Officially, nearly 1.1 million individuals have died from COVID-19 in the U.S., according to the Centers for Disease Control and Prevention (CDC), but that’s not counting the 268,176 people who died from the disease in the first two years of the pandemic whose death certificates listed different causes, according to researchers with Boston University and the University of Pennsylvania.
In addition, their findings contradict the conventional wisdom that the majority of excess deaths not labeled as being related to COVID-19 occurred early in the pandemic, but rather “differences between excess deaths and reported COVID-19 deaths were substantial in both the first and second year of the pandemic,” said their study on the website medRxiv, a repository for research that has not yet been peer reviewed.
The researchers examined excess mortality rates—the difference between the number of deaths during the pandemic and the number of deaths that would be expected to have occurred if the pandemic hadn’t happened—in 3,127 counties from March 2020 to February 2022.
They cited several reasons excess deaths might not have shown up in the COVID-19 mortality tally, including:
- Lack of COVID-19 testing before death
- Lack of post-mortem COVID-19 testing because of limited investigative resources
- The death certifier may not have recognized it as a COVID-19 death, instead listing the cause as an underlying comorbidity such as heart disease, dementia, diabetes or respiratory disease.
- Resistance by family members to list COVID-19 as the cause because of personal beliefs
- Atypical presentations of COVID-19 symptoms
The CDC’s guidebook (PDF) for physicians about the proper way to certify cause of death states that if the attending physician isn’t available to do so, another physician can and then send the body to the funeral director. However, as the researchers pointed out, physicians may lack enough knowledge of the patient to accurately pinpoint the cause of death.
There are other reasons that physicians and other providers need to take note of the study’s findings, said Richard Stefanacci, chief medical officer at the Jefferson College of Population Health at Thomas Jefferson University.
It will possibly prod them into examining “how they themselves report the data, [and] reports of underreporting will move them to increase their own reporting,” Stefanacci told Fierce Healthcare. Incorrect death counts might misdirect how intensely providers guide their patients in terms vaccination and testing. “Higher incidence, more push,” said Stefanacci. “Lower incidence, less.”
In addition, as the CDC guidebook notes, mortality figures “are valuable to physicians indirectly by influencing funding that supports medical and health research that may alter clinical practice and directly as a research tool.”
Kevin Kavanagh, M.D., president and founder of patient advocacy organization Health Watch USA, told Fierce Healthcare that “the importance of having accurate data and the impact of COVID-19 for our country’s workforce and our healthcare system cannot be overstated.”
Kavanagh adds that “our healthcare system may not be able to withstand the continued stresses of the pandemic, transforming it into a dysfunctional system not able to take care of heart attack or cancer patients during high rates of COVID-19. We thus should not choose to understate the actual numbers and mitigate the impact of the pandemic; this results in a lack of resources and inhibits our ability to effectively confront the pandemic.”
Mountain states, Southern states and non-metro counties exhibited the largest discrepancies between COVID-19 and excess mortality rates. Possible causes include a lack of COVID-19 testing and a larger portion of COVID-19 deaths occurring in non-hospital settings.
“Another potential contributing factor is the greater reliance on coroners in these regions, who are typically elected and often hold other positions within the county such as sheriff-coroners,” the study said. “Medical training required for coroners is limited and highly variable across states, whereas medical examiners are physicians with extensive training in forensic pathology and death investigation.”
Some coroners simply ask the family to name the cause of death.
On the other side of the leger, New England and the Mid-Atlantic states tallied more COVID-19 deaths than excess deaths mostly in metro areas. The researchers posited that this might be because the regions include some of the more economically affluent counties that allowed residents to work from home and avoid overcrowded housing.
Variation in coding may have played a part. In Massachusetts, for instance, until March 2022 a COVID-19 death included any death in which the individual had been diagnosed with the disease within the last 60 days. Most other states drew the line at 30 days.
The authors also noted that their calculations could not account for deaths that COVID-19 indirectly caused. “These deaths could be caused by changes in health resulting from food insecurity, housing instability and other stressors and by increases in poisonings, suicide and accidents," they said.
Kavanagh said the “authors’ data and conclusions further build on a mountain of evidence of the dangers of the COVID-19 pandemic. Death certificate death numbers will greatly underestimate actual COVID-19 deaths. Many COVID-19 deaths are going uncounted and unnoticed since the public and policymakers seem fixated on just those resulting from acute respiratory disease.”
Delayed complications from COVID-19, such as thrombotic and cardiac sequela, are killing individuals as well, said Kavanagh. He cites a study in Nature that argues that delayed deaths from a multitude of different organ systems result in an additional 8.4 per thousand COVID-19 deaths.
“That would almost double the total number of COVID-19 deaths,” said Kavanagh. “The vast majority of these additional deaths are in COVID-19 negative patients and are stealth deaths not reported to COVID fatality registries.”