About 30% of COVID deaths may not be classified as such, US daily COVID-19 cases near 50,000 as 19 states pause reopening

July 2, 2020

In the first three months of the United States coronavirus epidemic, the number of excess deaths in the US was 122,300, 28% higher than the reported number of COVID-19 deaths, according to an observational study published in JAMA Internal Medicine.

Led by researchers from Yale University, the study analyzed data from the National Center for Health Statistics and the Centers for Disease Control and Prevention to better characterize the burden of the novel coronavirus during the beginning of the US epidemic and compare death counts to those of the same period in previous years.

From March 1 to May 30, there were about 781,000 all-cause deaths in 48 states, 95,235 officially attributed to COVID-19, leaving 122,300 more than would be expected during that period. The researchers said that although they cannot classify the deaths as due to COVID-19, flu activity had fallen to historically low levels in March.

In several states, the deaths occurred before the availability of COVID-19 diagnostic tests and thus weren't counted as coronavirus deaths. The estimated number of excess deaths varied significantly among states. For example, in New York City, all-cause deaths were seven times higher than baseline at the pandemic peak, with 25,100 excess deaths, of which 26% were not attributed to COVID-19. In other parts of New York, excess deaths were only twice as high as baseline, with 12,300 excess deaths. Other states with high numbers of excess deaths were New Jersey, Massachusetts, Louisiana, Illinois, and Michigan, while there were few or no excess deaths reported in some smaller central states and northern New England.

The gap between deaths attributed to COVID-19 and the estimated number of all-cause excess deaths also varied among states, with California reporting 4,046 coronavirus deaths and 6,800 excess deaths, leaving 41% of excess deaths not attributed to COVID-19. The gaps were even wider in Texas, with 55% of excess deaths not classified as due to the coronavirus, and in Arizona, where 53% of excess deaths were attributed to causes other than COVID-19. Minnesota showed the best agreement, with only 12% of excess deaths unattributed to COVID-19.

The authors noted that the discrepancies could be partly due to the intensity and timing of increased testing. For example, in states like Texas and California, excess all-cause death rates occurred several weeks before diagnostic COVID-19 testing was widely available. In contrast, states such as Massachusetts and Minnesota, where the gaps were smaller, were able to increase testing before or at the same time as the rise in excess deaths.

The differences could also be the result of guidelines on the recording of deaths that are suspected but not confirmed to be due to COVID-19 and the location of death. For example, nursing home deaths may be more likely to be correctly attributed to the coronavirus because they have a higher chance of being recognized as part of the epidemic. The reported increase in excess deaths could also reflect increased numbers of deaths directly caused by the virus, avoidance of visiting the healthcare setting, and declines in deaths due to automobile crashes or air pollution.

According to the researchers, official death counts became better matched with excess death estimates as the pandemic progressed, perhaps because of increased testing and recognition of the clinical signs and symptoms of COVID-19. For example, New York City added another 5,048 COVID-19 deaths after carefully reviewing death certificates, generating a number that more closely aligns with the researchers' estimates.

The authors noted that, in the early part of the pandemic, when diagnostic tests were in especially short supply, only about 10% to 15% of all coronavirus infections were diagnosed. "These findings demonstrate that estimates of the death toll of COVID-19 based on excess all-cause mortality may be more reliable than those relying only on reported deaths, particularly in places that lack widespread testing," they wrote. 

The United States saw another record-setting day this week, with more than 48,000 new cases of COVID-19 reported, according to the New York Times. New US cases have risen by 80% in the past two weeks, leading several states and cities to cancel upcoming Fourth of July celebrations. 

CNN reports that at least 19 states that were progressing through reopening have now paused or rolled back plans. In Colorado, which gained praise for its early — but cautious — reopening of businesses, bars will now be closed for 30 days. 

Colorado Governor Jared Polis said that his state has seen a slight uptick in cases over the last two weeks. Bars and nightclubs opened just over two weeks ago, but Polis said the state may not yet be able to open those establishments safely. 

California Governor Gavin Newsom closed all indoor establishments, including restaurants, movie theaters, and bars, in 19 counties where case counts are rising. The closing will last for at least three weeks. Newsom also announced today that parking facilities at state beaches in Southern California and the Bay Area will be closed for the Fourth of July weekend. 

In New York City, which has successfully contained the outbreak after seeing cases soar in April and May, Mayor Bill De Blasio said he will not allow indoor dining to resume next Monday as planned after watching what is happening in other states. 

Also, the governors of New York, New Jersey, and Connecticut are now asking visitors from Alabama, Arkansas, Arizona, California, Florida, Georgia, Iowa, Idaho, Louisiana, Mississippi, North Carolina, Nevada, South Carolina, Tennessee, Texas, and Utah to quarantine for 14 days upon arrival, National Public Radio reports. 

According to the tracker maintained by Johns Hopkins University, the United States has 2,686,928 cases of the virus, including 128,064 deaths.

Americans' worries about the novel coronavirus are at the highest reported level since May, according to a new poll from Reuters/Ipsos. A public opinion poll conducted on Jun 29 and 30 found that 81% of American adults said they are "very" or "somewhat" concerned about the global pandemic. 

Harvard's Global Health Institute launched a new framework for communities in the midst of the pandemic that will incorporate key metrics and performance indicators to help guide policy.

Other contributors included Harvard's Edmond J. Safra Center for Ethics, the Rockefeller Foundation, CovidActNow, Covid-Local, and the University of Minnesota's Center for Infectious Disease Research and Policy, which publishes CIDRAP News. 

The metric is based on red, orange, yellow, and green risk levels that correspond to more than 25 cases per 100,000 people per day, 10 to 25 new cases, one to 10 cases, and less than one. At red levels, jurisdictions may need to move to mandatory stay-at-home orders; such orders are advised at orange levels, unless there is adequate testing and contact tracing. At yellow levels, nonpharmaceutical interventions should be used, and at green levels, a jurisdiction is on track for containment. The metrics also lay out goals for contact tracing, testing, and surveillance. 

"Local leaders need and deserve a unified approach for suppressing COVID-19, with common metrics so that they can begin to anticipate and get ahead of the virus, rather than reacting to uncontrolled community spread," said Beth Cameron, PhD, vice president of Global Biological Policy and Programs at the Nuclear Threat Initiative and a member of the COVID-Local.org team. "Unless and until there is a whole of government response, with measurable progress communicated similarly and regularly across every state and locality, US leaders will be left to react to the chaos of the virus — rather than being able to more effectively target interventions to suppress it," she said in a press release. 

CIDRAP has the first report.  

CIDRAP has the second report

More COVID-19 coverage HERE.