Colorado, on the other hand, has included certain deaths where the disease caused by the new coronavirus was deemed probable – based on symptoms and possible exposure – but not confirmed by a test.
Health officials in both states say their approach is more specific. Their divergent methods reflect a national debate on how to count the dead.
The death toll in the US government’s Covid-19 is widely regarded as an undercoverage because, at a time when access to tests was severely limited, federal officials described their tally as including only people tested positive for the virus.
The Centers for Disease Control and Prevention updated its website this week to explicitly state that cases where the infection has not been confirmed by a test can now be counted. But attributing death to the virus can be a judgment, experts say, and potentially annoying as indications emerge that the disease damages not only the lungs but also the heart, kidneys and other organs.
As a result, the overall tally – a benchmark that is continuously broadcast on cable news and elsewhere – is less concrete than it seems. Inconsistent counting methods also raise questions about the ability to compare across states, and they play into a political debate over the reliability of the numbers.
The extent of the undercoverage that can result from counting only laboratory-confirmed cases was made clear on Tuesday when New York City officials began reporting the deaths of people suspected of having covid-19 but never tested. The city’s count has soared to over 10,000 while the change has left more than 3,700 dead.
“We are working to ensure that every New Yorker who died from COVID-19 is counted,” said health commissioner Oxiris Barbot in a statement, adding: “Although this data reflects the tragic impact the virus has had on our city, they will also help us determine the scale and magnitude of the epidemic and will guide us in our decisions. “
For at least the past month, Colorado has been reporting the deaths of people who have never been tested but who have symptoms and have been in close contact with an infected person. Three percent of Colorado’s 329 deaths fall into this “epidemiologically linked” category.
“They don’t represent a large number of deaths, but including them gives a more accurate number than excluding them,” said Ian Dickson, spokesperson for the Colorado Department of Health.
Asked about how the national count is compiled, a CDC spokesperson said on April 4 that the agency aggregates state counts and only counts deaths in which the presence of the coronavirus has been confirmed in a laboratory test, a method which it has admitted leads to an “underestimation”. . ”
The next day, the State Council and territorial epidemiologists, who represent state health officials, recommended reporting of probable covid-19 deaths, in addition to those with laboratory confirmations.
Ohio, Connecticut and Delaware have since started reporting deaths of people who are believed to be infected but have not been tested. Ohio reports 361 deaths, 15 of which are listed as “probable” on the state’s coronavirus data portal. The websites of the other two states do not show the number of probable deaths among their total.
On Tuesday, the day the CDC updated its website to indicate that its tally now includes probable cases, agency spokeswoman Kristen Nordlund said that three jurisdictions – she did not identify them – report the deaths of people who have died of the disease but have never been tested.
The next day, a spokesperson for Governor Larry Hogan (R) announced that Maryland would also begin counting the probable deaths. In the afternoon, the state reported 349 deaths in laboratory-confirmed cases and 64 in probable cases.
Pennsylvania also includes deaths in probable cases, said Nate Wardle, state health department press secretary. The state does not distinguish probable cases from confirmed cases in its public death tally.
Alabama doctor examines medical records of anyone who died and tested positive for the virus to determine whether a death should be attributed to Covid-19, according to Karen Landers, spokesperson for the public health agency. State.
Landers declined to provide information on people who died with Covid-19, but was not counted in the state’s official Covid-19 report. Those who had no respiratory symptoms could be excluded, she said, as could those who had an acute event such as a stroke or heart attack or who suffered a trauma such as a car accident.
“Just because people have other medical diagnoses, they are not automatically excluded,” she said. “On the contrary, other factors during the illness are taken into account when examining the medical record. “
Asked about the Alabama method, Nordlund said the agency “reports the numbers the states provide us with. “
As of Tuesday, a total of 110 people across Alabama had died and tested positive, but only 73 of them had been counted as covid-19 deaths and reported to the CDC, according to state data released online . Twenty-five were still under review.
Twelve deaths – or one in seven for which a decision has been made – have not been attributed to Covid-19, said Landers. These deaths are not reported to the CDC and are not included in the official federal government tally.
Jefferson County health officials, including Birmingham, the state’s largest city, said the 17 deaths of people who tested positive for the coronavirus were reported to the county coroner’s office. A doctor performing the health department medical examination found that 11 deaths were attributable to Covid-19 and five were not. One was still under investigation.
The two patients who died each with problems in one lung were excluded because both lungs are affected in most cases of covid-19, said Mark Wilson, who heads the Jefferson County health department. Also excluded are two hospice patients for other asymptomatic diseases for the coronavirus, he said, and a person who died of sepsis and had other problems unrelated to covid-19.
Wilson said he was concerned that Alabama is missing some deaths due to a lack of widespread testing. While other counties rely on the state to make these decisions, Jefferson alone conducts his own medical examination of the deaths of Covid-19.
Alabama’s approach runs counter to the nationwide counting method described by Deborah Birx, physician and response coordinator for the White House Coronavirus Task Force, which was the one of the most visible leaders in the federal response.
“In this country, we have taken a very liberal approach to mortality,” she said in a briefing on April 7, explaining that the United States counted the deaths of people suffering from underlying diseases as type 19 deaths, although some other countries are not.
“The intention is, right now, that. . . if someone dies with Covid-19, we count that as a death of Covid-19, “she said.
The CDC has recently started to use national data on respiratory illnesses, hospital visits and death certificates to better estimate coronavirus infections and deaths for a separate count it intends to start. to declare.
Health experts and elected officials use the official death count, as well as the case count and other data points, to help assess the areas most affected and determine the appropriate response. The count also became a politically charged statistic for a president who initially downplayed the pandemic and downplayed its threat.
President Trump has dismissed concerns over undercoverage, despite recognition from the CDC. “Deaths count, I think they are very, very accurate,” he said last week in response to a question from a reporter about limited access to tests.
Some of the President’s supporters have pushed the theory – heavily promoted on Fox News and conservative social media – that the death toll in the country is in fact inflated as it includes the deaths of people who may have had lust -19 but died from other causes.
In Alabama, Governor Kay Ivey (R) was initially reluctant to order residents to stay at home, saying she wanted to balance public health and state economic interests.
“I want to echo the president who said today,” We have to go back to work, “” she said on March 24. “We have to do everything we can to keep businesses open and, if they are closed, get them back. as soon as possible. ”
The next day, Ivey confirmed the state’s first Covid-19 death.
As of April 2, the state’s website includes the number of deaths of people who tested positive, as well as the lowest number of people determined to have died of Covid-19 that is reported to the CDC.
“It’s really a matter of data accuracy,” said Landers. “It is an attempt to really look at it a little more deeply than just asking, well, that person was positive for this and positive for that. “
State representative Anthony Daniels, the Democratic leader of Alabama House and a member of the state’s coronavirus task force, said he was unaware of the approach to the Reported to count the deaths of Covid-19 until a Washington Post reporter contacted him about it last week. On Friday, he asked Alabama state health official Scott Harris for a report detailing the number and causes of all deaths not attributable to covid-19. Harris declined a request for an interview for this story.
“I didn’t know we were doing it differently from other states,” said Daniels. “This is a good question to ask: how do you make these attribution decisions versus notification? “
Jonathan Arden, a medical examiner who chairs the board of the National Association of Medical Examiners, said there may be a “gray area” when assessing the death of a person who tested positive for the virus, showed symptoms of covid-19 and had an underlying condition such as heart disease or heart attack. The virus could affect the amount of oxygen this person received, he said.
“Can there be disagreement on how these things are concluded? Absolutely, ”he said. “You are talking about medical judgments, a diagnostic process which means that you come to an opinion. “
Arden said Alabama’s approach is invaluable because including anyone who has a positive coronavirus test in the death toll “would increase the death rate.” At the same time, he said, the Colorado approach is “valid unless or until we have much more widespread testing.” Otherwise, it is more likely that we will miss cases that we should have caught. “
Marc Lipsitch, an epidemiologist at Harvard who studied deaths from the flu, said he was concerned that Alabama could filter deaths caused by the new coronavirus, even if they did not appear to be. Because getting the flu can make patients more susceptible to a variety of problems, most deaths from the flu appear to have other immediate causes, such as heart attacks, strokes, cancer, and diabetes.
“What Alabama is doing makes no sense,” he said. “It is a well-established fact that respiratory viruses can cause much of their mortality from other causes. With something so new, to say that if you don’t see respiratory symptoms, you don’t attribute it to Covid is at best too safe. ”
Rachael Lee, a health care epidemiologist at the University of Alabama at Birmingham Hospital, said the state approach was a good way to try to get a more accurate count.
“We have the capacity to do it right now because we don’t see as many dead,” she said. “I don’t know how a state like New York could follow the process we are leading. “
Rendi Murphree, an epidemiologist at the Mobile County health department, said, “If we don’t determine the cause of death, we potentially distort the information. “
Lina Evans, Shelby County coroner, said she was not informed that the deaths of Covid-19 would be investigated before being counted. She said she started asking questions after reporting four deaths and noticed that none immediately appeared on the death toll. In the end, she says, they were all counted – but it took days and, in one case, a week and a half.
Evans said she was concerned that such delays would keep the numbers artificially low, contributing to a feeling of complacency among the Alabamians.
“They always go to Walmart and social gatherings and keep pushing the pic further. They don’t take it seriously, ”she said.
State officials said the medical examination is done quickly, often within a day, although the process may take longer if there is a delay in obtaining medical records.
Tyler Berryhill, Madison County coroner, said he was more concerned about the undercoverage of the limited tests than about the possibility of overcoverage. After someone with respiratory problems died in his county without being tested for coronavirus, he sent a sample to a state laboratory for post mortem testing.
“In rural hospitals and medical facilities, we know there was a shortage of tests,” he said. “There is great concern that we may not have a full understanding of the real numbers in our state. “
Jacqueline Dupree and Lena H. Sun contributed to this report.