The United States Centers for Disease Control and Prevention only counts deaths for which the presence of the coronavirus is confirmed by a laboratory test. “We know this is an underestimate,” said agency spokeswoman Kristen Nordlund.
A widespread lack of access to tests in the first weeks of the epidemic in the United States means that people with respiratory illnesses died without being counted, according to epidemiologists. Even now, some people who have died at home or in overcrowded nursing homes are not being tested, according to funeral directors, medical examiners, and nursing home representatives.
Post-mortem tests by forensic scientists vary widely across the country, and some officials say testing the dead is a misuse of scarce resources that could be used in life. In addition, some people who test negative for the virus say experts.
As a result, public health officials and heads of government do not have a complete picture of the death toll from the pandemic as they assess its course and scramble to react.
Scientists analyzing mortality statistics from influenza and other respiratory illnesses say it is too early to estimate the number of unregistered deaths. For a disease with common symptoms such as COVID-19, they said, deaths with positive results are almost certainly only a fraction of the total caused by the disease.
“You can’t just rely on laboratory-confirmed cases,” said Marc-Alain Widdowson, an epidemiologist who left the CDC last year and is now director of the Antwerp Institute of Tropical Medicine in Belgium. . “You are never going to apply the test to everyone who is sick and everyone who dies. So without a doubt – it’s a truism – the number of deaths worldwide is underestimated because you don’t apply the test. “
Clay Marsh, the “coronavirus tsar” of West Virginia, admitted that the state’s count was likely to be incomplete. West Virginia was the last state to report a virus and had only two deaths on Saturday.
“Based on the best recent information on limited tests and significant false negative rates, we are probably underestimating the number of deaths,” said Marsh, vice president and executive dean of health sciences at West Virginia University. Counts are also low in West Virginia, said Marsh, as the state has a small rural population and had closed schools and non-essential businesses early.
The CDC has launched an effort to use national disease, hospitalization and death certificate data to estimate COVID-19 infections and deaths. The agency already publishes such estimates every week for influenza, where laboratory-confirmed cases and deaths also account for only a fraction of the total attributable to the disease.
“We are probably getting more information about COVID-19 because the community is more aware of what it is,” said Nordlund.
The CDC’s official death toll, which is based on reports submitted by states, was 6,593 on Saturday. Due to a delay in reporting, the number was significantly lower than the figures most frequently updated by the media and academic researchers. The Washington Post’s death toll exceeded 8,000 on Saturday.
The federal government’s death toll is released daily worldwide to indicate how quickly the virus is spreading and how sick the nation is. This has clear political implications for President Donald Trump, whose approval rating increased in late March despite the fact that he downplayed the dangers of the virus for weeks.
On Wednesday, the White House estimated that 100,000 to 240,000 Americans could be killed by COVID-19, far exceeding the nearly 60,000 soldiers killed in the Vietnam War. Scientists said they did not know how the White House arrived at its screening, and the White House declined to provide details.
The death toll has become a highly politicized benchmark. Trump advocates say the official number is inflated because it includes all of the deceased who tested positive for COVID-19, even if there was another cause of death, such as a heart attack or an accident.
Marc Lipsitch, a professor of epidemiology at Harvard, said that there are probably people who die with COVID-19 who do not die from COVID-19. Such misallocation is a problem for any cause of death, he said, but it is a minor problem that is “overwhelmed by the opposite problem: deaths that are caused by COVID but never attributed, therefore the number of deaths is underestimated ”.
Officials around the world are wondering whether the number of deaths officially attributed to the virus is deceptively low.
In northern Italy, the city of Nembro recorded 31 deaths from the virus from January to March. But Mayor Claudio Cancelli recently said that the total number of people killed during this period – 158 – was four times the average for this time of year.
“The difference is huge and cannot be just a statistical deviation,” he wrote in a newspaper article co-authored with a medical professional.
The number of deaths attributable to the virus in France soared last week after authorities began including previously unreported deaths in nursing homes, increasing the number by more than 2,000.
Observers inside and outside China, where the virus first appeared at the end of last year, accused the ruling Communist Party of reporting infection and death rates artificially low. Media, including The Post, reported that a count of cremation urns ordered from Wuhan in central China’s Hubei Province indicates that far more people have died from COVID-19 than the number official death certificate for approximately 2,500 people.
Trump said on Wednesday that “China’s numbers seem to be a bit light, and I’m kind when I say that.” The Chinese authorities have denied the accusation, saying that the American authorities were trying to divert responsibility for the count of the American bodies.
Flu studies have found that in the midst of a pandemic, the number of deaths in real time is often misleading.
Widdowson, the former CDC scientist, was part of a team that estimated deaths worldwide from the 2009 H1N1 swine flu pandemic. The World Health Organization has recorded only 18,631 people with laboratory-confirmed diagnoses dying of this disease. But the pandemic has likely caused 15 times more deaths, the CDC team concluded in 2012.
A 2013 study by government and university researchers suggested that laboratory-confirmed deaths from H1N1 in the United States accounted for only 1 in 7 deaths from the disease.
In the United States, federal and national public health officials have refused for weeks to test people unless they meet strict eligibility criteria. The tests are more widely available today, but some experts say the tests may not detect everyone with the virus. It is unclear how common false negatives are.
Post-mortem testing for COVID-19 is uneven across the country, experts say. Forensic pathologists, coroners and health care providers should “use their judgment” to decide whether these tests are appropriate, as directed by the CDC.
In addition to 6,593 laboratory-confirmed deaths, the CDC reported on Friday that death certificate data shows that 1,150 people died from COVID-19.
Figures differ in part due to delay in notification and because the code for registering COVID-19 as a cause of death was not announced until March 24, weeks after the first known case of American death coronavirus disease. . The death certificate data will be part of the CDC’s new efforts to estimate the total number of deaths from COVID-19.
To estimate the total number of deaths from a disease, scientists often look at “excessive deaths” – the number of deaths beyond the average number in a particular period.
The most robust estimates require national statistics which, in the United States, can take two or three years to compile, according to Cécile Viboud, a scientist from the National Institutes of Health who is co-author of the study estimating the undercoverage during the H1N1 flu.
The number of deaths from influenza initially not counted usually includes people with pneumonia and other respiratory symptoms who have never been tested for influenza, as well as more people who get the flu and are more likely to die from conditions such as cardiac arrest, stroke and diabetes. These people may not die from the flu, but the flu still contributed to their death.
Scientists do not yet know whether or how often COVID-19 kills people with these types of secondary problems. But it’s clear that COVID-19 can cause non-respiratory symptoms, scientists say.
Last week, a group of Italian scientists published a study on an otherwise healthy 53-year-old woman who arrived at the hospital to complain of extreme fatigue. She suffered from acute heart problems, including inflammation of the heart muscle. It tested positive for the coronavirus.
In Albany, Georgia, which has one of the most explosive epidemics in the country, funeral director Jeffery F. Wakefield Sr. said he treats every body as if it were infected with the virus. Wakefield recently handled the body of a young man, approximately 40 years old, who died alone at home and was not found for several days. The man’s death has been attributed to cardiac arrest. It has never been tested for coronavirus.
“We will never really get real numbers,” said Wakefield. “We will be almost close, but we will never have the true number of those who died from it. “
Epidemiologists say that patients who need medical treatment for conditions other than COVID-19 may also suffer and die in places where the health system is overwhelmed by the virus.
Although screening has become much more widespread, it remains limited in places like prisons and nursing homes where the disease is spreading rapidly. The CDC says inpatients and healthcare workers should be on the front line for testing. People in long-term care facilities should come next, the agency said.
The country’s largest hot spot in New York, Suffolk County medical examiner Michael Caplan said in a note to funeral directors on Wednesday that nursing homes and hospitals are responsible for collecting samples for post mortem testing.
This is unrealistic, said Michael A. L. Balboni, executive director of the Greater New York Health Care Facilities Association, which represents long-term care homes.
“The last thing a nursing home will do is try to determine if a deceased person is COVID or not COVID,” he said in an interview. “They have their hands full to try to dispose of their remains appropriately. … Why waste the swabs on the deceased? ”
A Suffolk County nursing home operator, who spoke on condition of anonymity to protect the company’s reputation, said that some residents were ill with respiratory symptoms and some had died, but virtually no one was tested, dead or alive. The exception is when residents are taken to hospital, the operator said.
“We assume everyone is positive,” said the operator. “To use a test on the deceased, it won’t be very useful. Because at the end of the day, there is a shortage of tests to start with. We don’t have any tests. We don’t have swabs. “
The Federal Bureau of Prisons no longer tests in a Louisiana prison where a dozen inmates have already tested positive and at least one has died. Sue Allison, a spokesperson for the office, said that because the virus is spreading inside the facility, any inmate with symptoms is presumed to be infected.
Allison said the decision to posthumously test deceased COVID-19 detainees would be made with health officials on a case-by-case basis, depending on the availability of tests and other factors.
In most states, people who die at home or go untreated are reported to a disparate system of forensic scientists, lay and sheriff coroners, justices of the peace and other local authorities.
Sally Aiken, President of the National Association of Medical Examiners, wrote in a press release that “the general public does not understand that there is no uniform death investigation system in the United States . … Thus, a uniform response to COVID-19 by forensic pathologists will not occur. “
Medical examiners typically investigate accidental deaths, homicides and suicides, and are not going to be involved in “natural death” such as that caused by COVID-19, said Amy Schaefer, supervising investigator for the medical examiner’s office in Summit County, Ohio. , near Akron.
“You will certainly have numbers that are not counted because the dead are not tested,” she said. “We have to test people who are still alive.”
But in Wyoming – the only state that had not reported a death from COVID-19 on Saturday – Laramie County coroner Rebecca Reid said she was ready to test anyone with symptoms who dies at House.
“We need a specific cause of death to close the family and make sure they are safe,” she said. “It is also very important that the public know the truth. “
She has supplies to test five people, she said.
Jacqueline Dupree, Abigail Hauslohner, Dalton Bennett and Lena H. Sun, of the Washington Post, contributed to this report.