June 25, 2020

So far, officials have reported nearly 122,000 U.S. deaths tied to the novel coronavirus. But the country's epidemic likely has taken far more American lives than are included in that figure—and not just because of Covid-19, Markian Hawryluk reports for Kaiser Health News.

'Her death wasn't counted': Why many who die of Covid-19 don't show up in America's death tolls

Data suggests America's coronavirus deaths are undercounted

According to Hawryluk, data suggests that potentially thousands of Americans who died from the new coronavirus aren't being included in the country's official coronavirus death toll for several different reasons.

One major reason is tied to differences in how localities, states, and the federal government track and report coronavirus deaths.

For instance, CDC and New York previously had stipulated that officials should only report deaths as being tied to the coronavirus if the deceased individual had been tested for the virus and received a positive result. However, both CDC and New York eventually changed their policies in light of testing shortages throughout the United States. Now, both CDC and New York officials include cases in which a deceased individual had a "presumed" or "probable" case of the virus in their death counts, as well.

In addition, former acting CMS Administrator Andy Slavitt has pointed out that, in some states, it's common that patients who tested positive for the new coronavirus but who also had other health are not included in the states' official coronavirus death counts. Slavitt in a series of tweets posted last month wrote, "[A] number of states have decided that if you die from [Covid-19] but have another condition, you died from that other condition. … Have skin cancer? You didn't die from Covid. Have diabetes? You didn't die from Covid."

Further, some Americans who died from the new coronavirus may have died at home without ever seeking care or being tested for the virus. Those individuals' cause of death might not be reported on their death certificates, and the individuals therefore may not be included in official coronavirus death counts.

Tracking 'excess deaths'

According to Hawryluk, data showing the so-called "excess deaths" that have occurred in America since the country's coronavirus epidemic first began seems to support these theories.

Researchers are tracking the country's number of excess deaths by comparing the number of non-coronavirus deaths reported in each county so far in 2020 with the total number of deaths that occurred in each county during the same time in previous years—and they're finding some notable gaps.

New York City, for instance, reported more than 32,000 deaths from March 11 to May 2 of this year. Almost 14,000 of those deaths occurred among patients with confirmed coronavirus infections, and another 5,000 occurred among patients with probable cases of the new coronavirus. That means the city reported about 13,000 deaths that weren't tied to the new coronavirus from March 11 to May 2 of this year.

But during those same weeks in 2014 through 2019, before the new coronavirus emerged, the city reported an average total of 7,935 deaths—which is nearly 5,300 deaths lower than the number of deaths the city reported during March 11 to May 2 of this year. Those 5,300 deaths make up the city's excess death total for those weeks, because they represent the amount of deaths that occurred in the city that were unexplained and not in line with that the city typically sees.

New York City officials also reported an average of 200 at-home deaths per day during the city's peak of the epidemic, which was far higher than the average of 35 deaths per day that officials had reported during the same periods in 2013 through 2017.

Nationally, the number of excess deaths that have occurred since the coronavirus epidemic began has followed a similar trend, Hawryluk reports. For example, she notes that an analysis from the Health Care Cost Institute that looked at obituaries published across the United States found that the number of deaths that occurred in April of this year was about 12% higher when compared with the average number of deaths that occurred in April from 2014 through 2019.

Many experts believe that a portion of the excess deaths that have occurred in the country so far this year is directly tied to the coronavirus.

"The excess mortality tells the story," Jeremy Faust, an emergency medicine physician at Brigham and Women's Hospital, told Hawryluk. "We can see that [Covid-19] is having a historic effect on the number of deaths in our community."

Some excess deaths may be indirectly tied to the epidemic

But Hawryluk reports that a portion of the excess deaths that have occurred throughout the country this year may stem from the epidemic in a less direct fashion.

For instance, Hawryluk reports that some Americans may have died as the result of delaying care for other medical conditions, either because they feared they could be exposed to the new coronavirus at medical facilities or because of issues related to their insurance coverage or finances due to employment losses tied to the epidemic. Hospitals across the country had reported seeing decreases in non-Covid patients as the new coronavirus swept through the nation.

And some doctors are worried that death toll could continue to grow, as delaying or not seeking care for critical and chronic conditions could lead to long-lasting health consequences.

"You're not necessarily going to see the direct effect of poor diabetes management now, but when you start having kidney dysfunction and other problems in 12 to 18 months, that's the … result of the [epidemic]," Payal Kohli, a cardiologist, told Hawryluk. "As we're flattening the curve of the [epidemic], we're actually steepening all these other curves."

Some of the excess deaths also may be tied to an increase in so-called "deaths of despair" driven by the isolation people could experience as a result of social distancing or being unable to connect with services critical to their health, such as support groups for individuals with substance use disorders, according to Hawryluk.

Hawryluk reports that 32-year-old Sara Wittner had recently completed a 30-day detox program and was receiving monthly injections to treat an opioid use disorder. Wittner was working for a local health association, was counseling others with substance use disorders, and was regularly attending in-person Narcotics Anonymous meetings and sessions with a recovery sponsor.

However, the country's coronavirus epidemic began, those in-person meetings and sessions were canceled, and an appointment Wittner had at the hospital for her monthly injection was delayed by 15 days. On April 12, Wittner again began misusing opioids—and she died from a fentanyl overdose one day before her appointment at the hospital, Hawryluk reports.

"Anybody … struggling with a substance [use] disorder, anybody [who] has an alcohol issue and anybody with mental health issues, all of a sudden, whatever safety nets they had for the most part are gone" due to the coronavirus epidemic, Wittner's father told Hawryluk. "And those are people … living right on the edge of" death, he said.

"People lose their jobs and they lose their sense of purpose and become despondent, and you sometimes see them lose their lives," said Benjamin Miller, chief strategy officer at Well Being Trust, which recently released a report predicting that up to 75,000 people could die from suicide, a drug-related overdose, or alcohol misuse as a result of uncertainty and unemployment caused by the country's coronavirus epidemic.

And health experts say the excess deaths that are tied to, but not directly caused by, the epidemic may never be properly accounted for—particularly because these types of excess deaths could continue for months, and perhaps even years, after the epidemic ends with no uniform way to report them.

"All those things, unfortunately, are not going to be determined by the death record," Oscar Alleyne, chief of programs and services for the National Association of City and County Health Officials, told Hawryluk (Hawryluk, Kaiser Health News, 6/23).

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