The issue of how to determine whether a person died from COVID-19 or some other underlying health condition has turned political in parts of the country.

Some politicians believe the numbers are inflated and have called for changes to how they are calculated. In Florida, state officials have been accused of hiding detailed data on COVID deaths from the public’s view.

On the opposite end of the spectrum, a recent university study found that the U.S. death toll from COVID-19 is likely to be a significant undercount of the actual number.

Physicians’ Role is Key

In Fresno County, the determination of cause of death — whether from COVID or another factor — is left to the discretion of doctors.

“It really just depends on the physicians’ judgement about exactly what part the COVID played,” said interim Fresno County Health Officer Dr. Rais Vohra during a online news conference with reporters on Monday.

“The common sense way to approach this is to say if the person didn’t have coronavirus, would they have died?” said Vohra. “Sometimes the answer is very easy and obvious. Sometimes the answer isn’t so obvious and then you just have to figure out how much role did the coronavirus play in the cause of death.”

Primary Cause of Death

Dr. Vohra says that a person that dies of another traumatic condition or unrelated cause of death could also test positive for COVID-19, but it wouldn’t be considered a coronavirus death. That would still count in the daily COVID-19 case counts for the county, but not in the death counts.

“It’s up to the physician who’s filling out that death certificate to determine whether the COVID — and all the things that we know about its biology at this point — contributed to the death in a meaningful way to where that would be named as the primary cause of death,” Vohra explained.

Under Reporting or Over Reporting?

KUSA Television in Colorado reported in May that Republican state Representative Mark Baisley claimed health officials were falsifying death records to inflate death totals from COVID-19.

Shortly after Baisley’s claim, the state of Colorado changed its reporting methodology, splitting the COVID death count into two categories.

• The number of deaths among people with COVID-19. This represents the total number of deaths reported among people who have COVID-19, but COVID-19 may not have been the cause of death listed on the death certificate.
• The number of deaths among people who died from COVID-19. This represents the total number of people whose death was attributed to COVID-19 as indicated on a death certificate.

After the new reporting protocol took effect, KUSA reported the total number of COVID-19 deaths dropped from 1,019 deaths to 878 the next day.

Florida Today has objected to the state Department of Health’s refusal to release medical examiner data to the public, alleging that the state may be underreporting deaths.

Scientific American reports data on excess deaths in the United States over the past several months suggest that COVID-19 deaths are probably being undercounted rather than overcounted.

No Uniform Reporting

The National Association of Medical Examiners says there is not a uniform death investigation system in the United States.

NAME says the U.S. has a variety of systems: elected lay coroners, physician medical examiners, sheriff-coroners, justices of the peace, state systems, county systems, among others. Each of these types of death investigation systems is governed by varying state laws. So a completely uniform approach counting COVID-19 fatalities is not possible, the organization says.

CDC Guidance

The Centers for Disease Control and Prevention provides guidance on how physicians and medical examiners should classify COVID-19 deaths.

The CDC states, “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), it is acceptable to report COVID–19 on a death certificate as “probable” or “presumed.”

The CDC concludes by saying keeping an accurate count of deaths due to COVID-19 is critical to ongoing public health surveillance and response.