A May 16 2020 Facebook post claiming that Colorado had revised its COVID-19 death count from 1150 to 878 and “ADMITTED” that the state was including deaths from other causes in its count to make the virus seem more lethal took off across social media platforms:
A text-based status update image in bold letters blared:
BREAKING: Colorado just REDUCED their Covid death toll from 1150 to 878 after their Department of Health ADMITTED they were counting those who tested positive for the virus but died from OTHER CAUSES!🙄
Pass it on!
Rumor Strains Mutate Like Viruses
Based on share count alone, the post resonated with many Facebook users, as it was clearly part of a larger and more pervasive rumor, which held that various state and federal entities sought to exaggerate the mortality rate of COVID-19, engaging in a nationwide (and possibly global) conspiracy to attribute virtually any death due to any cause to novel coronavirus in order to keep “the masses” frightened and compliant:
Before examining the claim, it is worth noting that the numbers cited in the post (1150 and 878, respectively) were not indicative of any grand conspiracy to fleece the public into fearing a threat where none existed. The cited adjustment amounted to a decrease of 23 percent, which seemed more in line with a change in record-keeping than a plot to bamboozle Colorado residents with crafty math.
As we noted in our fact check embedded above (regarding whether the Centers for Disease Control and Prevention, or CDC, “ordered” all deaths in the United States to be recorded as COVID-19), nomenclature frequently used early in the pandemic included the term “novel coronavirus.”
Why a Novel Coronavirus Complicates Facts and Figures
A CDC page last updated in April 2019 (before SARS-CoV-2 even leapt from animals to humans) covering the well-known threat of novel pathogens explains the “novel” element of “novel coronavirus” and the challenges presented by newfound infectious diseases. In that particular page, the CDC explains that novel influenza strains are a constant looming threat, due both to the fact that little information exists to combat new pathogens, because they are new, and because each novel virus is a potential pandemic:
Some novel influenza A viruses are believed to pose a greater pandemic threat than others and are more concerning to public health officials because they have caused serious human illness and death and also have been able to spread in a limited manner from person-to-person. Novel influenza A viruses are of extra concern because of the potential impact they could have on public health if they gain the ability to spread easily from person to person, which might cause the next influenza pandemic.
As we all now know, the “next pandemic” was nearer than the public expected in April 2019, and it wasn’t influenza — it was a new strain of coronavirus. As explained by the University of Colorado in March 2020, the virus posed the threat it did (and does) precisely because it was not just new to those sickened with it, but also to those attempting to formulate a treatment plan.
Not only was medicine ill-equipped to address the novel threat, so too were those who contracted it:
Why is the new coronavirus so contagious and spreading so quickly? Is there something about it that makes it a super villain among viruses? Or is it just behaving the way viruses do?
What makes the new coronavirus so dangerous to humans is simply that it’s “novel,” meaning it’s new to humans, so we don’t have any way to fight it.
“This is the first time it’s ever circulated in humans,” [Dr. Dan] Pastula said.
So, the virus isn’t more powerful, per se, than other viruses. But when it enters the human body, we have no pre-existing defenses since our bodies don’t immediately recognize it as a dangerous intruder. Imagine an old, walled medieval town. If this virus were a disguised attacker arriving at the town’s protective walls, but open gates, the guards would not immediately know to be suspicious. With this coronavirus, it’s as if the guardians of our cells have kept the gates open and let the coronavirus in without immediately recognizing its danger.
Then the virus starts to spread.
“It gets in and hijacks the human cell’s machinery. Instead of the cell doing what it’s supposed to do, the virus overrides the cell’s normal programming and turns it into a machine to make more of the virus. It goes and goes and goes until the immune system stops it,” Pastula said.
Updating Records During an Active, Severe Pandemic
Challenges inherent in novel viruses stemmed from other places too. As SARS-CoV-2 made its way across Washington and leveled New York City, doctors scrambled to save the sick and hospitals struggled to protect workers.
Further, as the medical system struggled under the wake of a burgeoning pandemic, medical record-keeping required edits too. Initial victims of the virus in Wuhan, China were thought to have an aggressive form of pneumonia, as reflected in a January 9 2020 World Health Organization (WHO) statement.
That odd snapshot in time illustrated precisely how little medicine knew about a virus on the verge of infecting millions globally:
WHO Statement regarding cluster of pneumonia cases in Wuhan, China [9 January 2020 Statement China]
Chinese authorities have made a preliminary determination of a novel (or new) coronavirus, identified in a hospitalized person with pneumonia in Wuhan. Chinese investigators conducted gene sequencing of the virus, using an isolate from one positive patient sample. Preliminary identification of a novel virus in a short period of time is a notable achievement and demonstrates China’s increased capacity to manage new outbreaks.
Initial information about the cases of pneumonia in Wuhan provided by Chinese authorities last week – including the occupation, location and symptom profile of the people affected – pointed to a coronavirus (CoV) as a possible pathogen causing this cluster. Chinese authorities subsequently reported that laboratory tests ruled out SARS-CoV, MERS-CoV, influenza, avian influenza, adenovirus and other common respiratory pathogens.
One hundred and twenty-eight days passed between the WHO’s January 9 2020 statement that a novel coronavirus was identified in Wuhan, and the appearance of the Facebook status above — or just over four months. It was easy to lose sight of just how novel the novel coronavirus was.
In terms of record-keeping (a vital but often overlooked aspect of medical administration), SARS-CoV-2 of course posed its own challenges. This aspect of hospital administration was one we touched upon on our original page about purportedly exaggerated COVID-19 case counts — because codes for COVID-19 fatalities and related deaths were not even created until at least late March 2020.
As we noted on that previous page, a National Vital Statistic System (NVSS) memo issued on March 24 2020 [PDF] explicated the ways in which past, present, and future record-keeping would be evaluated, adjusted, and recalculated based on the introduction of the new codes.
In that memo, NVSS outlined scenarios wherein cases would be initially coded, evaluated, re-coded, and adjusted where necessary. It was evident on a layperson’s review that the introduction of new codes would not result in static data from March 24 2020 onward:
The WHO has provided a second code, U07.2, for clinical or epidemiological diagnosis of COVID-19 where a laboratory confirmation is inconclusive or not available. Because laboratory test results are not typically reported on death certificates in the U.S., NCHS is not planning to implement U07.2 for mortality statistics.
Will COVID-19 be the underlying cause?
The underlying cause depends upon what and where conditions are reported on the death certificate. However, the rules for coding and selection of the underlying cause of death are expected to result in COVID-19 being the underlying cause more often than not.
What happens if certifiers report terms other than the suggested terms?
If a death certificate reports coronavirus without identifying a specific strain or explicitly specifying that it is not COVID-19, NCHS will ask the states to follow up to verify whether or not the coronavirus was COVID-19. As long as the phrase used indicates the 2019 coronavirus strain, NCHS expects to assign the new code. However, it is preferable and more straightforward for certifiers to use the standard terminology (COVID-19).
What happens if the terms reported on the death certificate indicate uncertainty?
If the death certificate reports terms such as “probable COVID-19” or “likely COVID-19,” these terms would be assigned the new ICD code. It is not likely that NCHS will follow up on these cases. If “pending COVID-19 testing” is reported on the death certificate, this would be considered a pending record. In this scenario, NCHS would expect to receive an updated record, since the code will likely result in R99. In this case, NCHS will ask the states to follow up to verify if test results confirmed that the decedent had COVID-19.
Colorado’s Adjusted COVID-19 Death Toll
The status update above claimed that Colorado’s Department of Health “ADMITTED” it revised its number of COVID-19 fatalities down 23 percent from 1150 to 878, again, arguably a fairly reasonable adjustment to occur as the manner in which deaths were tabulated and classified actively changed.
The numbers cited in the meme were provided in a May 15 2020 Denver Post article, which contained significant context lacking in the Facebook post above, although for some reason this update did not link to the article. Its headline alone pointed to an oddly political angle to quibble over how many COVID-19-positive patient deaths in Colorado ought to be attributed to the virus: “As coronavirus deaths become political flashpoint, Colorado changes how COVID-19 fatalities are publicly reported.”
Colorado’s health department changed the way it publicly reports coronavirus deaths [on May 15 2020], introducing a second category of fatalities after its methods came under scrutiny — including by a state representative who’s calling for the agency’s chief to be investigated.
How COVID-19 deaths are counted has become politically divisive, with critics claiming the numbers are inflated and medical experts saying deaths may actually be undercounted. Still, the number of deaths is a crucial data point that informs public understanding of the pandemic’s severity and health officials’ response to the crisis.
The second paragraph mentioned rumors that COVID-19 deaths were exaggerated, adding that medical experts believed that COVID-19 deaths were broadly underestimated. It continued, providing further information about the supposed discrepancy between the 1150 deaths officially tallied, and the adjusted number of 878:
The Colorado Department of Public Health and Environment is now clarifying that its death tally includes the total number of fatalities among people who had COVID-19, including those deaths in which the respiratory disease was not the cause of death listed on the death certificate.
By the agency’s count, there were 1,150 people who had died with COVID-19 in their systems as of [May 14 2020].
Unlike that total, which has been updated daily by the agency since the start of the outbreak, death certificate data only shows 878 deaths were caused by the new coronavirus between Feb. 1 and May 9 — but that number is expected to increase as there is a several-week lag.
There was a lot to unpack in those three short paragraphs, but they noted in part:
- Of the 1,150 deaths, 878 definitively died of COVID-19 alone, leaving 272 people with other causes listed on their death certificates;
- Part of the alleged discrepancy involved people who died and tested positive for COVID-19 — allowing for the very likely possibility that COVID-19 hastened or caused the deaths of individuals suffering a primary illness such as cancer or heart disease;
- All 1,150 deaths counted in the official tally occurred among people who had contracted and tested positive for SARS-CoV-2, the virus responsible for COVID-19;
- The figure of 878 was separately tabulated based on “death certificate data” alone;
- All 878 people who died due solely to COVID-19 died between February 1 and May 9 2020;
- A “several-week lag” (not further clarified) existed, suggesting COVID-19 deaths were undercounted, not over-counted.
The Colorado Sun also addressed discrepancies in the numbers and conspiracy theories that have sprung up around them:
The issue even drew a pointed response from Gov. Jared Polis at his own news conference on [May 15 2020].“What the people of Colorado want to know is not who died with COVID-19, but who died of COVID-19,” said Polis, who has rarely expressed such public frustration with his health leadership before. “And the numbers are very close, of course. There’s only a few cases that we’re aware of where there is some gray area. But where there is a gray area, we should always use — for reporting — the numbers that come from the physician or the coroner that actually addressed the patient or inspected the body.”
Dr. Eric France, CDPHE’s chief medical officer, said the state’s surveillance-system reporting is in line with federal guidance and matches how other states are also reporting deaths, allowing for a quick apples-to-apples comparison across states. Death certificate data also gets reported to the federal government, but it can take weeks or months for those numbers to trickle in. Having uniform surveillance definitions across states is vital for tracking the spread of the virus and allocating federal resources, France said.“Having that standard measure so that I can be confident that the way we’re measuring it and the way it’s being measured in Texas or Florida is the same really is important for the whole nation in how it manages this pandemic,” he said.
Subsequent reporting indicated that the controversy stemmed primarily from the objections of Colorado State Representative Mark Baisley, who called for a criminal investigation into Jill Ryan, executive director of the Colorado Department of Public Health and Environment (CDPHE). In response to the letter in which Baisley requested that investigation, Colorado’s Department of Public Health and Environment issued a statement explaining essentially what NVSS outlined ought to be expected in their March 24 2020 memo:
Officials with the Department of Public Health and Environment said [on May 15 2020] they are not altering death certificates, but noted it is difficult to track deaths during such a large public health crisis.”
“When COVID-19 is reported as a cause of death on the death certificate, more than likely it will be determined to be the underlying cause of death and contribute to those underlying mortality statistics,” said Kirk Bol, manager of the vital statistics program, during a news conference. “But again, if COVID-19 was not determined to be part of the cause of death it should not be reported on the death certificate.”
In the final sentence, Bol made an important distinction: “if COVID-19 was not determined to be part of the cause of death” then “it should not be reported on the death certificate.” In a separate May 14 2020 statement to KUSA, the department explained:
“We classify a death as confirmed when there was a case who had a positive SARS-CoV-2 (COVID-19) laboratory test and then died. We also classify some deaths as probable.“
According to the Denver Post, Baisley’s letter was less about the 272 deaths where COVID-19 was not the sole listed cause than three deaths at a Colorado nursing home. An April 2020 letter from that nursing home to the families of residents counted four deaths, but the state of Colorado counted seven — likely the “only a few” Polis mentioned:
Baisley’s call for an investigation into the state health director was inspired by an April 17 letter written by Tim Rogers, executive director of the Someren Glen retirement community. The letter, which went to residents and their families, said the Centennial facility was aware of four residents whose deaths were confirmed to be related to COVID-19.
Someren Glen’s attending physician, Rogers wrote, determined other recent deaths, including at least one of a resident who tested positive for the virus, were not caused by the coronavirus.
However, he said, the Department of Public Health and Environment counted at least seven resident deaths from the coronavirus — three more than his staff had calculated — and was deciding whether to include a potential eighth death that a physician had ruled was not COVID-related.
Outside the nursing home, the paper described one death of possibly indeterminate cause in an individual with chronic heart disease who tested positive for COVID-19, then negative. That individual later died and their death was included in the tally.
A Final Factor: Excess Deaths During the COVID-19 Pandemic
A related matter to COVID-19 mortality involved the number of “excess deaths” in any given jurisdiction, state, or the entire country in a specific period. The CDC explained how the number of excess deaths (versus seasonal averages) informed understanding of COVID-19 mortality, due to the possibility some deaths occurred due to uncounted cases:
Estimates of excess deaths can provide information about the burden of mortality potentially related to COVID-19, beyond the number of deaths that are directly attributed to COVID-19. Excess deaths are typically defined as the difference between observed numbers of deaths and expected numbers. This visualization provides weekly data on excess deaths by jurisdiction of occurrence. Counts of deaths in more recent weeks are compared with historical trends to determine whether the number of deaths is significantly higher than expected. Counts of deaths from all causes are provided, including deaths due to COVID-19. As many deaths due to COVID-19 may be assigned to other causes of deaths (for example, if COVID-19 was not mentioned on the death certificate as a suspected cause of death), tracking all-cause mortality can provide information about whether an excess number of deaths is observed, even when COVID-19 mortality may be undercounted. Additionally, deaths from all causes excluding COVID-19 were also estimated. Comparing these two sets of estimates — excess deaths with and without COVID-19 – can provide insight about how many excess deaths are identified as due to COVID-19, and how many excess deaths are reported as due to other causes of death. These deaths could represent misclassified COVID-19 deaths, or potentially could be indirectly related to COVID-19 (e.g., deaths from other causes occurring in the context of health care shortages or overburdened health care systems).
Although the above text involved a lot of words, the CDC also maintained several regularly updated charts and a toggle function. One of the graphs, simply labeled “Number of Excess Deaths” (since February 1 2020 across the United States) put the figures into stark relief:
On the low end of the CDC’s estimates, 84,891 deaths in excess of seasonal averages occurred between February 2 and May 9 2020. On the higher end, 113,129 excess deaths occurred between those two dates.
We selected “excluding COVID-19” from a dropdown menu on the right of the bar graph, and the following result was returned for the same time period:
According to the CDC, between 22,105 and 43,204 excess deaths were recorded when excluding COVID-19 as a cause of death. The Denver Post noted that medical experts believe that the true mortality rate or death toll of COVID-19 is underestimated, not overestimated — and those figures appeared to support their supposition.
A Facebook status update accused the Colorado Department of Public Health and Environment (CDPHE) of “admitting” it exaggerated COVID-19 deaths, and subsequently reduced the number of such deaths from 1150 to 878. The claim grossly misconstrues the circumstances of COVID-19 record-keeping both in the state of Colorado and the United States overall. A persistent rumor falsely claimed COVID-19 deaths have been exaggerated deliberately — in actuality, hospitals and medical examiners worked constantly to include and rule out individual deaths during the pandemic, adjusting figures as necessary and often with a weeks-long lag in case data on any given day.