Cause of death in fatal cases associated with positive COVID-19 PCR tests

The response to the COVID-19 pandemic is heavily influenced by reported fatalities from the virus and, by implication, the criteria used to determine those fatalities. Given complications, such as the presence of comorbidities and limitations in testing, the World Health Organization (WHO) guidelines recommend counting both confirmed and suspected COVID-19 deaths as fatalities. While easily implementable, this method does little to indicate the degrees of certainty for a COVID-19 death, and thus concerns have arisen that this may overcount the number of COIVD-19 fatalities. In response, we developed and implemented a scoring system to determine the likelihood that COVID-19 contributed to patient death. Three reviewers independently assessed records of 47 patients who reportedly died from COVID-19. Greatest consensus was observed at the ends of the scoring spectrum, with twelve patients having complete consensus among reviewers. Intraclass correlation among the three reviewers was 0.52 (95% CI, 0.25-0.72). Middle scores had the greatest variability, possibly due to plausible alternative diagnoses, suggesting the potential for variability in death certification and the need for a scoring system that reports degrees of certainty. Although scoring rules can guide reviewers toward greater consensus about cause of death, in the absence of an objective criteria for COVID-19 disease, the determination of cause of death in paitents with positive PCR tests for SARS-CoV-2 who also have significant comorbid conditions will remain subjective. Keywords: COVID-19; fatality; cause of death