There are two avenues for the public reporting of COVID-19 deaths in Oregon:
- By health care facilities
- Through death certificates
1 - By health care facilities
Health care facilities provide one source of COVID-19 reporting. Because COVID-19 is a reportable infectious condition, healthcare facilities report cases of COVID-19 directly to Public Health. Later, if those patients pass away, their deaths are also reported.
The benefit of health care facility reporting is that it occurs in real time; the state can therefore report the death within days. However, this method may not capture deaths of Oregonians who die outside of Oregon. Further, this more real-time method means that death records have not yet undergone review by CDC.
2 - Through death certificates
Death certificates provide a second source of COVID-19 reporting. Every death occurring in Oregon, as well as deaths to Oregon residents occurring in another state, results in the production of a death record, also known as a death certificate. A death record contains the who, what, when, and where of a death. The cause of death section of a death record provides the 'why'. A death record is registered by OHA's Center for Health Statistics (CHS). All states forward death records to CDC's National Center for Health Statistics (NCHS), where the cause of death language is coded by nosologists (professionals trained to classify disease) using the International Statistical Classification of Diseases and Related Health Problems (ICD-10) medical classification. Once coded, the data are sent back to CHS. These data serve as the final cause of death description.
The benefit of reporting deaths that moved though the NCHS process is that these data represent the most accurate death counts. The cause of death statements have undergone review and been coded as U07.1. However, a death certificate takes an average of 8 days from the death to be registered by the state. This is before the NCHS review. The disadvantage is a delay of one to three weeks for data review and return to the state. The data lag means NCHS provisional death counts may not reflect all deaths reported by the state during a given time period, especially for more recent periods.
Cross-referencing sources 1 and 2
The two sources of COVID-19 reporting described above are cross-referenced. Each week, CHS compares the list of COVID-19 deaths reported to Public Health to the list of death records where the underlying cause of death is determined to be COVID-19 (i.e., the underlying cause of death is coded as U07.1). Staff then follow up on any deaths appearing on one list but not the other to determine how the death should be categorized.
Categorization of an Oregon COVID death
In Oregon a death is reported as a COVID death if:
- The death is of a confirmed or probable COVID-19 case within 60 days of the earliest available date among exposure to a confirmed case, onset of symptoms, or date of specimen collection for the first positive test; or
- The death results from any cause in a hospitalized person during admission or in the 60 days following discharge AND a COVID-19-positive laboratory diagnostic test at any time since14 days prior to hospitalization; or
- The death is of someone with a COVID-19-specific ICD-10 code listed as a primary or contributing cause of death on a death certificate, regardless of the dates of diagnosis or death.
The Death Certificate Process
The federal government has worked with states to collect and standardize death reporting since the early 1900s. Cause of death and a decedent's demographics are first recorded onto a death record. Death records are administered by the vital records program in the state where the death occurred. A death record is first filled out by a funeral director; the cause of death section is provided by a medical professional; and final registration is completed by a state's vital records office.
CDC considers “Cause of Death" to be a best medical opinion. CDC wants the cause of death to come from medical professionals.
People can die from more than one cause. CDC reporting conventions allow death certificates to capture the many conditions that contribute to a person's death.
The Cause of Death section on a death certificate has two parts:
Part I is the chain of events – the diseases, injuries, or conditions that directly cause the death. There are four lines available, 'a' through 'd'.
- Line 'a' is reserved for the immediate cause of death. The immediate cause of death is the final disease or condition that resulted in death.
- Line 'b' (and 'c' if necessary) are reserved for intermediate causes of death. The medical professional outlines the logical sequence of causes, or etiology that leads from the underlying cause of death to the immediate cause of death. Sometimes, there is no intermediate cause of death.
- The last line available is reserved for the underlying cause of death. This is the disease or injury that initiates the chain of events leading to the immediate cause of death.
Part II is where a medical professional may enter any medical conditions that contributed or exacerbated, but did not cause, the death.
Note that for a death by a virus, if the symptomology and circumstances are compelling, and the medical professional is convinced a specific virus caused the death, NCHS will accept a cause of death certification without laboratory confirmation. Again, CDC is looking for a medical opinion. CDC does, however, encourage confirmation of viral deaths with testing.
After a death record has been certified, the cause of death section is forwarded to CDC's NCHS. NCHS nosologists review the data, determine its accuracy, electronically and manually code the deaths using ICD-10 classification, and report back the final and coded cause of death to the states. Nosology is a branch of medicine that deals with classification of disease. To become competent takes many years of training. This process has been in place since the 1980s for all causes of death.