Are deaths of patients with, but not because of, COVID-19 recorded as COVID-19 deaths in the USA?

Question

A long Mises Institute article questions the US COVID-19 metrics.

It ends with this claim, quoted from a Daily Caller reporter's Twitter feed:

Here is Dr. Birx saying that the government is recording anyone who dies with coronavirus in the United States, regardless of any other health issue, as a death from coronavirus.

Is this simple claim true?

Also are inferences from it like

Fox News’s Brit Hume, who has previously tweeted that New York’s “fatality numbers are inflated”, appeared on Tucker Carlson’s late-night show on Tuesday to claim that any person with the virus is being counted as a Covid-19 death “regardless of what else may be wrong”. Carlson responded by saying, “There may be reasons people seek an inaccurate death count,” adding: “When journalists work with numbers, there sometimes is an agenda.”

The rightwing radio host Rush Limbaugh, who received the presidential medal of freedom from Trump, previously dismissed Covid-19 as similar to the “common cold” but changed tack recently to claim: “It’s admittedly speculation, but … what if we are recording a bunch of deaths to coronavirus which really should not be chalked up to coronavirus?”

... justified?

Answer 1

The larger context of Birx's quote is::

There are other countries that if you had a preexisting condition and let's say the virus caused you to go to the ICU and then have a heart or kidney problem some countries are recording as a heart issue or a kidney issue and not a COVID-19 death. Right now we are still recording it and we will I mean the great thing about having forms that come in and a form that has the ability to market as COVID-19 infection the intent is right now that those if someone dies with COVID-19 we are counting that as a COVID-19 death.

Specifically, she seems to be talking about people hospitalized because of covid19 who are counted as covid19 deaths even if they may have other conditions.

She later clarified:

Add another doctor who has now rejected this theory: Birx. She was asked about it at Wednesday’s briefing and referenced the point above about how the coronavirus exacerbates existing conditions.

“Those individuals will have an underlying condition, but that underlying condition did not cause their acute death when it’s related to a covid infection,” Birx said. “In fact, it’s the opposite.”

Fauci also rejects these claims as conspiracy theories:

“You will always have conspiracy theories when you have a very challenging public health crisis. They are nothing but distractions,”

Instead of overcounting, deaths are actually undercounted (see also here) because there is still a lack of testing:

The U.S. Centers for Disease Control and Prevention counts only deaths in which the presence of the coronavirus is confirmed in a laboratory test. [Emphasis added.] “We know that it is an underestimation,” agency spokeswoman Kristen Nordlund said.

A widespread lack of access to testing in the early weeks of the U.S. outbreak means people with respiratory illnesses died without being counted, epidemiologists say. Even now, some people who die at home or in overburdened nursing homes are not being tested, according to funeral directors, medical examiners and nursing home representatives.

Answer 2

There is actually a fairly standard statistical method of deriving event death numbers, when official sources aren't trusted: You check the total mortality during the event, and compare it to expected mortality for that period (based on historical data). This technique, sometimes called "mortality displacement", or "excess mortality", is a tool commonly used by historians and other professionals that has been employed worldwide to get more accurate mortality estimates from events like hurricanes, earthquakes, and tsunamis.

Of course when this is done, it almost always gives a number far higher than official death tolls. For instance, Wikipedia puts the Katrina Death toll in New Orleans at 1,464, while this excess mortality report shows about 2,751 more deaths than normal for the first six months of 2006 (on a lower population too, as the city had been evacuated). The main reason is it accounts for "butterfly effects".

For example, take a New Yorker who dies having an asthma attack at a hospital due to lack of respirators, who if they'd had that same attack the previous year they would have gotten on a ventilator and recovered. Mr.'s Hume and Limbaugh would clearly argue that's certainly not a Covid-19 death, even though that person would have lived if not for the pandemic.

This is why you should look askance at anyone who claims deaths are going overreported, due to some technicality. Actual deaths from events like these, due to the knock-on effects they have that are hard to account for, are invariably underreported. There's no good (non-political partisan) reason to be trying to lower death counts, in all but the most far-fetched contrived cases.

So how does excess mortality compare to official reported mortality in New York? Well, this graph from the New York Times 3 days ago tells an interesting story:

Flavor this with this bit of reporting:

The recent numbers are most likely an undercount. Even in normal times, death certificates take time to be processed and collected, and complete death tallies can take weeks to become final. This is especially true for cases involving coronavirus.

So that gives us a death toll in New York City alone as of 3 days ago of about 5,000 (likely to be revised upwards). The best numbers I can find for the date that graph was made (April 4) based instead of Covid 19 case reporting from the CDC said the city's Covid death toll at that point so far was 2,634^*. That means the CDC's numbers at that time weren't accounting for at least half the pandemic-induced deaths.

^{* - As of yesterday, April 12th, that total number of deaths for NYC had ballooned to 6,898}

Results from Europe back up these estimates. For example The Economist compared weekly excess deaths in some of the early affected regions in this chart:

And British data released on April 14 suggested something similar according to this BBC story which used this chart:

So results elsewhere analysing excess mortality are starting to look consistent with the idea that–whatever death certificates record–they are undercounting the effect of the virus on the total count of deaths.

Answer 3

See Provisional Death Counts for Coronavirus Disease which is a more-official but more delayed count of COVID-19 deaths by the US National Center for Health Statistics.

Here, the standard is "Deaths with confirmed or presumed COVID-19, coded to ICD–10 code U07.1".

There is also an explanation:

When a death occurs, a certifier (e.g. physician, medical examiner or coroner) will complete the death certificate with the underlying cause of death and any contributing causes of death. In some cases, laboratory tests or autopsy results may be required to determine the cause of death. Completed death certificate are sent to the state vital records office and then to NCHS for cause of death coding. At NCHS, about 80% of deaths are automatically processed and coded within seconds, but 20% of deaths need to manually coded, or coded by a person. Deaths involving certain conditions such as influenza and pneumonia are more likely to require manual coding than other causes of death. Furthermore, all deaths with COVID-19 are manually coded.

and

Coronavirus disease deaths are identified using the ICD–10 code U07.1. Deaths are coded to U07.1 when coronavirus disease 2019 or COVID-19 are reported as a cause that contributed to death on the death certificate. These can include laboratory confirmed cases, as well as cases without laboratory confirmation. If the certifier suspects COVID-19 or determines it was likely (e.g., the circumstances were compelling within a reasonable degree of certainty), they can report COVID-19 as “probable” or “presumed” on the death certificate

Standards for using the code U07.1 including in combination with other codes are further explained by the American Hospital Association .

Overall, COVID-19 must be an actual cause of death as listed on the death certificate to be included in the National Center for Health Statistics count.

Answer 4

Birx said that (CSPAN transcript timestamp 00:55:06), in the USA, if someone is hospitalised because of Covid-19 and dies in hospital from a pre-existing health condition - e.g. with the heart or kidney - it is recorded as a Covid-19 death. While some other countries would record the death was due to the heart or kidney problem, not Covid-19.

Therefore some people, including the Mises writer Ryan McMaken, are saying the death rate of Covid-19 is over-stated in countries like the USA with that counting method (the UK is doing the same) - the patient didn't die 'of' Covid-19, they died 'with' Covid-19, whereas other patients are dying 'of' Covid-19. In which case, the logic seems to go, a lockdown is less justifiable because the problem the lockdown is supposed to solve or mitigate is not as big as is claimed.

But the context is hospitalisation because of Covid-19 and exacerbation of the condition because of Covid-19. So to me it seems like a distinction without a practical difference.

And the excess death rate (which some people seem overly focussed on) is not the only concern - on top of that, we don't want excess rates of hospitalisation or intensive care or infections of medics (who then need care themselves and some die before their time).

The root of this seems to be the idea that this is nothing out of the ordinary, it's just like the flu or common cold and we wouldn't notice if we weren't looking. The standard of proof demanded essentially seems to be the deaths that we're trying to avoid.

Answer 5

Another useful document has turned up in tansy's answer (this concerns NVSS death coding), but I think the most relevant part from it is:

Will COVID-19 be the underlying cause?

The underlying cause depends upon what and where conditions are reported on the death certificate. However, the rules for coding and selection of the underlying cause of death are expected to result in COVID19 being the underlying cause more often than not.

So yea, they clearly say "more often than not", but not "always".

Answer 6

Yes, they do.

Let me explain by quoting Q and A on death certificates published by the CDC on March 24 (it's a document from an official goverment site):

What happens if the terms reported on the death certificate indicate uncertainty?

If the death certificate reports terms such as “probable COVID-19” or “likely COVID-19,” these terms would be assigned the new ICD code. It Is not likely that NCHS will follow up on these cases.

(My emphasisis)

And another one:

Should “COVID-19” be reported on the death certificate only with a confirmed test?

COVID-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death. (...) (See attached Guidance for Certifying COVID-19 Deaths)

(Their emphasis)

In other words - if they are not certain - even if they didn't do a COVID-19 test, it is attributed to COVID-19.

I read all cited in question articles and quoted Q&A transcript. It is clear that they will attribute deaths by many causes to COVID-19.

The question was "Are deaths of patients with, but not because of, COVID-19 recorded as COVID-19 deaths in the USA?"

The simple response was given by Dr. Birx on April 7, 2020 on Coronavirus Task Force Briefing:

Right now, we’re still recording it, and we’ll (...) if someone dies with COVID-19, we are counting that as a COVID-19 death.

Source: WhiteHouse Briefings Statements, C-SPAN (with timeline) (kudos: @Lag)

Answer 7

In the USA, a Covid19 death must be verified via testing or autopsy, which is standard for any death, before the NCHS adds the death to the official count.

In the case of Covid19, there is a new death code of U07.2 which allows for a death to be temporarily coded as a possible Covid19 death. If the death is coded U07.2, that death IS NOT included in the official death toll until such time that an autopsy or testing confirms the death is from Covid19.

The reason for this code is because Covid19 is new, hospitals can be overrun, and testing/autopsy capacity may not be able to handle the load. So, U07.2 is a temp code until the death can be correctly/officially/accurately determined.

Here's the PDF explaining U07.2

PDF