When COVID-19 deaths in the U.S. stood at 56,246 on April 25, it is been estimated that 30,755 excess deaths have not been accounted for. In the early phase of the pandemic, all COVID-19 deaths might not have been correctly recognised due to inadequate knowledge of the infection or lack of testing availability.

Many countries, India included, have argued that hiding excess deaths caused COVID-19 is not possible even as underreporting of cases has become a norm. Now, a study points out excess deaths in the U.S. as on April 25 which have not been accounted for as being COVID-19.

On April 25, the number of COVID-19 deaths in the U.S. stood at 56,246. Now, a study published in the Journal of the American Medical Association (JAMA) has estimated that the only about two-thirds of excess deaths caused by COVID-19 was captured in the first weeks of the pandemic. According to the estimates by a team of researchers about 30,755 excess deaths have not been accounted for.

The study led by Steven H. Woolf from the Virginia Commonwealth University School of Medicine, Richmond, Virginia found that between March 1 and April 25, a total of 5,05,059 deaths were reported in the U.S. Compared with previous years, 87,001 were excess deaths. The number of COVID-19 deaths as on April 25 stood at 56,246 and accounted for 65% of excess deaths as being due to COVID-19. But the remaining 35% (30,755) has not been accounted for.

“Potential explanations include delayed reporting of COVID-19 deaths and misattribution of COVID-19 deaths to other respiratory illnesses (for example, pneumonia) or to nonrespiratory causes reflecting complications of COVID-19 (for example, coagulopathy, myocarditis). Few excess deaths involved pneumonia or influenza as underlying causes,” they write.

How excess deaths were estimated

The authors obtained weekly death data for the 50 States and the District of Columbia from the National Center for Health Statistics for the period January to April 2020. They also collected data for six preceding years — 2014-2019. They used a hierarchical Poisson regression model and fitted it to weekly death data from January 2014 to February 2020.

The analysis included total deaths and deaths from COVID-19, influenza/pneumonia, heart disease, diabetes, and 10 other grouped causes. If a mention of COVID-19 was made on the death certificate, then the death was attributed to the novel coronavirus.

According to them, in 14 states, more than half of excess deaths were attributed to underlying causes other than COVID-19. And five States that experienced the most number of COVID-19 mortalities have seen a large proportional increase in deaths from causes other than underlying respiratory causes — diabetes (96%), heart diseases (89%), Alzheimer disease (64%), and cerebrovascular diseases (35%). In the case of New York, which reported the most number of COVID-19 deaths in the U.S., deaths from underlying causes other than respiratory has seen the sharpest spike — heart disease (398%) and diabetes (356%).

What accounts for excess deaths

About the 30,755 excess deaths, they say “further investigation is required to determine the extent to which these trends represent nonrespiratory manifestations of COVID-19 or secondary pandemic mortality caused by disruptions in society that diminished or delayed access to health care and the social determinants of health”.

Writing in a linked Editorial, Jody W. Zylke, Deputy Editor of JAMA says that in the early phase of the pandemic, people who might have died of COVID-19 might not have been correctly recognised due to “inadequate knowledge of the infection or lack of testing availability”. This could have led to their deaths being attributed to other causes. While those dying at homes or nursing homes might not have been tested for coronavirus and their infection status thus being missed. Since COVID-19 has not been mentioned on the death certificate, the cause of death would not have been counted as COVID-19.

Also, deaths not caused by COVID-19 but concerns about exposure to the virus in hospital settings and social distancing measures would have played a role, Zylke writes. “People may have ignored symptoms as they obeyed stay-at-home orders or were concerned about going to a hospital where they might contract the virus. Data on whether avoidance of care has translated into additional deaths are not yet available,” he says.