MDH: Here's why Minnesota COVID-19 death figures aren't inflated

It follows misinformation being shared on social media relating to death certificates.
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The Minnesota Department of Health has provided an explanation to why Minnesota's coronavirus death figures aren't being inflated, following confusion over death certificates and misinformation being spread online.

There have been 50 confirmed deaths of COVID-19 in Minnesota so far, but the confusion has arisen because of new guidance issued by the CDC last week about how doctors, registered nurses and other medical certifiers classify deaths that may have resulted from the virus.

Due to a chronic and ongoing shortage of testing kits, the guidance said that it is acceptable for a medical certifier to report COVID-19 on a death certificate "if the circumstances are compelling within a reasonable degree of certainty." Ie. If a doctor is confident based on what they know of the patient's symptoms and possible contact with other confirmed COVID-19 patients that their patient had the virus.

This means that COVID-19 can be listed as "probable" or "presumed" cause of death on the certificate. In Minnesota, they are listed as "suspected" or "probable" cases.

However, these deaths are not included in Minnesota's official COVID-19 fatality figures.

Minnesota Health Commissioner Jan Malcolm said that all of the 50 confirmed deaths in the state had "COVID-19" explicitly stated as the cause of death and have been confirmed by lab testing.

Cases of "suspected," "probable" or "possible" COVID-19 are not included in the figures.

Deaths where the medical certifier has listed COVID-19 as a "suspected" cause, it's classified differently and the Minnesota Department of Health then follows up with the doctor/RN/physician's assistant who submitted the certificate to ask whether a COVID-19 test had been conducted on the patient.

She said:

"There are death records that list the immediate cause of death as COVID-19 because it was confirmed through laboratory testing. When deaths are registered as 'suspected' or 'probable' COVID-19 we don't just leave it at that. The MDH office of Vital Records... follows up on these records. Staff contact the medical certifiers to ask them if testing came back to confirm COVID-19. When it has, the certifier updates the Cause of Death statement they have previously registered or provided. There may be records that stay as 'suspected' or 'probable' if the cause of death statement was written but testing was never ordered, or the health record doesn't get updated by the healthcare provided. These will be updated with ICD-10 codes that are related to but different from the confirmed COVID-19 deaths and will not be counted as COVID-19. This will give us better clarity of on the confirmed number of COVID-19 deaths versus deaths that may be but remain in a less certain status."

Malcolm says this is common practice in instances of major disasters such as hurricanes to provide greater clarity as to the potential number of deaths caused by the disaster.

Furthermore, the only people who can make corrections to the death certificate is the doctor/medical certifier who submitted it.

"Correcting the record and medical accuracy is important to us," Malcolm said. "That's why we're trying to do extra investigation. There is no political motivation to increase the number of deaths reported, we're just trying to clear up this confusion."

Malcolm also notes there were possible COVID-19 deaths before testing was available that can't be determined because the victims have been buried or cremated. These figures are also not included in any official counts.

The language matters too. Death certificates that state "corona infection," or "due to pandemic" were the cause of deaths are not counted. It must specifically state "COVID-19" on the death certificate.

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CDC reporting huge increase in pneumonia deaths

Malcolm's comments come after an interview between Fargo-based TV host Chris Berg and Minnesota State Senator and medical doctor Scott Jensen went viral. In it, Jensen explained how the CDC guidance was that doctors should consider putting COVID-19 as a cause of death where it's suspected, even in the absence of a positive test.

Jensen has since appeared on FOX News to express his concerns about the CDC guidelines, claiming "fear is a great way to control people," and his views have also appeared on the notorious conspiracy website Infowars.

Berg tweeted the interview claiming the Minnesota Department of Health was "inflating" COVID-19 death numbers, even though the guidance came from the CDC and even though Minnesota's death rate is lower than many other states.

"My assumption was there was confusion about what was the CDC's protocol and why. It was detailed it was attempting to correct records that were unclear, but it's not seeking to in any way inflate the numbers," Malcolm said.

One of the reasons the CDC is trying to expand its understanding of the extent of COVID-19 appears to be because of an apparent huge increase in the number of pneumonia deaths in the United States – with pneumonia a common complication of the coronavirus.

The last set of annual figures for pneumonia deaths provided by the CDC date back to 2017, when there were 49,175 deaths that weren't linked to influenza.

However, between the week ending Feb. 2, 2020, and Apr. 8, 2020, there have been 35,230 pneumonia deaths not linked to influenza. Around two-thirds of the pneumonia deaths seen in all of 2017 in a little over 2 months.

By the same time, the CDC had only been informed of just over 4,000 coronavirus deaths (there is a reporting lag, with total U.S. deaths now over 13,000).

Screen Shot 2020-04-09 at 2.45.48 PM

That suggests that with the lack of available testing for COVID-19, rather than being inflated, coronavirus deaths are being undercounted in the U.S.

The CDC also provides Minnesota-specific figures, where it states the CDC has been informed of 15 COVID-19 deaths (it's now at 50), but it had also been informed of 584 non-flu pneumonia deaths in that same two-and-a-half month period.

You can find this data here.

It's worth noting too that pneumonia is often the "immediate" cause of death, namely the "disease or condition that directly preceded death," but that it is not typically the "underlying cause of death," as it tends to follows infections – ie. COVID or flu – or inhaling liquids or chemical agents.

"Pneumonia is important to report in a cause-of-death statement but, generally, it is not the UCOD," the CDC notes. 

The New York Times also did a report on the undercount that you can find here.

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