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PRDoH MSS is a passive surveillance system that was enhanced for the COVID-19 response by including additional data sources to verify information on deaths attributed to COVID-19. PRDoH MSS includes information on deaths from regional epidemiologists, vital statistics from physicians, and COVID-19 laboratory results (confirmed [RT-PCR molecular test for SARS-CoV-2 RNA] and probable [SARS-CoV-2 serology test])8,9 from Puerto Rico’s laboratory reporting system and the National Electronic Disease Surveillance System Base System.10 The National Electronic Disease Surveillance System Base System is an integrated information system developed by the Centers for Disease Control and Prevention (CDC) to help local, state, and territorial public health departments, such as PRDoH, manage notifiable disease data and send reports to CDC. Puerto Rico’s regional epidemiologists receive death information from all hospitals and collect and verify additional COVID-19 death data, including pending laboratory test results, requested by the central PRDoH MSS team. Regardless of where the COVID-19 death occurs (hospital, other health care facility, or home), death certificates are completed by physicians and sent to vital statistics. The PRDoH MSS central team links its data with data on COVID-19 deaths from vital statistics using the International Classification of Diseases, Tenth Revision code U07.1, COVID-19.11 The PRDoH MSS central team reconciles classification (confirmed or probable) from all reporting sources and reports the daily number of deaths (per date of death) due to COVID-19 into an electronic centralized system at the PRDoH. Deaths that were undefined or under investigation were reviewed by a multidisciplinary team when COVID-19 testing (confirmed and probable) and clinical or pathology information became available. Because public health surveillance data collected by PRDoH and analyzed in this article are not considered research, no institutional review board review was required.

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