, and COVID-19 and subtracting the expected seasonal number of cases of pneumonia and influenza computed from trends in the previous 5 years (12). This method is currently in use and has been described in the technical notes on the provisional death counts for COVID-19 published by the National Vital Statistics System (12). At this point in the pandemic, better physician education would improve adherence to existing CDC guidelines, especially for documenting presumed cases.

    Indirect Deaths From COVID-19

    On 13 March, the COVID-19 pandemic was declared a national emergency under the Stafford Disaster Relief and Emergency Assistance Act and the National Emergencies Act. Although the 2017 National Vital Statistics System Reporting Guidance largely speaks to natural and manmade disasters and does not explicitly mention epidemics, the CDC defines a disaster as a “serious disruption of the functioning of society, causing widespread human, material, or environmental losses” (4). The guidance states that disaster-related deaths include indirectly related deaths from unsafe or unhealthy conditions; in the context of the COVID-19 pandemic, this would include loss of wages or housing, disruption to medical care from temporary suspension of outpatient facilities, hospital or emergency department avoidance, postponement of surgeries or chemotherapy, and loss of health insurance, all of which could result in premature deaths. There is growing concern that economic stagnation and social isolation may also increase “deaths of despair”—that is, deaths hypothesized to be due to psychological distress, such as those from accidental poisonings, suicide, and alcohol-related liver disease (13).


    For indirect deaths to be attributed on death certificates to a particular disaster, the disaster name and type must be listed in part I or II or as a response to question 43, “Describe how injury occurred” (4). Medical practitioners are generally not adequately trained in certifying disaster-related deaths and may not recognize that indirect deaths can occur weeks or even months after the event (14). As observed in Puerto Rico after Hurricane Maria, many practitioners are unaware of or unfamiliar with the CDC guidelines or have insufficient resources and time to pay due attention, and most deaths related to that disaster were left out of the initial official count (15).

    The attribution of indirect deaths from the COVID-19 pandemic, which could last for years, will not be straightforward because economic and social disruptions will intersect in complex ways to affect morbidity and mortality. There is also no global consensus on the timescale over which postdisaster deaths should be measured (16). The CDC recommends applying the “but for” principle when ascertaining disaster-related deaths: “But for the [pandemic], would the person have died when he/she did?” (4). This inclusive definition of indirect deaths is similar to that proposed by the Emergency Events Database maintained by the Centre for Research on the Epidemiology of Disasters, but it is far more expansive than that espoused in the Sendai Framework for Disaster Risk Reduction, which recommends counting only persons who died “during or directly after the disaster, as a direct result of the hazardous event” (17, 18).

    Such attribution is not without consequence. For example, some insurance policies may not cover expenses related to indirect deaths because the deaths were attributed to a “disaster,” for which payouts may be exempt. Conversely, a life insurance policy that would not otherwise cover suicides may be compelled to cover a disaster-related death if coverage extended to death in natural calamities. Attribution of death to a disaster has in the past enabled families to avail themselves of various tangible assistance provisions offered by the Federal Emergency Management Agency, including funeral assistance, although funds appropriated via the Coronavirus Aid, Relief, and Economic Security Act have not been allocated for funeral assistance during the COVID-19 pandemic (19).

    Proposed Solution

    Given the importance of COVID-19 attribution on the death certificate and absence of current federal guidelines on the matter, coordinated efforts to improve reporting at the institutional, city, and state levels are urgently warranted. Applying the CDC's “but for” test to include “COVID-19” in part II or question 43 is therefore a simple and feasible intervention that may greatly improve the reporting of indirect death, albeit with significant legal, financial, and political ramifications.

    Any guidelines on the matter published by public health departments should ideally be disseminated across key stakeholders involved in death certification, including junior physicians, other health care professionals, nursing homes, hospitals, hospital associations, medical societies, medical examiners, coroners, and funeral directors (9). Most providers have been required to take online training on COVID-19–related personal protection or clinical management guidelines. Requiring a short refresher training for death certification is not unreasonable given the salience of timely mortality surveillance.

    Estimating Excess Deaths

    Disaster mortality can also be estimated by comparing observed deaths versus expected mortality rates based on prior years. The difference between the 2, the “excess deaths,” includes direct deaths attributed to COVID-19; deaths from undiagnosed COVID-19; and, later in the pandemic as discussed before, indirect deaths from the effect of delayed care and disrupted livelihoods (20). As the pandemic continues for months or even years and intersects with other disasters, like the impending hurricane and wildfire season, causal attribution of indirect deaths will be harder or simply not knowable, necessitating the estimation of excess deaths to plan a timely, equitable response (21) (Figure).

    Figure. Schematic representation of deaths due to the COVID-19 pandemic.

    Early in the pandemic, deaths not directly attributed to COVID-19 included unrecognized deaths from severe acute respiratory syndrome coronavirus 2 (white band) because of evolving case definitions and inadequate testing. As the pandemic continues, it is likely that they will include a greater proportion of indirect deaths (dark green band) from disruptions to society and health systems caused by the pandemic.


    The estimation of excess mortality requires both modeling and timely data from reliable civil registries and vital statistics records, and it may be associated with significant margins of uncertainty (20, 22). The mortality baseline varies from year to year and can be influenced, for example, by heat waves, the severity of an influenza season, distress migration after a disaster, and stochasticity (6). It should therefore not be represented as a number, but rather a range. The delays and variation in COVID-19 testing strategies and reporting further complicate estimation of excess deaths and also contribute to uncertainty (10).

    Proposed Solutions

    Excess mortality estimates must include uncertainty associated with both the baseline and new mortality ranges. This uncertainly must be clearly communicated. To build and fit useful statistical models promptly, epidemiologists need publicly available, well-curated historical data, with published application programming interfaces. The abrupt discontinuation of established reporting mechanisms to the CDC and engagement of contracted private partners while in the throes of the pandemic is unusual, and it disrupts data streams at a critical time (23). As much as accurate mortality estimates may have political effects, as seen in Puerto Rico, they are also subject to political interference, where state policies can erect hurdles to gathering timely and reliable data, even if inadvertent (5). These data would ideally be available in near real time from the states before being sent to the CDC or Department of Health and Human Services for further coding or analysis, allowing scientists prompt access to the most up-to-date information from each state.


    Accurate mortality estimates have real-world consequences (20). Although official counts have historically relied on disaster attribution in death certificates, during this pandemic the CDC, state agencies, and researchers have also been estimating all-cause excess mortality (24, 25). The approaches we describe are complementary, but they present the following 4 sets of challenges.

    First, improving COVID-19 attribution for both direct and indirect deaths on death certificates will require concerted efforts (and consensus) now among health care institutions, medical examiners, and public health agencies.

    Second, actionable mortality estimation requires easier and timely access to structured vital registry data and improved consensus on standardization and methodology, which may be provided by the ad hoc committee on best practices in assessing mortality and significant morbidity following large-scale disasters, constituted by the National Academies of Sciences, Engineering, and Medicine, whose recommendations are due this year (26).

    Third, mortality data are first collected at the state level and should be shared directly by the states to minimize reporting delays and ensure that the localities most affected by COVID-19 outbreaks have readily available information.

    Finally, disaggregated mortality data on age, gender, and race (for example, in part II of the death certificate) provide critical information on the differential effect of the pandemic on U.S. society; these data must be released, although with privacy-preserving safeguards to prevent stigmatization and discrimination of individuals or groups (27, 28). To prevent reidentification from mortality data published by the National Center for Health Statistics, for example, all subnational death data are already suppressed when cell sizes are smaller than 10.

    Estimates of direct, indirect, and excess deaths are critical to our understanding of the pandemic and its effect on human life. They also illuminate the weaknesses in our health system and societal structures. It is imperative to get them right.



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    Joshua D. Brown14 September 2020
    Counting COVID-19 sequelae as direct deaths.

    Kiang et al. summarize the current challenges and consequences in counting mortality during the coronavirus disease 2019 (COVID-19) pandemic.1 Direct, indirect, and excess mortality are defined, with the latter being underreporting of both direct and indirect events. It is the author’s opinion that one category of death is not addressed although it is likely a significant contributor to what should arguably be defined as direct deaths. 

    In epidemiology and during the pandemic, a disease severity metric, “case fatality rate (CFR),” has been widely reported. CFR is calculated as deaths among confirmed or probable cases. The definition of CFR used by the World Health Organization implies a death should count towards the numerator when there is “no clear alternative cause” and there is “no period of complete recovery.” 2

    In addition to the acute respiratory distress syndrome it is, COVID-19 has also been described as a disease of the circulatory system with systemic inflammation, coagulopathies, and myocarditis, among other pathologies.3 Growing evidence links COVID-19 to increased risk of heart attacks, strokes, venous thromboembolism, etc. both during and after hospitalization.3 This is not dissimilar to what we observe with typical pneumonia4 – though COVID-19 appears to generate much higher risks both pre- and post-discharge.

    The challenge is attributing these and other events to COVID-19. As Gerberding describes,5 physicians are not well trained to attribute cause of death and may not attribute a heart attack or stroke to COVID-19. More challenging is attributing these cases post-discharge. If COVID-19 is to be characterized as both an acute respiratory distress syndrome and an inflammatory syndrome, then the CFR definition implies that both must subside before COVID-19 is no longer implicated. Otherwise, the medical community should recognize direct sequelae resulting from pathological changes associated with COVID-19 as direct deaths.

    The challenge remains then to operationalize what is a “case” and how long of a window post-discharge is amenable to the CFR definition. While this may vary, practically it is a period where inflammation and other effects of COVID-19 are not fully subsided. Without strong evidence for this length of time, but growing evidence of long-term complications, fixed post-discharge intervals can be defined, similar to how 30-day readmissions are assessed. Within this period, recognizing that “full recovery” from COVID-19 has not occurred, a more accurate picture of direct deaths due to COVID-19 clinical sequelae can be adequately captured.


    1. Kiang MV, Irizarry RA, Buckee CO, Balsari S. Every Body Counts: Measuring Mortality From the COVID-19 Pandemic. Annals of Internal Medicine. 2020/09/11 2020.
    2. World Health Organization. Estimating mortality from COVID-19. 2020; Accessed September 11, 2020.
    3. Zheng Y-Y, Ma Y-T, Zhang J-Y, Xie X. COVID-19 and the cardiovascular system. 2020;17(5):259-260.
    4. Musher DM, Abers MS, Corrales-Medina VF. Acute Infection and Myocardial Infarction. N Engl J Med. Jan 10 2019;380(2):171-176.
    5. Gerberding JL. Measuring Pandemic Impact: Vital Signs From Vital Statistics. Annals of Internal Medicine. 2020/09/11 2020.
    Brian Murphy, Arnold Zidulka19 January 2021
    Excess Mortality

    Annals Of Internal Medicine

    In the recent article by Kiang et al (1) the authors state that 170,000 U.S. residents died of COVID-19 as of August, 2020.  Many of the difficulties in making death calculations and estimates are described.  We concur with the authors emphasis on the importance of accurate death statistics in determining public policy, especially in these difficult times during the pandemic.  However, in the analysis of excess mortality, one serious calculation factor appears to have been overlooked by the authors.

     From the CDC article which estimates excess mortality as a result of Covid-19 (2), the estimate of current 2020 mortality is compared to the average of the same months of the 2017, 2018 and 2019 years. It turns out that the mortality between these years is increasing between 1.0 and 1.1% per year. If one takes the linear extrapolated estimated mortality for 2020, it should be between 1.0 and 1.1% higher (this extrapolation also holds for the years 2015 to 2019 inclusive). When the CDC compared 2020 mortality, it did not compare it to this higher estimated mortality. Rather, it compared it to the average of the 2017 to 2019 years, which in a much lower mortality number. 

    This resulted in the CDC overestimating the excess mortality that occurred in 2020 from Covid-19. Our calculations suggest that the mortality from Covid is much lower, resulting in an excess mortality of only 127,835, rather than 299,028 (3).  It is noteworthy that this excess mortality is now similar to the 1958 influenza pandemic when there were no lock downs.  Based on the exaggerated calculations by the CDC, many lock downs occurred across North America.

    1.        Mathew V. Kiang, Rafael A. Irizarry, Caroline O. Buckee and Satchit Balsari Every Body Counts: Measuring Mortality From the COVID-19 Pandemic, Annals of Internal Medicine, December 15, 2020

    2.       "Excess Deaths Associated with COVId-19, by Age, Race and Ethnicity – United States,  January 26-October 3, 2020."

    3.       Murphy, Brian. “Excess Mortality – A Better Estimate of COVID-19 Deaths” December 4, 2020.

    Brian Murphy, B. Eng., Ph.D.

    Vice President

    ClinDatrix, Inc.

    Irvine, CA, USA


    Arnold Zidulka MD, FRCP(C), 

    Associate Professor of Medicine, McGill University

    Montreal, Quebec, Canada

    [email protected]