Estimating and Characterizing COVID-19 Deaths, Puerto Rico, March-July 2020

Abstract

Objectives: Using the Council of State and Territorial Epidemiologists (CSTE) classification guidelines, we characterized coronavirus disease 2019 (COVID-19)-associated confirmed and probable deaths in Puerto Rico during March-July 2020. We also estimated the total number of possible deaths due to COVID-19 in Puerto Rico during the same period.

Methods: We described data on COVID-19-associated mortality, in which the lower bound was the sum of confirmed and probable COVID-19 deaths and the upper bound was excess mortality, estimated as the difference between observed deaths and average expected deaths. We obtained data from the Puerto Rico Department of Health COVID-19 Mortality Surveillance System, the Centers for Disease Control and Prevention's National Electronic Disease Surveillance System Base System, and the National Center for Health Statistics.

Results: During March-July 2020, 225 COVID-19-associated deaths were identified in Puerto Rico (119 confirmed deaths and 106 probable deaths). The median age of decedents was 73 (interquartile range, 59-83); 60 (26.7%) deaths occurred in the Metropolitana region, and 140 (62.2%) deaths occurred among men. Of the 225 decedents, 180 (83.6%) had been hospitalized and 93 (41.3%) had required mechanical ventilation. Influenza and pneumonia (48.0%), sepsis (28.9%), and respiratory failure (27.1%) were the most common conditions contributing to COVID-19 deaths based on death certificates. Based on excess mortality calculations, as many as 638 COVID-19-associated deaths could have occurred during the study period, up to 413 more COVID-19-associated deaths than originally reported.

Conclusions: Including probable deaths per the CSTE guidelines and monitoring all-cause excess mortality can lead to a better estimation of COVID-19-associated deaths and serve as a model to enhance mortality surveillance in other US jurisdictions.

Keywords: COVID-19; Puerto Rico; excess deaths; mortality; surveillance.

Figure

Number of laboratory-confirmed (n = 119) and probable (n = 106) COVID-19–associated deaths and total estimated excess deaths, Puerto Rico, March–July 2020. A death case is a person meeting confirmatory laboratory evidence (reverse transcriptase–polymerase chain reaction [RT-PCR] molecular test) during March–July 2020 reported by the Puerto Rico Department of Health. A death case is a person meeting 1 of the following criteria: (1) meets clinical criteria and epidemiological evidence without a positive RT-PCR molecular test result, (2) meets a presumptive laboratory evidence (serology antibody test) and either clinical criteria or epidemiological evidence, or (3) meets vital records criteria (“a death certificate that lists COVID-19 disease or SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] as a cause of death or significant condition contributing to death”) without a positive RT-PCR molecular test during March 17–July 31, 2020 (calendar weeks 12-31) reported by the Puerto Rico Department of Health. Total excess all-cause deaths reported by the National Center for Health Statistics were estimated using the Farrington surveillance algorithm with the data from 2013 through July 31, 2020, as the difference between observed and expected deaths during March 2–August 2, 2020 (calendar weeks 10-31). Negative excess death estimates were set to zero and are not depicted. Abbreviation: COVID-19, coronavirus disease 2019.