Please note: because this piece is specifically about COVID-19, it goes to all subscribers, paid and unpaid. I just simply cannot bring myself to try to make money off sharing COVID-19 information. Paid subscribers will get a separate and exclusive piece later today about the situation with China. But everyone needs to read this one.

I hate to do a Vox style explainer on this, but I already see people on the right asserting some pretty wild claims about this New York Times story and I actually did pick up the phone, talk to people at the CDC, and have an accurate understanding of what is going on.

First, here is the story that has people riled up:

New York City, already a world epicenter of the coronavirus outbreak, sharply increased its death toll by more than 3,700 victims on Tuesday, after officials said they were now including people who had never tested positive for the virus but were presumed to have died of it. The new figures, released by the city’s Health Department, drove up the number of people killed in New York City to more than 10,000, and appeared to increase the overall United States death count by 17 percent to more than 26,000.

It makes it look like New York is trying to exacerbate the death toll. Actually, what New York is now doing brings COVID-19 death analysis in line with flu analysis.

Most people skimmed over the bottom of the article.

New York City has been reporting the probable cases to the federal National Center for Health Statistics for more than a week, health officials said. But Dr. Barbot said that the city would continue reporting only confirmed cases to the Centers for Disease Control and Prevention for its coronavirus tracker, because the agency requested those statistics. “We are more than happy to report on probables,” she said. The C.D.C., in its guidance to local governments, has recommended that cases of “assumed” coronavirus infection be noted on death certificates since before New York City recorded its first death on March 14. On Tuesday, the city’s count of confirmed cases went up to 6,589.

What gives?

The CDC had guided local governments that they should note presumptions of COVID-19 as causes of death on death certificates but had also only wanted confirmed cases in its overall listing of deaths in the CDC database. New York is still only going to send the CDC what it wants for its tracking data, i.e. confirmed cases only, but will now follow CDC guidelines for death certificates and make that information public.

What the CDC is doing for tracking purposes is tracking the confirmed spread nationally with testing. This is different from how the CDC tracks seasonal flu. Essentially, the CDC is asking states to only send it confirmed COVID-19 tests, but keep information handy on presumptive deaths for later review.

In 2009, the CDC changed the way the seasonal flu was tracked. Prior to 2009, the CDC only tracked confirmed flu cases. But in 2009 with the H1N1 outbreak, the CDC also started keeping count of presumptive flu cases. Here is the CDC revised guidance from 2009:

Beginning August 30, 2009, CDC modified this surveillance and asked states to report either laboratory confirmed hospitalizations and deaths or syndromic cases, i.e. cases of presumed influenza and/or pneumonia based on ICD-9 coded hospitalizations or death reports each week. This is a new system will be used to monitor trends in hospitalizations and deaths. CDC believes this system will provide a fuller picture of the burden of serious flu illness and deaths during this pandemic. This number will be cross-checked periodically against modeling studies to assess its validity. CDC has provided guidance for states on how to count and report these cases.

The CDC changed the guidelines for a number of reasons. First, “there are too many cases of flu to test and confirm so laboratory-confirmed data is a vast underestimate of the true number of cases.” Second, “influenza and pneumonia syndrome are diagnostic codes used by all hospitals. Capturing this number will reflect a fuller picture of influenza and influenza-related serious illness and deaths in the United States during the pandemic.”

Currently, with COVID-19, to get a very accurate picture, the CDC has used only confirmed testing in its nationwide reporting. But we know testing is insufficient. As a result, just like with the flu, the CDC is asking states to keep a record of presumed cases for later analysis and to accurately document on death certificates if COVID-19 is suspected.

How do they know COVID-19 is suspected? Well, if someone has all the symptoms and we know they either were around an infected person before the symptoms or others got it after coming into contact with them, we can be sure they had COVID-19 even if they did not get tested. Likewise, if they have air sac damage and symptoms consistent with COVID-19, we can know they had it, even if they did not get a test.

The New York Times may not have explained this well, but it is not difficult to understand.

Put more broadly, we have been comparing COVID-19 confirmed deaths to flu deaths, which have included both confirmed and presumed deaths. What New York City is now doing is providing a better apples to apples comparison. Now, in their public release of data, New York City will have confirmed and presumed COVID-19 deaths just as all previous reports of flu deaths in New York had both confirmed and presumed deaths in that total.

This gives us a fuller picture of what is happening. There’s no conspiracy and no effort to make it seem worse than it is. The situation is bad. Getting an accurate picture of just how bad it is makes sense.

Why NYC Adjusted Its Death Count for COVID-19