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How Many Americans Have Really Died From COVID-19?

How Many Americans Have Really Died From COVID-19?

The pandemic’s death toll is likely much greater than previously thought. Here’s why.

Updated on October 30, 2020 at 3:00pm EDT.

The United States has seen nearly 300,000 “excess deaths” between late January and October 3, 2020, according to an October 20 report from the Centers for Disease Control and Prevention (CDC). That’s the difference between the number of deaths that were expected to occur during that time period and the number of people who actually died.

The grim statistic has sparked concerns that the COVID-19 death toll may be much higher than what’s been reported.

As of October 30, the CDC has confirmed more than 228,000 deaths from the disease in the U.S. This leaves many people wondering if thousands more have died from undiagnosed COVID-19 or causes stemming from the pandemic.

What should we make of the CDC’s new number?

Excess deaths: another way to estimate coronavirus deaths
Attributing deaths to a health crisis, such as the COVID-19 pandemic, is a complex task.

Researchers can look at surveillance data from reports made directly to the CDC. By law, doctors and labs are required to report cases of certain diseases, like anthrax, tetanus and COVID-19, to public health departments.

Researchers can also study death certificates, which tend to include more details based on more complete medical records. Scientists may even analyze other data sources, including funeral home or emergency medical services records as well as death scene investigation and news reports.

For the CDC study, rather than relying on surveillance data from states, territories and other jurisdictions, researchers first looked at death certificates, which are collated by the agency’s National Vital Statistics System.

They counted up all deaths—regardless of the cause listed on the certificates—between January 26, 2020 and October 3, 2020.

Next, they estimated how many deaths were expected to occur during that time period based on previous years. They did this with the help of statistics that account for seasonal changes, such as the fact that more people tend to die in winter.

After comparing the two numbers they estimated that 299,028 more people died from all causes than expected.

COVID-19 was indicated as a contributing factor or presumed cause of death in about two-thirds of these excess deaths. That indicator alone would yield an estimate of 198,081 COVID-19 deaths.

Why that’s not the full picture
Death certificates are not always complete or accurate. Some people who were either directly or indirectly killed by the virus may never have been diagnosed with it. For example, an older person who lived alone could have had undiagnosed COVID-19, gotten weak and died from a fall at home. After people die, they may not be tested for COVID-19. This can result in missed cases that ideally should have been picked up and listed on the death certificate.

Indirect deaths are also important. Deaths related to the pandemic can occur when people delay or can’t access medical care. That could happen if someone loses their job and health insurance, becomes homeless as a result of job loss, avoids emergency care out of fear of exposure to the infection, or if their local health system is overwhelmed or postponing some services, like surgery or chemotherapy.

Even social isolation related to social distancing and stay-at-home mandates could result in deaths from depression, suicide or substance abuse that might not otherwise have occurred.

In fact, there is troubling evidence of such harms. During the pandemic, many hospitals have noticed a steep decline in the number of patients arriving at emergency departments with life-threatening medical conditions, such as stroke, appendicitis or worsened heart failure. This suggests that some people are delaying care or waiting out their symptoms at home. It’s very possible that some died as a result.

But deaths like these can be hard to link to the virus. That’s why a count of excess deaths can paint a more accurate picture.

The CDC found that the uptick in excess mortality began in March 2020. During the week that ended April 11, the number of deaths was 40.4 percent higher than we should have expected based on recent years. During the week that ended August 8, it was 23.5 percent higher.

Some groups suffered more
After breaking the numbers down further by age group, race and ethnicity, the researchers found that some groups are being hit especially hard.

The biggest jump in deaths compared to previous years occurred in people between 25 and 44-years old. The researchers determined that about 26.5 percent of the deaths in that age group exceeded the expected number.

Among ethnic groups, Hispanic people experienced the highest percentage increase of deaths at 53.6 percent. That means that for every 153 deaths of Hispanic people during the time period the researchers studied, roughly 53 of those deaths would not have been expected to happen based on previous years.

Other racial and ethnic minorities also fared poorly. Among Black people, the excess was 32.9 percent; among people of Asian descent, it was 36.6 percent. And among non-Hispanic American Indian or Alaska Natives, it was 28.9 percent. By comparison, there was an 11.9 percent higher number of deaths than expected among white people.

Dispelling conspiracy theories
Following an early September 2020 CDC report, conspiracy theories emerged claiming that only a small percentage of reported COVID-19 deaths were actually due to the coronavirus. These theories, however, are based on a misreading of death certificates.

The CDC report indicated that 6 percent of death certificates listed COVID-19 as the sole cause of death. But that 6 percent was likely incomplete, as death certificates require that the certifier describe a full sequence of medical events leading to death.

For example, a person could pass away after developing COVID-19, then pneumonia, then respiratory failure. It’s inaccurate to say that respiratory failure, not COVID-19, is the reason a person died if COVID-19 is what caused them to be unable to breathe.

Death certificates should also list other health issues, or preexisting conditions, such as diabetes or chronic heart disease, that may have made someone more vulnerable to the effects of COVID-19. But just because an underlying health issue is listed alongside COVID-19 does not automatically make that other disease the cause of death.

Yes, COVID-19 has likely killed more people
The CDC analysis has limits. It doesn’t prove that any individual death is due to COVID-19. Some of the data on death might have been reported late, while recent death data may underestimate the actual number.

When the pandemic first began, for example, not everyone with COVID-19 had access to testing, likely including some who died. Estimates of the expected number of deaths are just that—estimates. It could also be that deaths are also surging this year for an unrelated reason.

But what the CDC learned from this analysis echoes another study that came to similar conclusions for the time period of March through July 2020. The evidence is mounting that reported COVID-19 deaths represent an underestimate of the true death toll of the pandemic.

Medically reviewed in October 2020.

Sources:
Centers for Disease Control and Prevention. “Weekly Updates by Select Demographic and Geographic Characteristics Provisional Death Counts for Coronavirus Disease 2019 (COVID-19).” Oct 28, 2020.
Centers for Disease Control and Prevention. “Excess Deaths Associated with COVID-19, by Age and Race and Ethnicity — United States, January 26–October 3, 2020.” Oct 23, 2020.
Centers for Disease Control and Prevention. “CDC COVID Data Tracker.” Oct 30, 2020.
National Library of Medicine. “Reportable diseases.” Oct 8, 2020.
Centers for Disease Control and Prevention. “Daily Updates of Totals by Week and State. Provisional Death Counts for Coronavirus Disease 2019 (COVID-19).” Oct 30, 2020.
Rolden HJ, Rohling JH, van Bodegom D, Westendorp RG. “Seasonal Variation in Mortality, Medical Care Expenditure and Institutionalization in Older People: Evidence from a Dutch Cohort of Older Health Insurance Clients.” PLoS One. 2015;10(11):e0143154. Published 2015 Nov 16.
DeJong C, Katz MH, Covinsky K. “Deferral of Care for Serious Non–COVID-19 Conditions: A Hidden Harm of COVID-19.” JAMA Intern Med. Published online October 26, 2020.
U.S. Department of Health and Human Services. “Instructions for Completing the Cause-of-Death Section of the Death Certificate.”
Kiang MV, Irizarry RA, Buckee CO, Balsari S. “Every Body Counts: Measuring Mortality From the COVID-19 Pandemic.” Ann Intern Med. 2020 Sep 11:M20-3100.

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