Georgia mortality stats show marked January spikes in 2018 and 2020

First in a series of US and Georgia Mortality Statistic Charts - Includes CDC directives on Coding of COVID deaths and Death Certificate Cause-of-Death directives.


Georgia-specific mortality statistics for the past 20 years show that January, February and December are routinely the highest-fatality months. Recent data shows a large spike in January deaths in 2018, and significantly higher counts in January and March of 2020. Data from 2019 and 2020 is considered incomplete, with significant underreporting in the past four to five months.

Georgia Deaths - All Causes - By Month - 1999-2020 - January Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - February Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - March Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - April Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - May Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - June Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - July Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - August Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - September Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - October Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - November Numbers

Georgia Deaths - All Causes - By Month - 1999-2020 - December Numbers

ConnectLocal, on Aug. 15, received extensive US and State of Georgia mortality data records pursuant to a request submitted earlier in the month. I am formatting this data into a series of charts and statistical reviews that will be posted in the coming week.

A section of information describing the source of the data, the completeness of the data, and some general information will be included with each set of charts. This common information will be published below the charts, and will remain the same with each post. New data, or data specific only to the specific charts being posted, will be published above the charts.

Charts are uploaded at full resolution if they are charts created by ConnectLocal, and will open in a pop-up window in a larger format if clicked on. Charts or graphic images supplied by the CDC or other sources will be published at as large of a resolution as was available, and will be formatted, if possible, to open in a larger format in a pop-up window when clicked on. Any charts or graphics not specifically credited to a source are the creation and copyright of ConnectLocal. (ConnectLocal graphics and charts may be downloaded and shared, but may not be altered in any manner, and watermark must remain intact and credit included).

ConnectLocal makes no conclusions based on the data provided in these reports. These charts and data reports are provided for readers to have access to factual statistics from which to draw their own conclusions.

REPORTING NOTES FROM CDC:

Provisional counts may differ by approximately 2% from final counts, due to rounding and reporting variations. Provisional counts are not final and are subject to change, especially for more recent periods. Counts from previous weeks are continually revised as more records are received and processed. (source: CDC)


Currently, 63% of all U.S. deaths are reported within 10 days of the date of death, but there is significant variation between states. Some states report deaths on a daily basis, while other states report deaths weekly or monthly. (source: CDC)


It takes extra time to code COVID-19 deaths.While 80% of deaths are electronically processed and coded by NCHS within minutes, most deaths from COVID-19 must be coded by a person, which takes an average of 7 days. (source: CDC)

COVID-19 CAUSE OF DEATH NOTES:

(source: CDC)

ConnectLocal submitted a request to the CDC on Aug. 20 for clarification/verification of this statement – a5 3:30 p.m. today, we received the following response:


Hello Jessica,

Your questions were forwarded to us here at CDC’s National Center for Health Statistics.  Please see responses below:

CLARIFICATION: "COVID-19 is listed as the underlying cause on the death certificate in 94% of deaths (see Table 1)." This statement is printed in the Technical Notes link, under the "Cause-of-death classification and definition of deaths" subhead. This statement indicates that in 94 percent of all deaths - COVID--19, or U07.1, is listed on the death certificate as a contributing factor to the death. Please clarify what set or subset of deaths this "94%" refers to. This means that 94% of all COVID-19 deaths have COVID-19 listed as the underlying cause.  The remaining 6% of COVID-19 deaths have COVID-19 listed as a contributing (but not underlying) cause of death. We will update the Technical Notes so that it is more clear that the denominator is all COVID-19 deaths.


COVID-19 NOTES:

Coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an acute respiratory disease that can lead to respiratory failure and death. (Source: The Lancet)


Previous epidemics of novel coronavirus diseases, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), were associated with similar clinical features and outcomes. (Source: The Lancet)

One might anticipate that patients with chronic respiratory diseases, particularly chronic obstructive pulmonary disease (COPD) and asthma, would be at increased risk of SARS-CoV-2 infection and more severe presentations of COVID-19. However, it is striking that both diseases appear to be under-represented in the comorbidities reported for patients with COVID-19, compared with the global burden of disease estimates of the prevalence of these conditions in the general population (table); a similar pattern was seen with SARS. By contrast, the prevalence of diabetes in patients with COVID-19 or SARS is as high as or higher than the estimated national prevalence, as might be expected. (Source: The Lancet)

Influenza/Influenza-Like Illness Notes:

CDC estimates that the burden of illness during the 2017–2018 season was high with an estimated 45 million people getting sick with influenza, 21 million people going to a health care provider, 810,000 hospitalizations, and 61,000 deaths from influenza The number of cases of influenza-associated illness that occurred during 2017-2018 was the highest since the 2009 H1N1 pandemic, when an estimated 60 million people were sick with influenza.


The 2017–2018 influenza season was additionally atypical in that it was severe for all ages. The burden of influenza and the rates of influenza-associated hospitalization are generally higher for the very young and the very old, and while this was also true during the 2017–2018 season, rates of hospitalization in all age groups were the highest seasonal rates seen since hospital-based surveillance was expanded in 2005 to include all ages. This translated into an estimated 11 million cases of influenza in children, 28 million cases of influenza in working age adults (aged 18-64 years), and 6 million cases in adults aged 65 years and older.


Our estimates of hospitalizations and mortality associated with the 2017–2018 influenza season continue to demonstrate how severe influenza virus infection can be. More than 46,000 hospitalizations occurred in children (aged < 18 years); however, 67% of hospitalizations occurred in older adults aged ≥65 years. Older adults also accounted for 83% of deaths, highlighting that older adults are particularly vulnerable to severe disease with influenza virus infection. An estimated 9,600 deaths occurred among working age adults (aged 18–64 years), an age group that often has low influenza vaccination. (Source: CDC)

FYI - Trends in Mortality - Volume of deaths increasing, rate of death decreasing


The total number of deaths in the United States increased from 2.4 million in 2009 to 2.8 million in 2017. An increase in deaths can indicate an aging population and/or an underlying public health issue. According to the National Center for Health Statistics, the three leading causes of death in 2017 were heart disease, cancer, and accidents, such as motor vehicle accidents and accidental poisonings (drug overdose).


There have been marked reductions in U.S. mortality and increases in life expectancy at birth since the beginning of the 20th century. Between 1900 and 2016, the age-adjusted death rate dropped 60% from 1,860.1 to 728.8 deaths per 100,000 population, while life expectancy at birth in the U.S. rose from 47.3 to 78.6 years—an increase more than 30 years.


The rate of decrease in mortality fluctuated during this period, influenced by changes in the death rates for the leading causes of death. Some of the largest decreases in the age-adjusted death rate were observed during the first half of the 20th century, when improvements in sanitation and hygiene, the introduction of antibiotics, and the implementation of vaccination programs led to dramatic decreases in death rates for infectious diseases, which were among the leading causes of death


Beginning from the middle of the 20th century, the rate of decrease in the age-adjusted death rate slowed as the trend became more heavily influenced by the death rates for chronic diseases, such as heart disease and cancer. Between 1955 and 1968, for instance, the overall, age-adjusted death rate decreased at a slower rate than in years prior as these chronic diseases accounted for a growing proportion of deaths in the U.S.


Between 2000 and 2016, the overall age-adjusted death rate for the U.S. population decreased 16%—from 869.0 to 728.8 deaths per 100,000—while life expectancy at birth increased from 76.8 to 78.6 years. (source: CDC)


FYI GUIDANCE OF COMPLETING DEATH CERTIFICATES


COVID-specific directives, Published March 2020:

New ICD code introduced for COVID-19 deaths This email is to alert you that a newly-introduced ICD code has been implemented to accurately capture mortality data for Coronavirus Disease 2019 (COVID-19) on death certificates.

Please read carefully and forward this email to the state statistical staff in your office who are involved in the preparation of mortality data, as well as others who may receive questions when the data are released.

What is the new code? The new ICD code for Coronavirus Disease 2019 (COVID-19) is U07.1, and below is how it will appear in formal tabular list format.

U07.1 COVID-19

Excludes:

Coronavirus infection, unspecified site (B34.2) Severe acute respiratory syndrome [SARS], unspecified (U04.9)

The WHO has provided a second code, U07.2, for clinical or epidemiological diagnosis of COVID-19 where a laboratory confirmation is inconclusive or not available. Because laboratory test results are not typically reported on death certificates in the U.S., NCHS is not planning to implement U07.2 for mortality statistics.


When will it be implemented?

Immediately.

Will COVID-19 be the underlying cause? The underlying cause depends upon what and where conditions are reported on the death certificate. However, the rules for coding and selection of the underlying cause of death are expected to result in COVID- 19 being the underlying cause more often than not.

What happens if certifiers report terms other than the suggested terms? If a death certificate reports coronavirus without identifying a specific strain or explicitly specifying that it is not COVID-19, NCHS will ask the states to follow up to verify whether or not the coronavirus was COVID-19. As long as the phrase used indicates the 2019 coronavirus strain, NCHS expects to assign the new code. However, it is preferable and more straightforward for certifiers to use the standard terminology (COVID-19).

What happens if the terms reported on the death certificate indicate uncertainty? If the death certificate reports terms such as “probable COVID-19” or “likely COVID-19,” these terms would be assigned the new ICD code. It Is not likely that NCHS will follow up on these cases.

If “pending COVID-19 testing” is reported on the death certificate, this would be considered a pending record. In this scenario, NCHS would expect to receive an updated record, since the code will likely result in R99. In this case, NCHS will ask the states to follow up to verify if test results confirmed that the decedent had COVID- 19.

Should “COVID-19” be reported on the death certificate only with a confirmed test? COVID-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death. Certifiers should include as much detail as possible based on their knowledge of the case, medical records, laboratory testing, etc. If the decedent had other chronic conditions such as COPD or asthma that may have also contributed, these conditions can be reported in Part II. (See attached Guidance for Certifying COVID-19 Deaths)

Standard/generic Death Certificate and instructions for completing certificate (last updated 2017).





PER CDC:


Instructions for Completing the Cause-of-Death Section of the Death Certificate Accurate cause-of-death information is important: • To the public health community in evaluating and improving the health of all citizens, and • Often to the family, now and in the future, and to the person settling the decedent's estate. The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on Line a and the underlying cause of death (the disease or injury that initiated the chain of morbid events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases, conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I. The cause-of-death information should be YOUR best medical OPINION. A condition can be listed as “probable” even if it has not been definitively diagnosed.


General Instructions for Completing Death Certificates


Death certificates are permanent legal records from which official copies are made. It is essential that the certificate be prepared accurately. Funeral directors are responsible for completing most of the information on the death certificate with the assistance of an informant who is usually a family member.


Physicians are expected to use medical training, knowledge of medicine, available medical history, symptoms, diagnostic tests, and autopsy results, if available, to determine the cause of death. Generally, it is possible to file a certificate with the cause of death listed as pending or pending further study. This is especially useful when additional 7 investigation such as autopsy results are expected, but it obligates the attending physician to update the original information after the additional information becomes available.


Cause of death This section must be completed by either the attending physician, the medical examiner, or the coroner. The cause-of-death section follows guidelines recommended by the World Health Organization. An important feature is the reported underlying cause of death determined by the certifying physician and defined as


(a) the disease or injury that initiated the train of morbid events leading directly to death, or

(b) the circumstances of the accident or violence that produced the fatal injury.


In addition to the underlying cause of death, this section provides for reporting the entire sequence of events leading to death as well as other conditions significantly contributing to death. The cause-of-death section is designed to elicit the opinion of the medical certifier. Causes of death on the death certificate represent a medical opinion that might vary among individual physicians. A properly completed cause-of-death section provides an etiologic explanation of the order, type, and association of events resulting in death. The initial condition that starts the etiologic sequence is specific if it does not leave any doubt as to why it developed. For example, sepsis is not specific because a number of different conditions may have resulted in sepsis, whereas human immunodeficiency virus syndrome is specific.


In certifying the cause of death, any disease, abnormality, injury, or poisoning, if believed to have adversely affected the decedent, should be reported. If the use of alcohol and/or other substance, a smoking history, a recent pregnancy, injury, or surgery was believed to have contributed to death, then this condition should be reported. The conditions present at the time of death may be completely unrelated, arising independently of each other; they may be causally related to each other, that is, one condition may lead to another which in turn leads to a third condition; and so forth. Death may also result from the combined effect of two or more conditions.


In certifying the cause of death, any disease, abnormality, injury, or poisoning, if believed to have adversely affected the decedent, should be reported. If the use of alcohol and/or other substance, a smoking history, a recent pregnancy, injury, or surgery was believed to have contributed to death, then this condition should be reported. The conditions present at the time of death may be completely unrelated, arising independently of each other; they may be causally related to each other, that is, one condition may lead to another which in turn leads to a third condition; and so forth. Death may also result from the combined effect of two or more conditions.


As can be seen, the cause-of-death section consists of two parts. The first part is for reporting the sequence of events leading to death, proceeding backwards from the final disease or condition resulting in death. So each condition in Part I should cause the condition above it. A specific cause of death should be reported in the last entry in Part I so there is no ambiguity about the etiology of this cause. Other significant conditions that contributed to the death, but did not lead to the underlying cause, are reported in Part II.


In addition, there are questions relating to autopsy, manner of death (for example, accident), and injury. The cause of death should include information provided by the pathologist if an autopsy or other type of postmortem examination is done. For deaths that have microscopic examinations pending at the time the certificate is filed, the additional information should be reported as soon as it is available. If the physician has any questions about the procedure for doing this, he or she should contact his or her State registrar


For statistical and research purposes, it is important that the causes of death and, in particular, the underlying cause of death be reported as specifically and as precisely as possible. Careful reporting results in statistics for both underlying and multiple causes of death (i.e., all conditions mentioned on a death certificate) reflecting the best medical opinion.


Every cause-of-death statement is coded and tabulated in the statistical offices according to the latest revision of the International Classification of Diseases (5). When there is a problem with the reported cause of death (e.g., when a causal sequence is reported in reverse order), the rules provide a consistent way to select the most likely underlying cause. However, it is better when rules designed to compensate for poor reporting are not invoked so that the rules are confirming the physician’s statement rather than imposing assumptions about what the physician meant.


Statistically, mortality research focuses on the underlying cause of death because public health interventions seek to break the sequence of causally related medical conditions as early as possible. However, all cause information reported on death certificates is important and is analyzed.


In the sections that follow, detailed instructions on how to complete Parts I and II are given. A number of examples of properly completed certificates with case histories are provided in this section to illustrate how the cause of death should be reported. Some common problems are also discussed later in this section.


Instructions The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on line (a) and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases, conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I.


The cause-of-death information should be the physician’s best medical OPINION. Report each disease, abnormality, injury, or poisoning that the physician believes adversely affected the decedent. A condition can be listed as ‘‘probable’’ if it has not been definitively diagnosed.


If an organ system failure such as congestive heart failure, hepatic failure, renal failure, or respiratory failure is listed as a cause of death, always report its etiology on the line(s) beneath it (for example, renal failure due to Type I diabetes mellitus).

Part I of the cause-of-death section

Only one cause is to be entered on each line of Part I. Additional lines should be added between the printed lines when necessary. For each cause, indicate in the space provided the approximate interval between the date of onset (not necessarily the date of diagnosis) and the date of death.


For clarity, do not use parenthetical statements and abbreviations when reporting the cause of death. The underlying cause of death should be entered on the LOWEST LINE USED IN PART I. The underlying cause of death is the disease or injury that started the sequence of events leading directly to death or the circumstances of the accident or violence that produced the fatal injury. In the case of a violent death, the form of external violence or accident is antecedent to an injury entered, although the two events may be almost simultaneous.


Line (a) immediate cause In Part I, the immediate cause of death is reported on line (a). This is the final disease, injury, or complication directly causing the death. An immediate cause of death must always be reported on line (a). It can be the sole entry in the cause-of-death section if that condition is the only condition causing the death


The immediate cause does not mean the mechanism of death or terminal event (for example, cardiac arrest or respiratory arrest). The mechanism of death (for example, cardiac or respiratory arrest) should not be reported as the immediate cause of death as it is a statement not specifically related to the disease process, and it merely attests to the fact of death. Therefore, the mechanism of death provides no additional information on the cause of death.


Lines (b), (c), and (d) due to (or as a consequence of) On line (b) report the disease, injury, or complication, if any, that gave rise to the immediate cause of death reported on line (a). If this in turn resulted from a further condition, record that condition on line (c). If this in turn resulted from a further condition, record that condition on line (d). For as many conditions as are involved, write the full sequence, one condition per line, with the most recent condition at the top, and the underlying cause of death reported on the lowest line used in Part I. If more than four lines are needed, add additional lines (writing ‘‘due to’’ between conditions on the same line is the same as drawing an additional line) rather than using space in Part II to continue the sequence. The following certification is an example in which an additional line was necessary.


The words ‘‘due to (or as a consequence of),’’ which are printed between the lines of Part I, apply not only in sequences with an etiological or pathological basis and usually a chronological time ordering, but also to sequences in which an antecedent condition is believed to have prepared the way for a subsequent cause by damage to tissues or impairment of function.


If the immediate cause of death arose as a complication of or from an error or accident in surgery or other medical procedure or treatment, it is important to report what condition was being treated, what medical procedure was performed, what the complication or error was, and what the result of the complication or error was.


Case Scenarios, examples and further directives.


Cause of Death - Death Certificate tutorial


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