Italy didn’t change its definition of COVID-19 deaths; the disease killed more than 130,000 Italians

Key takeaway

When physicians determine what caused a person to die, the underlying cause of death is defined as a medical event that triggers a chain of clinical reactions leading to the death of a patient. Pre-existing medical conditions may weaken a patient’s resistance to diseases, but they aren’t the cause of death. Deaths are attributed to COVID-19 if the patient had a SARS-CoV-2 infection and the clinical circumstances of the death are compatible with the disease. Even though most people in Italy who were classified as COVID-19 deaths had pre-existing conditions, COVID-19 was medically determined to be responsible for their death.

Reviewed content

Verdict:

Flawed reasoning

Claim:

“Italian Higher Institute of Health has drastically reduced the country’s official COVID death toll number by over 97% after changing the definition of a fatality to someone who died from COVID rather than with COVID”

Verdict detail

Flawed Reasoning: By considering that people with pre-existing medical conditions shouldn’t be counted as deaths due to COVID-19, the claim conflates the notions of underlying cause of death and comorbidity.
Inaccurate: The Italian Higher Institute of Health didn’t change its definition of COVID-19 deaths. COVID-19 is considered as a cause of death if the patient had been diagnosed with COVID-19 and if the chain of clinical events leading to death was compatible with what is known from the disease, and if no other cause of death could be found.

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Full Claim

“Italian Higher Institute of Health has drastically reduced the country’s official COVID death toll number by over 97% after changing the definition of a fatality to someone who died from COVID rather than with COVID”; “only 3,783 are directly attributable to the virus alone”

In early 2020, during the first months of the COVID-19 pandemic, Italy became one of the hardest hit countries in the world. As of 9 November 2021, the country saw more than 130,000 deaths from COVID-19.

In November 2021, several websites claimed that Italian health authorities had “drastically reduced the country’s official COVID death toll number by over 97 per cent after changing the definition of a fatality to someone who died from COVID rather than with COVID”. This claim received more than 160,000 interactions on social media. It originated from the Italian newspaper Il Tempo, which reported that only 2.9% of the deaths registered as COVID-19 deaths in Italy were actually due to the disease.

As supporting evidence, Il Tempo cited a statistical study from the Italian National Institute of Health (the Istituto Superiore di Sanità or ISS in Italian) reporting that 97.1% of COVID-19 deaths occurred among patients with at least one pre-existing medical condition such as hypertension or diabetes.

The reasoning behind the claim, as Il Tempo described it, is that these people already suffered from conditions “that were already leaving them with little hope”, therefore, their deaths cannot be considered as directly due to COVID-19.

However, this interpretation is flawed and stems from a confusion between a “comorbidity” and a “cause of death”. Thus, this claim by Il Tempo is yet another iteration of the recurring misinformation about people dying with COVID-19, not from COVID-19. Health Feedback previously explained the flawed logic of similar claims. Here again, we show how the same mistakes led Il Tempo to the same erroneous conclusion.

First, Italian health authorities didn’t change their definition of a COVID-19 death nor did they reduce the number of COVID-19 deaths recorded after revising the figure. Indeed, the ISS came forward to refute the claim, declaring that “nowhere in the study is it affirmed that only 2.9% of deaths attributed to COVID-19 are due to the virus”. Furthermore, the ISS added that “COVID-19 is directly responsible for the death of 89% of the SARS-CoV-2 positive deceased patients”.

In order to understand why the claim’s analysis of ISS data is flawed, we need to understand the difference between an underlying cause of death and a comorbidity.

As defined by the World Health Organization (WHO) and the ISS in their respective guidelines for determining COVID-19 deaths, the underlying cause of death is the event that triggered the chain of medical reactions leading to the patient’s demise. The ISS and WHO guidelines clearly explain that COVID-19 is considered as the underlying cause of death only if the symptoms and the chain of events leading to death are compatible with what is known of the disease and if no other clear cause of death is possible.

Comorbidities are aggravating factors that decrease the overall health of the patient and weaken their ability to survive COVID-19. Hence, the major difference between a cause of death and a comorbidity is that comorbidities don’t trigger the series of events leading to the patient’s death.

Thus, a person dies from an underlying cause of death, but dies with comorbidities. In many cases, if the cause of death, like a disease or injury, had been avoided, those patients with comorbidities—including pre-existing conditions like diabetes—wouldn’t have died at that time. In other words, the comorbidities present in 97.1% of the deceased patients didn’t kill them. When interviewed by the Italian newspaper La Repubblica, Graziano Onder, director of the department of cardiovascular, endocrine and metabolic diseases and ageing at the ISS, declared:

“It is false that only 2.9% of deaths are due to COVID-19. Granted, the large majority of the dead are people who had pre-existing conditions but who very often were in a good health balance, and would have lived many more years.”

Indeed, medical conditions such as diabetes or hypertension can be routinely managed with treatments. While they make the patients more vulnerable, one can live many years with these medical conditions. Therefore, the presence of comorbidities among many deceased patients doesn’t change the fact that COVID-19 killed them.

Another important observation is that Italy and many other countries experienced excess deathsin 2020 and 2021 in terms of all-cause mortality. When comparing the number of deaths in Italy during this period to the average number of deaths in the previous years, many more people died in 2020 and 2021 than we would have expected based on all-cause mortality from previous years. There is no plausible explanation for why people with diabetes, hypertension, or Alzheimer’s disease would suddenly die at a higher rate during 2020 or 2021 compared to previous years. Therefore, it is more likely that the emergence of a new disease, COVID-19, caused most of the excess deaths.

In summary, Italy didn’t change its definition of COVID-19 deaths. While some people who died from COVID-19 may have suffered from pre-existing conditions, their symptoms showed that it was the SARS-CoV-2 infection that caused their death.