Counts Based on Death Certificates Underestimate COVID-19 Mortality Rates

Coronavirus Death

Relying on death certificate data to estimate COVID-19 fatalities results in a significant underestimation of the true mortality rate of the pandemic.

Researchers suggest ways to address challenges associated with measuring direct and indirect deaths attributable to COVID-19 pandemic.

Estimating deaths from COVID-19 based on death certificate data significantly underestimates the true mortality rate of the pandemic. Authors from Stanford University School of Medicine, Dana-Farber Cancer Institute, Harvard T.H. Chan School of Public Health, and Harvard Medical School describe how methods used to assess death tolls from disasters and other pandemics can be used to provide a more accurate picture of COVID-19 death rates now and moving forward. This means measuring direct, indirect, and excess deaths from COVID-19. Their proposed solution is published in Annals of Internal Medicine.

Overcoming challenges when calculating direct deaths will require a consensus among health care institutions, medical examiners, and public health agencies. The authors endorse 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, as currently done by the Centers for Disease Control and Prevention (CDC).

To calculate indirect deaths, the researchers recommend employing the CDC’s “but for” principle, which is used when ascertaining disaster-related deaths: “But for the [pandemic], would the person have died when he/she did?” Expected recommendations from the National Academies of Sciences, Engineering, and Medicine, could help with this. And to calculate excess deaths, publicly available, well-curated historical data, with published application programming interfaces is needed. According to the authors addressing these issues is critical to our understanding of the pandemic and its effect on human life.

The author of an accompanying editorial from Merck & Co. agrees that reliable and timely information about both direct and indirect mortality attributable to the COVID-19 pandemic is essential. The most accurate data to assess mortality in the United States from any cause are derived from the National Vital Statistics System (NVSS). Seeing as these data are crucial to informing health and emergency preparedness systems in the United States, they are worth greater investment.


“Every Body Counts: Measuring Mortality From the COVID-19 Pandemic” by Mathew V. Kiang, ScD, MPH; Rafael A. Irizarry, PhD; Caroline O. Buckee, DPhil and Satchit Balsari, MD, MPH, 11 September 2020, Annals of Internal Medicine.
DOI: 10.7326/M20-3100

“Measuring Pandemic Impact: Vital Signs From Vital Statistics” by Julie Louise Gerberding, MD, MPH, 11 September 2020, Annals of Internal Medicine.
DOI: 10.7326/M20-6348

2 Comments on "Counts Based on Death Certificates Underestimate COVID-19 Mortality Rates"

  1. If anything Covid deaths are overblown/overcounted – Dr Brix said early on ‘count everything as covid’.

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