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.