COVID-19 deaths not always clear-cut
Indiana expert says despite ‘gray zone,’ big picture is unmistakable
COVID-19 is a deadly virus, but should it be listed as a primary or possible cause of death on every COVID-related death?
“People want a clear answer, a black and white answer, about this issue. They do not like living in a gray zone. Yet COVID has pushed us well into a gray zone,” said Dr. Shaun Grannis, vice president of data and analytics at Regenstrief Institute in Indianapolis.
“We need to cut through the nonsense, the polarization and the politics to get to the facts,” he said. “We need to establish the clear principles that we know.”
The clearest principle is that the U.S. experienced a 20% increase in the category of “excess deaths” since the pandemic began in early 2020.
Understanding this total death toll during the current pandemic requires measuring what’s called “excess all-cause mortality,” which provides an estimate of the additional number of deaths from any cause — not just from coronavirus infections — beyond what is normally expected during a given period of time, according to the U.S. Census Bureau.
This measure includes anyone who died from COVID-19 as well as those who died from other reasons related to the pandemic.
“It’s obvious that COVID is a factor,” Grannis said. “Determining which cause of death factor is the primary one is not always a debate that someone can win or lose, scientifically or with exact data. So I think we need to be
measured about this issue by bringing in both perspectives to better understand the larger issue.”
The larger issue is this: 2020 was the deadliest year in U.S. history, with deaths topping 3 million for the first time. Nearly 500,000 of those Americans died from COVID-related causes or reasons, according to the Centers for Disease Control and Prevention. This figure includes more than 12,000 deaths in Indiana, and 22,000 deaths in Illinois, both from confirmed and probable cases.
The state of Indiana says “probable” counts when a physician listed COVID-19 as a contributing cause of death for a patient but no positive test was documented on that individual.
The clinical diagnosis of COVID-19 can be made using the patient’s X-ray, CT scan of the chest and the full clinical picture. Probable counts are not included in the total confirmed counts. These counts are subject to change as additional lab data or information is reported to Indiana State Department of Health.
COVID-related deaths certainly contributed to the one-year 16% jump in statewide mortality statistics, with the coronavirus factoring into 93% of COVID-19 deaths and 64% of hospitalizations for Hoosiers age 60 and older.
“Does this mean that COVID caused all of these deaths? Not necessarily. It certainly was an inciting factor,” Grannis said. “How many of these deaths? It’s hard to say at this point. We may never know.”
Another major point with this issue is that life expectancy in the U.S. dropped a staggering one year during the first half of 2020. And public health experts predict this figure to worsen when the second half of 2020 is factored in, as well as the first half of 2021 and beyond.
“This is a huge decline,” Robert Anderson, who oversees such stats for the CDC, told The Associated Press. “You have to go back to World War II, the 1940s, to find a decline like this.”
This startling point circles back to the statistical anomaly of excess deaths, as Grannis kept circling back to during our phone interview.
“The number of people who die each year is usually a predictable pattern. In 2020, about 20% more people died in our country. This is an aberration and unusual,” he said.
But why? People may have avoided health care in the pandemic. Other potential factors include a poor diet, lack of activity, decades of smoking or preexisting conditions such as heart disease and diabetes that were exacerbated by COVID.
If the decedent tested positive for COVID, the virus also gets placed on the death certificate. Many of these people likely died with COVID, not from COVID, Grannis said.
“There will always be some controversy with this subject,” he said. “It’s conjecture to argue that some of these COVID victims would have died anyway in 2020. There’s a probability associated with this.”
The National Center for Health Statistics uses incoming data from death certificates to produce provisional COVID-19 death counts, identified using a new ICD — 10 code. When COVID is reported as a cause
of death — or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation.
It’s important to note: Provisional counts are not final and are subject to change.
In Indiana, death reporting forms have four fields for physicians to fill out. A causal chain of factors should be cited. For instance, heart disease, diabetes, cancer and COVID. Physicians are expected to list the primary causes of death.
“It’s unquestionably complicated,” Grannis said. “There can be conjecture over which of the four elements actually caused someone’s death. Clearly, for some people the causative agent was COVID. The virus pushed their body over the edge.”
Grannis became associate director of the Clem McDonald Center for Biomedical Informatics at Regenstrief in 2015. For all the figures he sorts through, he never figured he would be interviewed for dozens of stories, including more than 20 TV interviews, about a pandemic. His message remains clearer than the complexities surrounding COVID deaths.
“People need to learn the ability to ferret out facts and process sciencebased information,” he said.
How? Through critical thinking, open mindedness and scientific inquiries. Not through political prisms, conspiracy theories, and fearful reactions to a frightening public health crisis.
“All of this is missing from the national dialogue today,” Grannis said.