Dying with or dying from COVID-19: When being able to count is relevant

Dear Editor,

Mass media has emphasized the controversy of dying “with” or dying “from” COVID-19. That is, the difference between having suffered COVID-19, but dying from another cause; or dying due to COVID-19.¹ This controversy overlapped the lack of official counts of death causes, in time and manner, by the National Institute of Statistics (INE acronym in Spanish),² based on official medical certificates of death (DC), which were adapted to the WHO standards in 2009, and are being codified by the Autonomous Communities according to the rules of the International Classification of Diseases. COVID counts have been published with little delay in our neighboring European countries.³ This controversy suffered political hyperbole, favored by different estimations of death counts because the cause of death information was not available.⁴

Let us remember, that in March 2020, WHO defined COVID-19 disease as SARS-CoV-2 virus identified and not identified by diagnostic tests; that the Ministry of Health has been modifying the COVID-19 case-definition during the course of the pandemic for better surveillance and control; and that in Spain, the official statistical institution is the INE (www.ine.es).

Because of this, we proposed to assess and quantify the co-mortality with COVID-19 in our regional health council based on INE data. We elaborated the co-mortality/mortality indexes of COVID-19 and other causes mentioning COVID-19 on the residents’ death certificates in the Region of Murcia in 2020. The indexes were described by area, age and sex. We compared the results using the Chi-square test with two-sided statistical significance for p < 0.05.

We recorded 786 deaths of COVID-19 (6.3% of 12,392 deaths), 746 confirmed and 40 unconfirmed cases. The 46% were women. The age-distribution was statistically significant according to sex (Fig. 1). The 84% of women and the 61% of men were over 74 years of age. We found 61 deaths “with” COVID-19 (29 women and 32 men, 0.8% of total COVID), which were mainly due to neoplasm (26%) and cardiovascular (20%) diseases.

Fig. 1.

COVID-19 death-counts (confirmed and suspected) by age group and sex* in residents of the Region of Murcia, 2020.

The mass media controversy of dying “from” or “with” COVID-19 does not seem very relevant, in our case, given the relatively low figures of those who suffered COVID-19 but died from other causes. We must comment that the deceased cases were validated with epidemiological surveillance information or digital medical records (without access to a large part of the private health care records of ISFAS/MUFACE/MUGEJU of civil servants).

Likewise, we have learned that the pilot tests of the new digital DC, first in the province of Ciudad Real, and later in Navarre, have not obtained the expected results; and it seems that other viabilities are being negotiated with the Medical College Organization (OMC in Spanish), owner of the DC. At the same time, the Ministry of Justice will give an “individual identification number” to every live birth on the Civil Register, enabling indexation throughout the National Health System.

It is still important to quantify deaths by their cause in time and manner in any health emergency (for example, heatstroke deaths) by completing the digital circuit of statistics publication. The OMC has a social responsibility to overcome technical difficulties of the implementation of the electronic CD, -an anachronism in the digital transformation era-, to allow death causes counts in time and manner, for the benefit of all.

Ethical considerations

Not applicable.

Financing

No financing.

Conflict of interest

No conflicts of interest to declare.