Guidance for Certifying Deaths Due to
Coronavirus Disease 2019 (COVID–19)



Introduction
In December 2019, an outbreak of a respiratory disease
associated with a novel coronavirus was reported in the city of
Wuhan in the Hubei province of the People's Republic of China
(1). The virus has spread worldwide and on March 11, 2020, the
World Health Organization declared Coronavirus Disease 2019
(COVID–19) a pandemic (2). The first case of COVID–19 in the
United States was reported in January 2020 (3) and the first death
in February 2020 (4), both in Washington State. Since then, the
number of reported cases in the United States has increased and
is expected to continue to rise (5).
In public health emergencies, mortality surveillance provides
crucial information about population-level disease progression,
as well as guides the development of public health interventions
and assessment of their impact. Monitoring and analysis of
mortality data allow dissemination of critical information to
the public and key stakeholders. One of the most important
methods of mortality surveillance is through monitoring causes
of death as reported on death certificates. Death certificates
are registered for every death occurring in the United States,
offering a complete picture of mortality nationwide. The death
certificate provides essential information about the deceased
and the cause(s) and circumstances of death. Appropriate
completion of death certificates yields accurate and reliable data
for use in epidemiologic analyses and public health reporting.
A notable example of the utility of death certificates for public
health surveillance is the ongoing monitoring of pneumonia and
influenza deaths. Accurate and timely death certificate data are
integral to detecting elevated levels of influenza activity in real
time (https://www.cdc.gov/flu/weekly/index.htm).
Monitoring the emergence of COVID–19 in the United States
and guiding public health response will also require accurate
and timely death reporting. The purpose of this report is to
provide guidance to death certifiers on proper cause-of-death
certification for cases where confirmed or suspected COVID–19
infection resulted in death. As clinical guidance on COVID–19
evolves, this guidance may be updated, if necessary. When
COVID–19 is determined to be a cause of death, it is important
that it be reported on the death certificate to assess accurately the
effects of this pandemic and appropriately direct public health
response.
Cause-of-Death Reporting
When reporting cause of death on a death certificate, use any
information available, such as medical history, medical records,
laboratory tests, an autopsy report, or other sources of relevant
information. Similar to many other diagnoses, a cause-of-death
statement is an informed medical opinion that should be based
on sound medical judgment drawn from clinical training and
experience, as well as knowledge of current disease states and
local trends (6).
Part I
This section on the death certificate is for reporting the sequence
of conditions that led directly to death. The immediate cause of
death, which is the disease or condition that directly preceded
death and is not necessarily the underlying cause of death
(UCOD), should be reported on line a. The conditions that led
to the immediate cause of death should be reported in a logical
sequence in terms of time and etiology below it.
The UCOD, which is “(a) the disease or injury which initiated
the train of morbid events leading directly to death or (b) the
circumstances of the accident or violence which produced the
fatal injury” (7), should be reported on the lowest line used in
Part I.
Approximate interval: Onset to death
For each condition reported in Part I, the time interval between
the presumed onset of the condition, not the diagnosis, and death
should be reported. It is acceptable to approximate the intervals
or use general terms, such as hours, days, weeks, or years.
Part II
Other significant conditions that contributed to the death, but
are not a part of the sequence in Part I, should be reported in
Part II. Not all conditions present at the time of death have to
be reported—only those conditions that actually contributed to
death.
Vital Statistics Reporting Guidance
U.S. Department of Health and Human Services • Centers for Disease Control and Prevention • National Center for Health Statistics • National Vital Statistics System
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Certifying deaths due to COVID–19
If COVID–19 played a role in the death, this condition should
be specified on the death certificate. In many cases, it is
likely that it will be the UCOD, as it can lead to various lifethreatening conditions, such as pneumonia and acute respiratory
distress syndrome (ARDS). In these cases, COVID–19 should
be reported on the lowest line used in Part I with the other
conditions to which it gave rise listed on the lines above it.
Generally, it is best to avoid abbreviations and acronyms, but
COVID–19 is unambiguous, so it is acceptable to report on the
death certificate.
In some cases, survival from COVID–19 can be complicated by
pre-existing chronic conditions, especially those that result in
diminished lung capacity, such as chronic obstructive pulmonary
disease (COPD) or asthma. These medical conditions do not
cause COVID–19, but can increase the risk of contracting a
respiratory infection and death, so these conditions should be
reported in Part II and not in Part I.
When determining whether COVID–19 played a role in the
cause of death, follow the CDC clinical criteria for evaluating a
person under investigation for COVID–19 and, where possible,
conduct appropriate laboratory testing using guidance provided
by CDC or local health authorities. More information on CDC
recommendations for reporting, testing, and specimen collection,
including postmortem testing, is available from: https://www.
cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html and
https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidancepostmortem-specimens.html. It is important to remember that
death certificate reporting may not meet mandatory reporting
requirements for reportable diseases; contact the local health
department regarding regulations specific to the jurisdiction.
In cases where a definite diagnosis of COVID–19 cannot
be made, but it is suspected or likely (e.g., the circumstances
are compelling within a reasonable degree of certainty), it
is acceptable to report COVID–19 on a death certificate as
“probable” or “presumed.” In these instances, certifiers should
use their best clinical judgement in determining if a COVID–19
infection was likely. However, please note that testing for
COVID–19 should be conducted whenever possible.
Common problems
Common problems in cause-of-death certification include:
1. reporting intermediate causes as the UCOD (i.e., on the
lowest line used in Part I),
2. lack of specificity, and
3. illogical sequences.
Intermediate causes are those conditions that typically have
multiple possible underlying etiologies and thus, a UCOD must
be specified on a line below in Part I. For example, pneumonia
is an intermediate cause of death since it can be caused by a
variety of infectious agents or by inhaling a liquid or chemical.
Pneumonia is important to report in a cause-of-death statement
but, generally, it is not the UCOD. The cause of pneumonia,
such as COVID–19, needs to be stated on the lowest line used
in Part I.
Additionally, the reported UCOD should be specific enough to
be useful for public health and research purposes. For example,
a “viral infection” can be a UCOD, but it is not specific. A more
specific UCOD in this instance could be “COVID–19.”
All causal sequences reported in Part I should be logical in terms
of time and pathology. For example, reporting “COVID–19” due
to “chronic obstructive pulmonary disease” in Part I would be an
illogical sequence as COPD cannot cause an infection, although
it may increase susceptibility to or exacerbate an infection. In
this instance, COVID–19 would be reported in Part I as the
UCOD and the COPD in Part II. While there can be reasonable
differences in medical opinion concerning a sequence that led
to a particular death, the causes should always be provided in a
logical sequence from the immediate cause on line a. back to the
UCOD on the lowest line used in Part I.
Manner of death
The manner of death, sometimes referred to as circumstances of
death, is also reported on death certificates. Natural deaths are
due solely or almost entirely to disease or the aging process (8).
In the case of death due to a COVID–19 infection, the manner of
death will almost always be natural.
When to Refer to a Medical Examiner or
Coroner
Some jurisdictions have requirements for referring deaths
involving threats to public health to the medical examiner
or coroner, so certifiers should follow the regulations in the
jurisdiction in which the death occurred. As always, if a death
involved an injury, poisoning, or complications thereof, then the
case should be referred. The local medical examiner or coroner
should be consulted with questions on referral requirements.
Conclusion
An accurate count of the number of deaths due to COVID–19
infection, which depends in part on proper death certification,
is critical to ongoing public health surveillance and response.
When a death is due to COVID–19, it is likely the UCOD and
thus, it should be reported on the lowest line used in Part I of
the death certificate. Ideally, testing for COVID–19 should be 
Vital Statistics Reporting Guidance
U.S. Department of Health and Human Services • Centers for Disease Control and Prevention • National Center for Health Statistics • National Vital Statistics System
3
conducted, but it is acceptable to report COVID–19 on a death
certificate without this confirmation if the circumstances are
compelling within a reasonable degree of certainty.
For more guidance and training on cause-of-death reporting
in general, see the Cause of Death mobile app available
from: https://www.cdc.gov/nchs/nvss/mobile-app.htm and the
Improving Cause of Death Reporting online training module
available from: https://www.cdc.gov/nchs/nvss/improving_
cause_of_death_reporting.htm (free Continuing Medical
Education credits and Continuing Nursing Education credits
available). For current information on the COVID–19 outbreak,
see the CDC website at: https://www.cdc.gov/coronavirus/2019-
nCoV/index.html.
References
1. World Health Organization. Novel coronavirus—China.
Geneva, Switzerland. 2020. Available from: https://www.
who.int/csr/don/12-january-2020-novel-coronaviruschina/en/.
2. World Health Organization. WHO Director-General’s
opening remarks at the media briefing on COVID–19—11
March 2020. Geneva, Switzerland. 2020. Available from:
https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-oncovid-19---11-march-2020.
3. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman
J, Bruce H, et al. First case of 2019 novel coronavirus in
the United States. N Engl J Med. 382(10):929–36. 2020.
Available from: https://www.nejm.org/doi/full/10.1056/
NEJMoa2001191.
4. Centers for Disease Control and Prevention. CDC,
Washington state report first COVID–19 death [press
release]. 2020. Available from: https://www.cdc.gov/
media/releases/2020/s0229-COVID-19-first-death.html.
5. Centers for Disease Control and Prevention. CDC confirms
possible instance of community spread of COVID–19 in
U.S. [press release]. 2020. Available from: https://www.
cdc.gov/media/releases/2020/s0226-Covid-19-spread.
html.
6. National Center for Health Statistics. Physician’s handbook
on medical certification of death. Hyattsville, MD: National
Center for Health Statistics. 2003.
7. World Health Organization. International statistical
classification of diseases and related health problems, 10th
revision (ICD–10), Volume 2. 5th ed. Geneva, Switzerland.