Across Colorado, there is a mystery brewing in mortality.
At least 1,200 more people died last month in the state compared to in April 2019, according to official — though preliminary — figures. But only a fraction of that increase is currently being attributed to the novel coronavirus.
So, in a time of unprecedented public health crisis and unprecedented restrictions on travel, what else is killing Coloradans?
The question has become politically heated, the topic of conspiracy theories and partisan bickering. It has brought almost unheard of scrutiny to the sometimes creaky world of vital statistics reporting. It has subjected the state’s coroners to deep criticism — including from their own neighbors — even as they are working like everybody else to understand what the heck is going on.
And, it likely won’t be answered for months or even years.
Having an accurate understanding of death in the time of coronavirus will ultimately help health officials better understand the virus’ spread and plan for future pandemics. Were deaths due to COVID-19, the disease caused by the coronavirus, underreported or overreported? Did the statewide stay-at-home order increase deaths from other causes?
But a slew of factors muddy the data right now, including lack of testing early on in the pandemic, delays in reporting, confusion over how to fill out and record death certificates and a patchwork of rules and regulations by local health departments and county coroner’s offices.
“Everybody is trying to do the best we can, every one of us,” said Jill Romann, the Douglas County coroner. “But the numbers are going to be wrong this first year, no matter what.”
Colorado’s new second-leading cause of death
Here is what we do know for certain: In 2019, 6,761 people died during March and April in Colorado. This year, that number increased by at least 17% with a total of 8,190 Coloradans dying in March and April. These numbers come from death certificates, which trickle through multiple jurisdictions before finally being recorded in official statistics, so it is possible the 2020 numbers will rise more.
But, drawing from the same data source, only 696 people in those months are recorded as having died from COVID-19. That means there are still hundreds of additional “excess deaths” — deaths over and above what would be expected based on historical averages — in March and April that have not been attributed to the pandemic, at least yet. (On Thursday, the state health officials reported that 1,001 people have died in Colorado so far due to COVID-19, but, again, it takes time for those deaths to be recorded in the numbers used in this analysis.)
In April, coronavirus was the second-leading specified cause of death in Colorado, ahead of heart disease and behind only cancer. But the largest category of deaths in April — at more than 1,300 — is currently the catch-all category of “other.” That category serves as something of a statistical holding pen for deaths that have been recorded but for which a specific cause has not yet been assigned. As the cases get sorted out, the number of deaths listed under “other” drops, while deaths from the specific causes rise.
But this is the whole trouble with trying to figure out in realtime why people are dying. Death investigations can take weeks, and death certificates can take longer to close. Recording the information in official statistics involves work at the local, state and federal level.
Dr. Kelly Lear, who has been the Arapahoe County coroner since June 2014, said the delays can be frustrating.
“I’ve got cases from March that the death certificates still aren’t done by the treating physician,” she said.
“If you look at the health department’s numbers for fatalities, it’s different from my case count, just because they haven’t caught up yet,” she added. “I give them my information and then they have to kind of do their own tracking. But without my information, it would be even further behind.”
Not every jurisdiction is seeing an increase — the coroners in Mesa and Adams counties said they haven’t. But the coroner in Morgan County has reported ordering a refrigerated truck to handle the sudden influx of bodies.
Steven Castro, the operations manager at the Denver Office of the Medical Examiner, said his office’s caseload has increased significantly. As of this week, he said the office has investigated 615 deaths; last year at this time, it had investigated only 459.
“We really don’t know right now what’s going on,” he said. “I really wish I could say what’s trending right now. But I can’t.”
Suicides, drug overdoses likely not to blame
There is no indication so far that deaths from suicide or drug overdose account for a significant portion of the increase in deaths.
Both Castro and Romann said they have not seen a rise in suicides. Castro said Denver has experienced an increase in drug-overdose deaths, driven largely by a rise in fatalities involving the powerful opioid fentanyl. But he said it’s unclear whether that increase is due to an increase in the dangerousness of the drug in circulation or whether stress associated with the pandemic played a role.
In the death-certificate statistics provided by the state Health Department, the category of “unintentional injuries” — which includes accidental drug overdoses — recorded 502 deaths in March and April of 2019 compared to 359 deaths in those months this year. There were 233 deaths by suicide in March and April of 2019 compared to 139 in the same time period in 2020. (Though, again, the reported 2020 numbers will likely rise in the coming months.)
Lear, in Arapahoe County, said she’s seen an increase in seemingly non-coronavirus deaths. But she said it’s too soon to determine if they are statistically relevant. She hypothesized that one explanation for the recent increase could be from people putting off their doctor’s appointments.
“I’ve had a few cases like that, where it’s the chronic pain patient who has to have their surgery that was put off and then they ended up overdosing on their pain medication,” Lear said. “Or the person who’s got heart disease or had chest pain but didn’t want to go to the hospital because they’ve been told not to go to the hospital. There are definitely some of those types of things happening.”
There are also some coroners in the state, including Logan County Coroner Dave Tennant, who think at least some of the increase in deaths in Colorado may be attributed to the state’s aging population.
As of May 17, Logan County ranked 22nd in the country for rural counties with the highest coronavirus infection rates, due in large part to an outbreak at the Sterling Correctional Facility –– the largest prison in the Colorado Department of Corrections system. At least 440 inmates there have tested positive for the coronavirus and two have died. The county has a total of 489 confirmed coronavirus cases.
“We are seeing a lot of elderly, 89 year olds pass away, even 100 year olds. And that’s just natural things,” Tennant said. “…I think we have an elderly population base here in Sterling and in Logan County in general. And that makes a difference in the death rate.”
But, statewide, Colorado’s age-adjusted death rate, which takes into account population growth and the aging population, took a significant jump in April. The rate in April 2019 was about 630 deaths per 100,000 people, according to the state statistics. It was about 830 deaths per 100,000 in April 2020.
The lack of early testing will haunt COVID-19 death statistics
One thing coroners agree on is that an early lack of coronavirus testing means the state likely missed a sizable number of COVID-19 deaths.
Monica Broncucia-Jordan, coroner for Adams and Broomfield counties, said her office has intercepted a couple of death cases from nursing homes that weren’t tested for coronavirus that should have been.
“If we had not stepped in and done that testing, that death certificate would have been filled out by that health care provider as whatever natural disease the person had,” Broncucia-Jordan said. “So those were some of the underreporting that can go on.”
Romann said hospice and palliative care facilities early on may not have had access to the testing needed to correctly determine a patient’s cause of death.
“When testing supplies were short out in the field, I believe initially we were not capturing half of the deaths where they died from COVID,” said Romann, who is a board-certified medical legal death investigator with about 35 years of experience. “So I believe that Douglas County had far more deaths than were actually being reported.”
The state’s testing capacity has now improved. But the suspicions that surrounded testing early on could also cut both ways.
Broncucia-Jordan said her office had a case where a man who later died had been hospitalized with all the symptoms of COVID-19. The hospital conducted four different tests on the man, but all came back negative.
“So we intervened and actually did our own testing on that person, both a rapid serology test and a nasal swab test and also got negative,” she said. “And they still wanted to fill out that death certificate as COVID, and the unlikelihood of that is extraordinarily high.”
Additional tests revealed the man died from hantavirus.
Confusion around death certificates
Colorado coroners are not required by law to investigate every death in their counties. Instead, the law limits their mandatory duties to investigating deaths due to injury, deaths where a doctor was not present and a handful of other circumstances.
Typical deaths that occur in hospitals or nursing homes — a category that includes almost every documented COVID-19 death — do not have to be looked at by coroners, though coroners can investigate deaths due to infectious disease. And that leaves a lot of room for different coroners to approach coronavirus deaths differently.
“It’s frustrating,” Lear said. “Every county does things differently as far as the coroners go. And there is no uniformity in what each county is doing.”
Lear said she is co-signing all death certificates for coronavirus cases that come from attending physicians, nursing homes or hospitals. That gives her the ability to better track the toll of the virus in her county.
Romann is doing the same in Douglas County, and she said coroners play a vital role in making sure death certificates are filled out consistently.
Colorado’s death certificates have three different lines where a cause of death can be listed, arranged in order of relevance, with the immediate cause being listed first and the underlying cause being listed last. Then, there is a whole other section where “other significant conditions” can be stated.
So if a person who has lung cancer contracts COVID-19 and dies of acute respiratory distress syndrome brought on by an associated pneumonia, what gets listed where?
Romann said some physicians will list the underlying condition first, seeing that as the ultimate cause of death. But, she said, that’s not how it’s supposed to work.
“If what tipped them over the edge is COVID, that is what the death certificate should read,” she said.
This issue burst into public view last week, when the Montezuma County’s coroner challenged how state health officials recorded a death in his county. The confrontation prompted the state Health Department to clarify the different ways it is tracking deaths and COVID-19. The state is not changing death certificates unless a change is requested through a formal process, officials said.
The federal Centers for Disease Control and Prevention has produced a seven-page document outlining how COVID-19 should be reported on death certificates. Romann said the state health department is trying to make sure everybody follows the same rules. But with so many doctors, coroners and other potential “certifiers” across the state, that’s hard to do, she said.
“So these death certificates, at a 30,000-foot view, can be a real mess,” she said.
Coroners are feeling the strain
In Denver, Castro said everyone in the office has been working overtime. In Douglas, Romann said she and her staff are burned out from the constant public skepticism surrounding COVID-19 deaths.
“I have my neighbors questioning me, all the time,” she said.
Romann said she used to try to respond to every criticism, but the task grew overwhelming. People seem too entrenched in their beliefs, she said. But it’s been difficult for her and her staff to have their sincerity and competence questioned.
She said coroners and everyone else working in public health are better at tracking the pandemic now than they were in March. And, because of what they’ve learned, they’ll be better in June than they are now.
“We’re all highly invested in getting it right,” she said. “And I believe when we look back, we will have as near to correct numbers as possible. And the public has got to be patient with us.”