"Introduction
... Since the beginning of the SARS-CoV-2 pandemic, there has been an ongoing debate on the definition of the COVID-19-attributable death. The European Center for Disease Control (ECDC) uses the guidelines issued by the World Health Organization (WHO), defining for surveillance purposes as COVID-19-attributable deaths all deaths 'resulting from a clinically compatible illness in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g., trauma)'. In the UK, Denmark, and other countries, all deaths, for which a positive SARS-CoV-2 PCR test was recorded within the 30 days prior to the date of death, were registered as COVID-19 deaths.
In Greece, a more concise and simple definition was used, defining as COVID-19-associated death, any death occurring in a person with positive testing for SARS-CoV-2 at the time of death...
The aim of this study was to assess whether in-hospital deaths, registered as COVID-19-associated deaths, in seven tertiary-care hospitals in the greater area of Athens, Greece, during the Omicron surge, were attributed to COVID-19 or to other causes...
Discussion
In this retrospective, observational study, we found that of 530 in-hospital deaths, who have been registered as COVID-19 deaths, in seven Greek hospitals during the Omicron wave, only 290 (54.7%) were 'due' to COVID-19. The rest were found to be deaths 'with' COVID-19. This is the first study based not solely on death certificates, but also on data extracted by expert physicians from the chart file of each individual patient, and on the opinion of the caring physician. We found that patients who died 'with' COVID-19 were more likely to be younger, to be admitted for any other cause but COVID-19, to have had malignancy or immunosuppression, and to have been infected in the hospital. Patients who did not exhibit COVID-19-related symptoms essentially did not experience the active effects of the infection. As a result, their deaths were not considered to be directly caused by COVID-19. This suggests that the absence of symptoms may indicate a lack of significant COVID-19-related impact, even if the virus was present...
In conclusion, we found that 45.28% of the deaths registered as COVID-19 deaths, in seven hospitals in Athens Greece, were reassessed as not directly attributable to COVID-19 in our analysis, but reflected the wide transmission of the Omicron variant in the community."
© The Author(s) 2025
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