https://www.washingtonpost.com/investigations/2020/04/27/covid-19-death-toll-undercounted/?arc404=true
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Investigations
U.S. deaths soared in
early weeks of pandemic, far exceeding number attributed to covid-19
An analysis of federal data for
the first time estimates excess deaths -- the number beyond what would normally
be expected -- during that period.
By Emma Brown ,
Andrew Ba Tran ,
Beth Reinhard and
Monica Ulmanu
April 27 at 11:11 AM
Sources:
Overall death data comes from the National Center for Health Statistics,
covid-19 death counts come from state health departments and are compiled by
The Washington Post, and estimates for expected deaths come from Yale School of
Public Health’s Modeling Unit.
In the early weeks of the
coronavirus epidemic, the United States recorded an estimated 15,400 excess
deaths, nearly two times as many as were publicly attributed to covid-19 at the
time, according to an analysis of federal data conducted for The Washington
Post by a research team led by the Yale School of Public Health.
The excess deaths — the number
beyond what would normally be expected for that time of year — occurred during
March and through April 4, a time when 8,128 coronavirus deaths were reported.
The excess deaths are not
necessarily attributable directly to covid-19, the disease caused by the
coronavirus. They could include people
who died because of the epidemic but not from the disease, such as those
who were afraid to seek medical treatment for unrelated illnesses, as well as
some number of deaths that are part of the ordinary variation in the death
rate. The count is also affected by increases or decreases in other categories
of deaths, such as suicides, homicides and motor vehicle accidents.
But in any pandemic,
higher-than-normal mortality is a starting point for scientists seeking to
understand the full impact of the disease.
The Yale analysis for the first time estimates excess deaths, both
nationally and in each state, in those five weeks. Relying on data that
the National Center for Health Statistics (NCHS) released Friday, the
analysis paints a picture of unusually high mortality that will come into
sharper view as more data becomes available.
The analysis calculates excess
deaths by using a model to estimate how many people probably would have died
absent the pandemic, and then subtracting that number from the overall deaths
reported by the NCHS.
The analysis suggests that the
deaths announced in the weeks leading up to April 4, based on reports
from state public health departments, failed to capture the full impact of the
pandemic. Those incomplete numbers were widely cited at a time when many states
were making critical decisions about closing businesses and taking other
actions to stem the spread of the virus.
The analysis also suggests that
the death toll from the pandemic is significantly
higher than has been reported, said Daniel Weinberger, a Yale professor of
epidemiology and the leader of the research team. As of Sunday, more than
54,000 people had been killed by the novel coronavirus, according to
numbers reported by state health departments and compiled by The Post.
“It’s really important to get the
right numbers to inform policymakers so they can understand how the epidemic is
evolving and how severe it is in different places,” Weinberger said.
The national tally also shapes
the public’s perception of how serious the disease is, and therefore how
necessary it is to continue social distancing despite economic disruption. The
figure has political implications for President Trump, who initially played
down the threat of the virus and whose administration failed to ramp up
covid-19 testing quickly, allowing the virus to spread undetected for weeks.
Some of Trump’s defenders have
claimed that covid-19 death figures are inflated because they may include
people who died with the disease but not of it.
“The death toll is being
held up by everyone, really, as a pretty direct metric for assessing the competence of the federal response,”
said Jeremy Konyndyk, a former USAID official who helped lead the U.S. response
to the Ebola outbreak and other international disasters during the Obama
administration.
The problem of undercounting
coronavirus deaths is not unique to this pandemic or to the United States. In
many countries, insufficient testing
is a major obstacle to understanding the scale of the pandemic.
In the United States, public
health experts say reporting lags, along with the fact that nearly every state
initially counted only cases in which the coronavirus was confirmed through a
test, contributed to an incomplete picture of deaths in those early weeks.
The NCHS recently started keeping
its own tally of covid-19 deaths, separate from the tallies based on states’
reports to the Centers for Disease Control and Prevention.
The NCHS’s tally, based on death
certificates, attempts to correct for reporting lags and includes cases that
lacked a lab confirmation of the coronavirus. But even the NCHS covid-19 death
total from those early weeks — 10,505 as of Sunday — is only two-thirds of the
excess deaths in the Yale estimate.
No jurisdiction has been as
aggressive as New York City, the U.S. epicenter of the epidemic, in revising
its death counts from those early weeks. As of Saturday, the city had added
2,542 covid-19 deaths to those figures, driving the total from that period up
to 5,085. The newly added deaths were almost equally split between cases that
were confirmed through lab testing and cases that were deemed “probable”
covid-19 deaths based only on symptoms and exposure.
All figures are for March through April 4. New York City
and Washington state have since updated their numbers for this period. New York
state figures exclude New York City.
The revisions brought the
covid-19 total for New York City closer to the Yale analysis’s estimate
of 6,300 excess deaths during that period.
A handful of states have also
begun reporting probable deaths in recent days, generally by adding them to
current tallies rather than by publicly revising figures from past weeks. Most
states have not added probable deaths.
For example, New York state, unlike New York City, has not.
The Yale analysis estimates that,
excluding New York City, approximately 1,700 more New York state residents than
would be expected had died as of April 4 — far more than the 1,022 counted as
covid-19 deaths.
Gov. Andrew M. Cuomo (D)
acknowledged at a news conference last week that his state’s tally is “not an
accurate total number of deaths, in my opinion.”
“That number is going to go up,”
he said. “Those deaths are only hospitalization or nursing home deaths. That
does not have what are called at-home deaths.”
The family of Long Island
resident Adrian Sokoloff say they believe he is one of the uncounted. The
retired owner of a pet products company, he had just celebrated his 99th
birthday when he started showing symptoms of covid-19 on March 19, his daughter
Karen Sokoloff said. His family said his pulmonologist diagnosed him with
covid-19 because of spiking fevers and coughing — and because two of his
caregivers had come down with chills and lost their sense of taste, a telltale
sign of the virus.
Sokoloff’s children had decided
not to take him to a hospital out of fear that he would die there alone. They couldn’t
get him tested for covid-19 at home.
On March 29, he died at home in
Sands Point, N.Y. His death certificate reads, “congestive heart failure,”
according to his daughter.
She says her father’s death
should be reflected in the covid-19 death toll and fears that an artificially
low count is giving some states license to reopen their economies prematurely.
“You have to have the data to make an intelligent decision, and if you’re not
counting the number of people who died from this, then you’re not making an
intelligent decision,” she said.
Has someone close to you died
from covid-19? Share your story with The Washington Post.
In New Jersey, another hard-hit
state, 9,854 people died during the period covered by the analysis —
approximately 2,200 more than would be expected, according to the Yale
estimates. Of those, however, only 846 were counted as covid-19 deaths.
Marco Navarro, an EMT who works
in three northern New Jersey cities, said that before the pandemic, he could go
two to three weeks without seeing a cardiac
arrest or a call that required his team to perform CPR. Now it happens two
or three times a day.
No one knows why. Is the virus
attacking the heart? Are blood clots causing cardiac issues? Are people terrified
they will contract the virus in a hospital ignoring their symptoms and
staying home until it’s too late, as
many doctors have concluded?
“I don’t really have an answer,”
said Navarro, who works in Union City and sometimes in Jersey City and North
Bergen.
Interviews and 911 call data from
other cities also suggest a spike in the numbers of people dying at home, a
circumstance that makes them less likely to be tested for the coronavirus or
included in the official death counts. For instance, the updates New York City
has made to its covid-19 death tolls include hundreds of such at-home deaths.
As of mid-April, paramedics for
the Chicago Fire Department were seeing about four times as many calls as usual
in which the patient is beyond resuscitation and pronounced dead at the scene,
spokesman Larry Langford said. Normally there are about four such cases; now,
some days, there are more than 20. In Detroit, as ProPublica has reported, 911
call data show that the number of calls coded “dead person observed” spiked in
the first 10 days of April.
But in dozens of states, the Yale
analysis shows that the reported number of overall deaths are either unchanged
or even slightly down compared with historical patterns.
In some states, the epidemic
started later and spread less quickly and so had killed few people as of early
April. Relatively small numbers of covid-19 deaths may have been offset by
decreases in fatal car accidents or other such traumatic events that are less
likely when people are sequestered in their homes.
Lags in the reporting of overall
deaths could also play a role, Weinberger said. Though the federal government’s
provisional death count through April 4 is more complete than its count for
more recent weeks, it remains incomplete, and the number of overall deaths is
likely to continue to rise in coming months as states report additional deaths
from those weeks. The number of overall deaths nationwide and in each
state won’t be known with confidence until
at least a year from now, Weinberger said.
In Washington, the first state to
battle a large-scale outbreak, 310 people were originally reported to have died
of the virus as of April 4. The state has since published data showing that, in
fact, nearly 600 people had died of covid-19 as of that date. Because of the
state’s relatively robust testing and contact-tracing infrastructure, experts
say, the covid-19 death count there is likely more accurate than in other
states.
The overall number of deaths in
Washington during those weeks climbed by only about 100 over the number that
would normally be expected, according to the Yale analysis. That could be in
part because fewer people have been dying on the roads. Statewide, there have
been 34 fatal collisions in March and April to date — about half the usual
number for this time of year, according to data from 2018 and 2019.
There are signs that traffic fatalities are declining more
broadly. Data collected by ESO, a company that provides software for about a
third of EMS services nationwide, show a steep decline in calls for motor
vehicle accidents as stay-at-home orders have taken hold.
Crime patterns are changing in
some places, too. Miami did not report a single homicide for seven weeks and
six days, from mid-February to mid-April, police said. The last time the city
was free of homicides for that long was in 1957.
Gov. Ron DeSantis (R) has been
pushing to lift restrictions in Florida as soon as possible to reopen the
economy. According to the Yale estimate, the state had only a small number of
excess deaths through early April, about 200, and that number is almost equal
to the official covid-19 tally.
“We expect there is some level of
undercounting,” said Natalie Dean, a professor of biostatistics at the
University of Florida. “It’s clear we are missing deaths.”
In Louisiana, the Yale analysis
seems to run counter to what might be expected based on news headlines.
The state is enduring one of the
worst coronavirus outbreaks in the country after more than 1 million people
gathered for Mardi Gras festivities in New Orleans in February. The analysis
estimates, however, that although 408 people were reported to have died of
covid-19 by April 4, Louisiana had slightly fewer deaths overall than normal
during the preceding five weeks. According to the Yale team’s estimates,
Louisiana has recently been among the slower states to report deaths.
Joe Kanter, an assistant state
health officer for the Louisiana Department of Health, confirmed that as of the
end of March, the state had not yet seen a surge in deaths overall compared
with prior years. He said he believes that Louisiana’s covid-19 count is as
close to accurate as possible, pointing out that last week, the state began
reporting probable deaths in addition to those confirmed by lab tests.
But some officials in that state
say the coronavirus death toll will end up higher than is currently known,
according to emails obtained by Columbia University’s Brown Institute for Media
Innovation that were shared with The Post.
In an April 4 email, New Orleans
Health Director Jennifer Avegno noted a spike in paramedics’ reports of
deaths on scene and of cardiac arrests requiring advanced life support,
including CPR. The number of such reports in March was 24 percent higher than
it had been in March 2019.
“Thus I would probably add about
15% or so to the known death toll,” she wrote to two city officials. “However —
no city or state will be factoring this in or reporting it, so I don’t think we
should either. We should just assume that the deaths are about 15% more than we can count, but not
include them in official modeling, because we will never really know.”
In a phone interview on Thursday,
Avegno said she is concerned about elected officials across the country
reopening cities and states based on what she believes is an undercount of covid-19 cases and
deaths.
“I worry that the numbers give
them a false sense of security that
they may be communicating to the public,” she said. “They may think the number
of cases is more limited but they are not testing widely enough to know.”
Lenny Bernstein, Lenny Bronner,
Jacqueline Dupree, Aaron Steckelberg and Reis Thebault contributed to this
report.
Methodology
A research team led by the Yale
School of Public Health used historical data on all deaths between 2015 and
early 2020, published by the National Center for Health Statistics (NCHS), to
model the number of deaths that would normally be expected each week from March
1 to April 4. The estimate takes into account seasonal variations, intensity of
flu epidemics, as well as the expected increase in deaths due to overall
population growth.
Details on the team’s statistical
approach estimating seasonal baseline deaths can be found in an article posted
online at the preprint server medRxiv. The method used for this analysis
differs in that researchers did not attempt to correct for data reporting
delays, as they did for their previous article. Instead, the analysis for The
Post relied only on reported deaths, a more conservative approach to estimating
excess deaths.
The number of overall deaths in
the United States and for each state was obtained from provisional death data
published weekly by the NCHS, part of the Centers for Disease Control and
Prevention. Figures for Connecticut, North Carolina and the District were not
up-to-date, and those jurisdictions are not included in this analysis.
Those data are collected from
state health departments, which report deaths at different rates. It usually
takes about three weeks for death data to stabilize, but even then, they are
still not complete. As a result, it is expected that the numbers of total
deaths as of April 4 will continue to increase as states continue reporting
additional data to NCHS.
The number of excess deaths was
calculated by subtracting the expected seasonal baseline from the number of all
deaths. Because the seasonal baseline is an estimate, there is some uncertainty
associated with the excess-death figure of 15,400. Based only on the deaths
reported so far, there is a 90 percent chance that the actual number of excess
deaths is greater than 12,000, and a 70 percent chance that it is greater than
14,000.(There is a 2.5 percent chance that the actual number of excess deaths
is lower than 10,000, and an equal chance that it is higher than 20,000.)
The covid-19 death toll as of
April 4 comes from figures reported by state public health departments and
compiled by The Post.
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