Are Patients Dying ‘from’ COVID or ‘with’ COVID?


George D. Lundberg, MD

June 05, 2020

Death is usually fairly easy to diagnose; cause of death, not so much. In fact, death certificates in the United States and around the world are notoriously wrong.

How does this happen? Death certificates are supposed to be completed by the “attending physician,” who is expected to know the most about the patient’s medical conditions. In a hospital setting, however, the physician who pronounces death may never have seen the patient before. Deaths that were unobserved or sudden often are referred to a medical examiner or coroner and may prompt an autopsy.

States must submit all death certificate information to the National Death Index for compilation into national vital statistics that guide public health and health policy decisions, and are the foundation of many vital statistics, such as the leading causes of death.

The Centers for Disease Control and Prevention (CDC) provides instructions for completing a death certificate online that are intended to make the process clear and relatively easy to do. Still, generations of American physicians have found it not at all easy to do this well.
One or Many Causes of Death

The death certificate form requires that an immediate cause of death be listed first. This is followed by a list of underlying (also referred to as predisposing) conditions that were contributory.

Take the example of influenza. The CDC notes a range of predisposing factors that could increase the risk for a serious complication from influenza, including death. These include an age of 65 years or older, pregnancy, chronic lung disease, heart disease, diabetes, and cancer.

We’re still learning about COVID-19, but similar factors seem to predispose to a more serious outcome: older age, chronic lung disease, serious heart conditions, being immunocompromised, and living in a long-term care facility.

Early on, there was confusion about whether this novel coronavirus was truly different or simply another form of the influenza virus. Emergency use ICD-10 codes were assigned by the World Health Organization for the COVID-19 outbreak, one for identified and one for suspected disease. Data on the use of those codes suggest that confusion may still linger.

The CDC website reports a provisional COVID-19 death count. This tally includes [a] thousands of deaths attributed solely to COVID-19. [b] A second category of deaths from both pneumonia and COVID-19 includes thousands more persons. [c] A third category of deaths lists three causes: pneumonia, influenza, and COVID-19. There are separate categories for deaths due to pneumonia or influenza alone, if you can believe that.

Have you got that straight? I am more confused than ever.

What we are seeing in the data is the long-standing practice of lumping influenza and pneumonia into a single category of death. COVID-19, it appears, has now been added to create a single, catch-all category.
Comparing Annual Causes of Deaths

The 1968 H3N2 pandemic was reported to have resulted in a million deaths worldwide, with over 100,000 of them in the United States. I studied autopsies conducted in the Los Angeles area during a period that included that pandemic and compared year-over-year pneumonia diagnoses. I found no real differences. As a result, I have been a long-term skeptic of numbers of annual deaths reported to be due to influenza.

As a pathologist with decades of autopsies under my belt, I have never examined an individual with proven influenza who did not also have a superimposed, likely fatal, bacterial infection. I queried 25 other pathologists to see if their experience was different, and most simply said “no.” One noted that H1N1 flu could cause diffuse alveolar damage and thus could be lethal all by itself. One responded with a “maybe.” Two described influenza patients with acute respiratory distress syndrome.

From 2010 to 2019, the CDC reported annual death rates from influenza that ranged from 12,000 to 61,000. These numbers are derived from a mathematical calculation of “influenza-associated deaths”; they do not rely on death certificate information.

Why such huge numbers? I would argue that it is the result of lumping influenza with bacterial pneumonia. Most patients are not dying from influenza but rather with influenza that is co-morbid with something else lethal.
