Update 18 Sep 2020: How COVID-19 Deaths Are Counted
As coronavirus has swept through the United States, finding the true number of people who have been infected has been stymied due to lack of testing. Now, official counts of coronavirus deaths are being challenged, too.
In Colorado, for example, a Republican state legislator has accused the state’s public health department of falsely inflating COVID-19 deaths; in Florida, local media have objected to the State Department of Health’s refusal to release medical examiner data to the public, alleging that the state may be underreporting deaths.
The reality is that assigning a cause of death is not always straightforward, even pre-pandemic, and a patchwork of local rules and regulations makes getting valid national data challenging. However, data on excess deaths in the United States over the past several months suggest that COVID-19 deaths are probably being undercounted rather than overcounted.
Why is Singapore's COVID-19 death rate the world's lowest
Singapore has the lowest coronavirus case fatality count globally, with just 27 deaths among the more than 57,000 people who have been infected with Covid-19 in the Southeast Asian island.
At 0.05 per cent, Singapore's death rate is well below the global average of around 3 per cent, according to data compiled by Reuters from countries that have recorded more than 1,000 cases.
A comparison with countries with a similar sized population shows a stark difference - Denmark's death rate is around 3 per cent, while Finland's is around 4 per cent. Further, nobody has died from the disease in Singapore for more than two months, according to its health ministry.
14th person who had COVID-19 & died but not added to the official toll
Singapore reported 327 new COVID-19 cases as of noon on Friday (Jul 17), with nine infections in the community, said the Ministry of Health (MOH).
This brings the total number of cases in the country to 47,453.
MOH said Case 47229, a 72-year-old Singaporean woman, died on Wednesday. "She had been conveyed to the National University Hospital’s emergency department on Jul 15 for reasons not related to COVID-19, and had a history of diabetes mellitus," the ministry added. She was confirmed to have COVID-19 infection on Jul 16 after her death. MOH said the cause of her death was confirmed to be intracerebral haemorrhage.
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13th person who had COVID-19 & died but not added to the official toll
The Ministry of Health (MOH) has reported another death in its evening press release on July 9. MOH stated that the 38-year-old male Bangladeshi national has passed away on July 7.
The man was admitted in to Ng Teng Fong General Hospital on June 28 after suffering a seizure, and subsequently developed intracranial haemorrhage. He was later tested with Covid-19 infection on the same day. The preliminary cause of death is reported to be cardiorespiratory failure, pending further investigations by the Coroner.
The death of this 38-year-old is not added to the death count of Covid-19. MOH explained that only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to Covid-19 infection will be added to the COVID-19 death count.
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12th person who had COVID-19 & died but not added to the official toll
On July 8, the Ministry of Health (MOH) reported that Case 45227, a 69 year-old male Singaporean, passed away on July 7, 2020. The man had been found unresponsive at his place of residence and was conveyed to Sengkang General Hospital’s emergency department on July 7. He was confirmed to have Covid-19 infection on the same day.
He had a history of diabetes mellitus, hypertension, hyperlipidaemia, hypothyroidism and chronic kidney disease. The preliminary cause of death is cardiorespiratory failure, pending further investigations by the Coroner.
As of July 8, 26 have passed away in Singapore from complications due to Covid-19 infection. Case 45227’s death was not added to the Covid-19 death count, as only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to Covid-19 infection will be counted.
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11th person who had COVID-19 & died but not added to the official toll
A 48-year-old male Indian national died of coronary heart disease on Tuesday (23 June) after he had recovered from COVID-19 infection, the Ministry of Health (MOH) said.
The man, identified as case 28388, was sent to the emergency department at Singapore General Hospital after fainting in the early morning of Tuesday at a temporary housing site for migrant workers.
He was confirmed to have COVID-19 infection on 15 May, and had recovered from the infection.
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Patient who recovered from Covid-19 dies of heart disease
Singapore has recorded its 11th case of a patient who tested positive for the coronavirus but died from other causes.
The Ministry of Health (MOH) said in its update yesterday that a 48-year-old male Indian national, who was earlier assessed to have recovered from the coronavirus, died from ischaemic heart disease.
He fainted yesterday morning at a temporary housing site for migrant workers and was taken to the emergency department at Singapore General Hospital.
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10th person who had COVID-19 & died but not added to the official toll
A 44-year-old man who died earlier this week from heart disease had COVID-19, the Ministry of Health (MOH) said on Thursday (Jun 11). The Indian national, known as Case 39327, developed chest and epigastric pain on May 28 and sought medical treatment at a general practitioner, MOH said in its press release. On Monday, he was found unconscious at his place of residence and taken to Singapore General Hospital’s emergency department. Two days after his death, which MOH attributed to ischaemic heart disease, he was found to have had COVID-19.
The man is the 10th person who had COVID-19 and died but was not added to the official toll because the death was not caused by the coronavirus. Seven deaths were attributed to heart- or blood-related issues. One death was attributed to cerebral haemorrhage and another to multiple injuries from a fall. MOH did not specify the cause of death for one of the cases, except that it was not related to COVID-19.
In some cases where patients died due to blood clots or heart-related issues, the patients were only confirmed to have had COVID-19 after their deaths. “Only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to COVID-19 infection will be added to the COVID-19 death count,” MOH said. "This is consistent with international practice for classifying deaths."
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Covid-19 case dies of heart disease in Singapore, but not included in official death tally
On Thursday (June 11), the Ministry of Health (MOH) announced in its daily update that another person in Singapore who was positive for Covid-19 died. However, like several other people in the past few months who were also positive for the coronavirus, his death is not considered to be part of the national tally of fatalities stemming from Covid-19.
Singapore reported 327 new COVID-19 cases as of noon on Friday (Jul 17), with nine infections in the community, said the Ministry of Health (MOH).
This brings the total number of cases in the country to 47,453.
MOH said Case 47229, a 72-year-old Singaporean woman, died on Wednesday. "She had been conveyed to the National University Hospital’s emergency department on Jul 15 for reasons not related to COVID-19, and had a history of diabetes mellitus," the ministry added. She was confirmed to have COVID-19 infection on Jul 16 after her death. MOH said the cause of her death was confirmed to be intracerebral haemorrhage.
read more
13th person who had COVID-19 & died but not added to the official toll
The Ministry of Health (MOH) has reported another death in its evening press release on July 9. MOH stated that the 38-year-old male Bangladeshi national has passed away on July 7.
The man was admitted in to Ng Teng Fong General Hospital on June 28 after suffering a seizure, and subsequently developed intracranial haemorrhage. He was later tested with Covid-19 infection on the same day. The preliminary cause of death is reported to be cardiorespiratory failure, pending further investigations by the Coroner.
The death of this 38-year-old is not added to the death count of Covid-19. MOH explained that only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to Covid-19 infection will be added to the COVID-19 death count.
read more
12th person who had COVID-19 & died but not added to the official toll
On July 8, the Ministry of Health (MOH) reported that Case 45227, a 69 year-old male Singaporean, passed away on July 7, 2020. The man had been found unresponsive at his place of residence and was conveyed to Sengkang General Hospital’s emergency department on July 7. He was confirmed to have Covid-19 infection on the same day.
He had a history of diabetes mellitus, hypertension, hyperlipidaemia, hypothyroidism and chronic kidney disease. The preliminary cause of death is cardiorespiratory failure, pending further investigations by the Coroner.
As of July 8, 26 have passed away in Singapore from complications due to Covid-19 infection. Case 45227’s death was not added to the Covid-19 death count, as only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to Covid-19 infection will be counted.
read more
11th person who had COVID-19 & died but not added to the official toll
A 48-year-old male Indian national died of coronary heart disease on Tuesday (23 June) after he had recovered from COVID-19 infection, the Ministry of Health (MOH) said.
The man, identified as case 28388, was sent to the emergency department at Singapore General Hospital after fainting in the early morning of Tuesday at a temporary housing site for migrant workers.
He was confirmed to have COVID-19 infection on 15 May, and had recovered from the infection.
read more
Patient who recovered from Covid-19 dies of heart disease
Singapore has recorded its 11th case of a patient who tested positive for the coronavirus but died from other causes.
The Ministry of Health (MOH) said in its update yesterday that a 48-year-old male Indian national, who was earlier assessed to have recovered from the coronavirus, died from ischaemic heart disease.
He fainted yesterday morning at a temporary housing site for migrant workers and was taken to the emergency department at Singapore General Hospital.
read more
10th person who had COVID-19 & died but not added to the official toll
A 44-year-old man who died earlier this week from heart disease had COVID-19, the Ministry of Health (MOH) said on Thursday (Jun 11). The Indian national, known as Case 39327, developed chest and epigastric pain on May 28 and sought medical treatment at a general practitioner, MOH said in its press release. On Monday, he was found unconscious at his place of residence and taken to Singapore General Hospital’s emergency department. Two days after his death, which MOH attributed to ischaemic heart disease, he was found to have had COVID-19.
The man is the 10th person who had COVID-19 and died but was not added to the official toll because the death was not caused by the coronavirus. Seven deaths were attributed to heart- or blood-related issues. One death was attributed to cerebral haemorrhage and another to multiple injuries from a fall. MOH did not specify the cause of death for one of the cases, except that it was not related to COVID-19.
In some cases where patients died due to blood clots or heart-related issues, the patients were only confirmed to have had COVID-19 after their deaths. “Only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to COVID-19 infection will be added to the COVID-19 death count,” MOH said. "This is consistent with international practice for classifying deaths."
read more
Covid-19 case dies of heart disease in Singapore, but not included in official death tally
On Thursday (June 11), the Ministry of Health (MOH) announced in its daily update that another person in Singapore who was positive for Covid-19 died. However, like several other people in the past few months who were also positive for the coronavirus, his death is not considered to be part of the national tally of fatalities stemming from Covid-19.
The latest death is that of a 44-year-old male Indian national who died on June 8. The MOH update says he had been treated at a General Practitioner clinic on May 28 after developing pain in his chest and and the upper central part of his abdomen. It was confirmed that the man had Covid-19 on June 10, only after his death.
In the footnote to the MOH update it says, “Only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to COVID-19 infection will he be added to the COVID-19 death count. This is consistent with international practice for classifying deaths.” There are 10 such individuals who have tested positive for Covid-19 but are listed as having died from other causes.
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Why 3 positive cases who died from heart issues were not added to Singapore’s official death toll
Not adding COVID-19 patients who died of heart issues instead of the coronavirus to the official death toll is "consistent with international practice", the Ministry of Health (MOH) said. Three confirmed cases have died of heart issues and not of COVID-19 since the start of April. Their causes of death include ischaemic heart disease and heart attack, and their deaths were not included in the official death toll of 20. There have been medical reports linking COVID-19 with heart issues.
MOH said in response to CNA’s queries that it reports all deaths in patients infected with COVID-19. “However, we add to the COVID-19 death count the cases where the attending doctor or pathologist attribute the primary or underlying cause of death as due to COVID-19 infection," the health ministry said.
“This has been our consistent practice, applied for both Singaporeans and foreigners in Singapore. It is consistent with international practice for classifying deaths.”
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26 Covid-19 patients have passed away in S'pore so far but why are 12 not considered Covid-19 deaths?
On May 5, the Ministry of Health (MOH) announced that a 44-year-old male Bangladeshi national (Case 16370) had passed away earlier that day. However, his death was not classified as a Covid-19 death, as the cause was stated to be acute myocardial infarction, or a heart attack.
Singapore currently has 20 recorded Covid-19-linked deaths, but there have so far been an additional six Covid-19 patients reported to have died from causes deemed not to be complications from their Covid-19 infection.
Why are they not counted as Covid-19 deaths by the authorities? The answer, perhaps, lies in how Covid-19 deaths are classified according to the World Health Organisation (WHO) and MOH. Singapore's non-Covid-19 deaths:
How deaths of Covid-19 patients are classified
So, how are the cases in Singapore classified, and how was the decision made to not classify the other Covid-19-positive patient deaths as Covid-19 deaths?
The World Health Organization's (WHO) guidelines for classifying Covid-19 as the cause of death, updated on Apr. 20, defines a death due to Covid-19 as the following:
read more
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In the footnote to the MOH update it says, “Only cases where the attending doctor or pathologist attributes the primary or underlying cause of death as due to COVID-19 infection will he be added to the COVID-19 death count. This is consistent with international practice for classifying deaths.” There are 10 such individuals who have tested positive for Covid-19 but are listed as having died from other causes.
read more
Why 3 positive cases who died from heart issues were not added to Singapore’s official death toll
Not adding COVID-19 patients who died of heart issues instead of the coronavirus to the official death toll is "consistent with international practice", the Ministry of Health (MOH) said. Three confirmed cases have died of heart issues and not of COVID-19 since the start of April. Their causes of death include ischaemic heart disease and heart attack, and their deaths were not included in the official death toll of 20. There have been medical reports linking COVID-19 with heart issues.
MOH said in response to CNA’s queries that it reports all deaths in patients infected with COVID-19. “However, we add to the COVID-19 death count the cases where the attending doctor or pathologist attribute the primary or underlying cause of death as due to COVID-19 infection," the health ministry said.
“This has been our consistent practice, applied for both Singaporeans and foreigners in Singapore. It is consistent with international practice for classifying deaths.”
read more
26 Covid-19 patients have passed away in S'pore so far but why are 12 not considered Covid-19 deaths?
On May 5, the Ministry of Health (MOH) announced that a 44-year-old male Bangladeshi national (Case 16370) had passed away earlier that day. However, his death was not classified as a Covid-19 death, as the cause was stated to be acute myocardial infarction, or a heart attack.
Singapore currently has 20 recorded Covid-19-linked deaths, but there have so far been an additional six Covid-19 patients reported to have died from causes deemed not to be complications from their Covid-19 infection.
Why are they not counted as Covid-19 deaths by the authorities? The answer, perhaps, lies in how Covid-19 deaths are classified according to the World Health Organisation (WHO) and MOH. Singapore's non-Covid-19 deaths:
- Case 1604, 32-yr-old Indian national
- Case 3381, 80-yr-old Malaysian national
- Case 4754, 40-yr-old Malaysian national
- Case 8190, 46-yr-old Indian national
- Case 17410, 47-yr-old Bangladesh national
- Case 16370, 44-yr-old Bangladesh national
- A 53-yr-old Indian national died after suffering a cardiac arrest on 9 May 2020
- 50-yr-old Thai national known as Case 23908, died on Tue 12 May 2020
- Deaths of Indian & Thai nationals not linked to Covid-19 though tested positive
- Male Indian national dies of heart disease, later found to have COVID-19
- Male Indian national dies of heart disease, recovered earlier from COVID-19
- 69-yr-old Sporean man identified as Case 45227, died on Tuesday
- 38-yr-old Bangladeshi man with Covid-19 dies from cardiorespiratory failure
- 72-yr-old Sporean woman, died from brain haemorrhage on Wed
How deaths of Covid-19 patients are classified
So, how are the cases in Singapore classified, and how was the decision made to not classify the other Covid-19-positive patient deaths as Covid-19 deaths?
The World Health Organization's (WHO) guidelines for classifying Covid-19 as the cause of death, updated on Apr. 20, defines a death due to Covid-19 as the following:
- "A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma).
- There should be no period of complete recovery from COVID-19 between illness and death.
- A death due to COVID-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19."
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Reporting of COVID-19 deaths not 'clear-cut', official numbers may not reflect true toll: Expert
Reporting the number of deaths from COVID-19 is not as straightforward as it may seem due to several reasons, said infectious diseases expert Professor Dale Fisher on Thursday evening (Jul 23) in a webinar.
The chair of Infection Prevention and Control at the National University Health System (NUHS) highlighted this in an online talk which also featured the editor-in-chief of British medical journal the Lancet, Richard Horton. Giving an example of a person who was in a traffic accident, Professor Fisher said that in such a case, it was clear that just because the victim had COVID-19 did not mean that the cause of death was the disease.
"Having COVID-19 and dying does not mean you died from COVID-19. In short, it has to be resulting from a clinically compatible illness in a probable case," he said in a virtual lecture that is the latest in a series of COVID-19 updates organised by the National University of Singapore's Yong Loo Lin School of Medicine and NUHS.
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