How are COVID-19 deaths recorded? A crash course on death certificates

State experts provide clarification on how deaths are reported during coronavirus pandemic

On Tuesday, May 5 an Anchor Point man who was over 80 years old died at South Peninsula Hospital, becoming the 10th Alaska resident whose death was associated with the novel coronavirus and sparking confusion among some about how the state, and the country, record deaths during the COVID-19 pandemic.

The Alaska Department of Health and Social Services announced the death along with the City of Homer Unified Command, which released a joint press release from both the city and South Peninsula Hospital. The local press release stated that the man’s death was related to COVID-19, and the DHSS release stated that the man had become the 10th Alaska resident to die “due to COVID-19.”

However, following the state’s report of the death, neighbors and residents of the Anchor Point area took to social media to voice doubts about whether COVID-19 had actually been a major factor in the man’s death. They posted that he had other medical conditions which they believed caused his death.

Both the state and the local unified command team noted in their reports of the death that the man had preexisting or underlying medical conditions, information that has been shared in a few other COVID-19 death reports from the state. The man was first admitted to South Peninsula Hospital, where he then tested positive for COVID-19 and subsequently died on May 5.

The Homer News reached out to Dr. Anne Zink, Alaska’s chief medical officer, on May 8 asking for clarification on how COVID-19 deaths are classified and recorded. Rep. Sarah Vance (R-Homer) also posted on her Facebook page on May 8 that she had composed a letter to Zink and DHSS Commissioner Adam Crum seeking similar clarification.

In a response to the Homer News via Communications Manager Elizabeth Manning, experts from Alaska Health Analytics and Vital Records, a section of the Division of Public Health, weighed in with a written statement.

All deaths, regardless of the cause, get reported to the Centers for Disease Control and Prevention, according to the statement.

“If COVID-19 is on the death certificate as a contributing cause, it will be counted by CDC as a COVID-19 death,” the Alaska Health Analytics and Vital Records employees wrote.

Cause of death is determined by medical professionals attending to patients, not by state agencies or the CDC, according to the statement.

“CDC wants a medical professional’s best judgment for any cause of death,” the statement reads. “Generally, a cause of death is determined by the medical professional in attendance at the time of death, or by a medical professional who tended to the decedent.”

The Health Analytics and Vital Records statement explained that if a person is classified as having died “of” or “from” COVID-19, that means the disease was put on the death certificate as a primary or contributing cause of death. A person is said to die “with” COVID-19 if something else (like a car crash) was the primary cause of death but the person also had a positive confirmed case of the disease. In a case like that, COVID-19 would not be listed on the death certificate at all, the employees wrote in the statement.

Cause of death in and of itself is not always a simple or straightforward thing — there can be more than one cause of a person’s death listed on a death certificate, according to the response from the state. The section on a death certificate where the cause of death is listed has four separate lines for multiple causes to be recorded there.

The state experts explained that cause of death is recorded as a chain of events — the medical events that directly lead to a person’s death. The “immediate” cause of death is listed on the first line of a death certificate, and it’s the “final disease or condition that resulted in death,” the statement reads.

Next, there are two lines available for one or two “intermediate” causes of death to be listed.

“Here, the medical professional outlines the logical sequence of causes that leads from the underlying cause of death to the immediate cause of death,” the statement reads. “Sometimes, there is no intermediate cause of death.”

The fourth or last line on the death certificate is reserved for the “underlying” cause of death, according to the state’s response.

“This is the disease or injury that initiates the chain of events leading to the immediate cause of death,” the statement reads.

Often, there is no single cause of a person’s death, according to the response from the state. When states and the CDC compile lists of the leading causes of death for different states, they use the underlying cause of death — the one that gets listed last and that started the chain of events leading to death.

If a condition, such as COVID-19, is listed on any of the lines of a death certificate in the cause of death section, it is considered a “contributory cause” of death, according to the Health Analytics and Vital Records experts.

“If COVID-19 was put onto the death certificate by a medical professional, then the death would be counted as a COVID-19 death,” the statement reads.

Again, this would not necessarily mean that COVID-19 was the singular or leading cause of a person’s death, but rather a contributory cause. If COVID-19 was listed on the fourth line in the cause of death section of a death certificate, that would mean it was the underlying cause that began the chain of medical events leading to a death.

Alaska, along with other states, records all deaths and COVID-19-related deaths according to guidelines set out by the CDC. These guidelines state that often, COVID-19 will be the underlying cause of death that gave rise to other conditions such as pneumonia or acute respiratory distress syndrome.

The CDC guidelines give a scenario of a 34-year-old woman testing positive for COVID-19. In the hypothetical scenario, the woman develops pneumonia and gets put on a ventilator. In the example, she develops acute respiratory distress syndrome and dies. In this kind of scenario, the CDC states that the immediate cause of death would be listed as acute respiratory distress syndrome on the first line, with pneumonia on the line under that and COVID-19 on the third line. In the chain of events for this scenario, COVID-19 would have caused pneumonia, which led to respiratory distress, which caused the death.

Other preexisting conditions that were not the cause of death, but that contributed to it or exacerbated it, are called “co-morbidities” and are listed underneath the four lines in the cause of death section of a death certificate in a location called “Part II.” The CDC guidelines state these could be conditions such as asthma or chronic obstructive pulmonary disease.

“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,” the CDC guidelines state.

Homer Public Health Nurse Lorne Carroll also weighed in on how these deaths are recorded during the City of Homer’s Unified Command update to the Homer City Council at its Monday meeting.

Carroll reiterated that COVID-19 should be recorded on a death certificate if it was a contributing factor in a death, per national guidelines.

“That’s according to the attending physician’s best judgment,” he said. “It’s important to underscore that it can be difficult to determine the extent to which a person has mild COVID symptoms when they have multiple underlying diseases, so the Department of Health and Social Services lists COVID deaths the same way we do all other causes of deaths, with the same standard format, and we recognize that sometimes the contributing causes of death can be subtle in some folks that are suffering multiple serious conditions. So reporting deaths has always been a challenge and that is carried, most of it by the health care provider who is certifying the death on the death certificate.”

Even small infections can be the “tipping point” that ends a person’s life, Carroll said — for example, things like urinary tract infections for someone who already had multiple underlying conditions.

Underlying and preexisting medical conditions are one of the reasons health care workers see a higher rate of death in older people with COVID-19, Carroll said.

“Even something like dementia can be a contributing factor to COVID-19,” he said.

You can watch a video presentation by the CDC on how COVID-19 deaths are recorded here:

Reach Megan Pacer at