Vital Statistics Reporting Gu idance

U.S. Department of Health and Human Services • Centers for Disease Control and Prevention • National Center for Health Statisti cs • National Vital Statistics System 2

Certifying deaths due to COVID–19

If COVID–19 played a role in the death, this condition should be specified on the death certificate. In many cases, it is likely that it will be the UCOD, as it can lead to various life- threatening conditions, such as pneumonia and acute respiratory distress syndrome (ARDS). In these cases, COVID–19 should be reported on the lowest line used in Part I with the other conditions to which it gave rise listed on the lines above it. Generally, it is best to avoid abbreviations and acronyms, but COVID–19 is unambiguous, so it is acceptable to report on the death certificate. In some cases, survival from COVID–19 can be complicated by pre-existing chronic conditions, especially those that result in diminished lung capacity, such as chronic obstructive pulmonary disease (COPD) or asthma. These medical conditions do not cause COVID–19, but can increase the risk of contracting a respiratory infection and death, so these conditions should be reported in Part II and not in Part I. When determining whether COVID–19 played a role in the cause of death, follow the CDC clinical criteria for evaluating a person under investigation for CO VID–19 and, where possible, conduct appropriate laboratory testing using guidance provided by CDC or local health authorities. More information on CDC recommendations for reporting, testing, and specimen collection, including postmortem testing, is available from: https://www. cdc.gov/coronavirus/ 2019-nCoV/hcp/cli nical-criteria. html and https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance- postmortem-speci mens.html . It is important to remember that death certificate reporting may not meet mandatory reporting requirements for reportable diseases; contact the local health department regarding regulations specific to the jurisdiction. 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.” In these instances, certifiers should use their best clinical judgement in determining if a COVID–19 infection was likely. However, please note that testing for COVID–19 should be conducted whenever possible.

Common problems

Common problems in cause-of-death certification include: 1. reporting intermediate causes as the UCO D (i.e. , on the lowest line used in Part I), 2. lack of specificit y, and 3. illogical sequences. Intermediate causes are those conditions that typically have multiple possible underlying etiologies and thus, a UCOD must be specified on a line below in Part I. For example, pneumonia is an intermediate cause of death since it can be caused by a variety of infectious agents or by inhaling a liquid or chemical. Pneumonia is important to report in a cause-of-death statement but, generally , it is not the UCOD. The cause of pneumonia, such as COVID–19, needs to be stated on the lowest line used in Part I. Additionally, the reported UCOD should be specific enough to be useful for public health and rese arch purposes. For example, a “viral infection” can be a UCOD, but it is not specific. A m ore specific UCOD in this instance could be “COVID–19.” All causal sequences reported in Part I should be logical in terms of time and pathology . For example, reporting “COVID–19” due to “chronic obstructive pulmonary disease” in Part I would be an illogical sequence as COPD cannot cause an infection, although it may increase susceptibility to or exacerbate an infection. In this instance, COVID–19 would be reported in Part I as the UCOD and the COPD in Part II. While there can be reasonable differences in medical opinion concerning a sequence that led to a particular death, the causes should always be provided in a logical sequence from the immediate cause on line a. back to the UCOD on the lowest line used in Part I.

Manner of death

The manner of death, sometimes referred to as circumstances of death, is also reported on death certificates. Natural deaths are due solely or almost entirely to disease or the aging process (8). In the case of death due to a COVID–19 infectio n, the manner of death will almost always be natural.

When to Refer to a Medical Examiner or

Coroner

Some jurisdictions have requirements for referring deaths involving threats to public health to the medical examiner or coroner, so certifiers should follow the regulations in the jurisdiction in which the death occurred. As always, if a death involved an injury, poisoning, or complications thereof, then the case should be referred. The local medical examiner or coroner should be consulted with questions on referral requirements.

Conclusion