Among death certificates from calendar year 2020 listing COVID-19 and at least one other co-occurring diagnosis, the documentation is consistent with these deaths being attributable to COVID-19. Specifically, in 97% of 357,133 death certificates with COVID-19 and at least on other diagnosis, the documented chain-of-event and significant contributing conditions were consistent with those reported in clinical and epidemiologic studies to occur among patients with severe COVID-19-associated outcomes. Only 5.5% of death certificates had COVID-19 without any other conditions listed. Attributability of death to COVID-19 could not be evaluated for these death certificates and represents an opportunity for improvement in documentation.

A small proportion (2.5%) of death certificates documented conditions that have not currently been described to be associated with COVID-19 critical illness or death. This was noted more often among those who died at home, declared dead on arrival, and whose manner of death was not natural. In particular, a higher percentage of decedents aged <18 years (35.2%) and 18-29 years (10.2%) did not have a chain-of-event or significant contributing condition listed on the death certificate, even though their death certificates did have at least one other diagnosis code along with COVID-19 in Part I or II.

These findings support the accuracy of COVID-19 mortality surveillance in the United States using official death certificates. High-quality documentation of co-occurring diagnoses on the death certificate is essential for a comprehensive and authoritative public record. Continued messaging to and training of professionals who complete death certificates remains important as the pandemic progresses. Accurate mortality surveillance is critical for understanding the impact of SARS-CoV-2 variants and of COVID-19 vaccinations and for guiding public health action.

Stay well, mask up, and stay tuned!