How do COVID-19 deaths in Alaska get counted?

Each day, the Alaska officials report new coronavirus cases, hospitalizations and deaths.

As of Thursday, 453 Alaskans have died after contracting COVID-19, according to the Department of Health and Social Services. But public confusion about which deaths are officially attributed to COVID-19 has lingered.

What’s the difference between someone dying with the coronavirus versus from the coronavirus? If a person had a terminal illness or other serious medical problems, who decides whether it’s COVID-19 that killed them, or something else? And which deaths get included as part of Alaska’s official toll?

The answer boils down to this: Government agencies rely on death certificates, which include the a doctor’s determination of a patient’s cause of death, to calculate the toll of the coronavirus pandemic.

If a physician judges that a COVID-19 infection contributed to a person’s death, it is included on the death certificate and ultimately counted in the state’s official toll, according to DHSS.

“Whether COVID-19 shortened a life by 15 years or 15 minutes; whether COVID-19 is an underlying or contributing condition, the virus was in circulation, infected an Alaskan, and hastened their death,” explains an infographic on the department’s website. “This must be reported.”

Death certificates include three lines, said Dr. Julian Rojas, an Anchorage physician who cares for people in intensive care.

On the first line, physicians record the most immediate cause of death.

[Impossible choices inside Alaska’s inundated hospitals]

Below that, physicians can list secondary or tertiary causes of death in order of the underlying disease processes.

For example: A person died of acute respiratory distress syndrome, when fluid collects in the lungs and starves the organs of oxygen.

The acute respiratory distress syndrome came as a consequence of pneumonia, which would be listed on the second line, that was in turn a consequence a COVID-19 virus infection.

In that case, acute respiratory distress, pneumonia and COVID-19 would all be included on the death certificate, said Rojas.

“It’s a sequence of events for what happened,” Gary Zientek, the state medical examiner.

In COVID-19 cases he has treated, the trajectory of illness is often clear.

“Generally speaking, there is not much ambiguity,” Rojas said. “In acute illnesses, there is a very short period of time. It’s easy to track the terminal cause of death.”

If a doctor judges that a person who already had terminal cancer contracted COVID-19 and the virus accelerated their death, they would also be counted as a death due to COVID, said Zientek.

There are clear and logical limits: If someone died in a car crash but was found to be positive for COVID-19 at the time, that would not be counted because there would be no evidence the virus contributed to the person’s death, Zientek said.

Determining the cause of death is left to the treating physician who last cared for the person, Rojas said.

That’s as it should be, Zientek said.

“I trust the (death certificate) process,” said Zientek. “If they think COVID contributed it’s hard to doubt them. They’re the treating physician, they know best why the person died.”

The state gets the information in two parallel processes, according to DHSS: If a person is hospitalized with COVID-19, the hospital is supposed to report it to the state Section of Epidemiology. If the patient dies, they report that too. Death certificate records are sent to the state’s Health Analytics and Vital Records section, which removes identifying data and sends the information to the CDC’s statistics hub.

There, the information is reviewed by professionals trained to classify diseases, reduced to a series of codes, and then returns to the state. The whole process can take up to three weeks, which is why the state sometimes announced a larger group of non-recent deaths.