Is the coronavirus death tally inflated? Here’s why experts say no

On Sunday, New York Gov Andrew Cuomo became the latest in a string of elected officials, including President Donald Trump, to question the death toll from the coronavirus, calling the process of assigning cause of death “fairly random.”

In May, the governor also questioned the use of “probable” deaths in public tallies, noting that New York would continue to keep these deaths from its total counts, even though many states and New York City post them publicly.

But public health experts say the method used to count deaths from a disease like COVID-19 is decades-old and some amount of uncertainty is simply part of the process.

“Everything is so politically charged, people are looking for excuses to question the data,” said Robert Anderson, who runs the mortality statistics branch of the Centers for Disease Control and Prevention’s National Center for Health Statistics.

States rely on two systems in partnership with the CDC. In one system, called disease surveillance, public health staff members and health care workers track the outcomes of people with COVID-19 infections, producing a quick but imperfect public number. In the other system, doctors and coroners submit death certificates to vital records offices, which work with the CDC to tally COVID-19 deaths to create the country’s official death toll from the disease.

Washington, the first state to announce COVID-19 deaths, reconciles these two systems to better understand COVID-19’s toll.

The president and conservative news media have accused states of inflating their counts, even as public health experts have said that undercounting is more likely. Limited awareness and testing during the initial months of the pandemic mean an unknown number of early COVID-19 deaths will never be counted.

Washington identified about 3,000 additional death certificates from early this year with causes of death that align with COVID-19 symptoms, like pneumonia. State health officials believe a small portion of these deaths may be from undetected COVID-19 infections.

With the number of dead in the United States approaching 120,000, according to figures compiled by The New York Times, state health officials grappling with the demand for real-time information have taken different approaches about which information to share with the public.

About half of states are now reporting probable deaths to the CDC and publicly on their health department websites, although sometimes these are unlabeled or tucked away in a footnote. Some states lump these deaths with lab-confirmed deaths. Washington is one of several states that track probable deaths internally, although it announced Wednesday that it will include those deaths in its state total next month.

How confirmed and probable COVID-19 deaths are reported can vary from state to state.

The CDC asked states to start reporting probable deaths in April, based on guidance from the Council of State and Territorial Epidemiologists, which cited a lack of standardized COVID-19 surveillance among states.

“If we only counted lab-confirmed deaths, we all agree that we will undercount the number of individuals that have died,” said Janet Hamilton, the executive director of the Council for State and Territorial Epidemiologists, a group that helps the CDC define cases and deaths from disease.

During the coronavirus pandemic, states have been facing the challenge of providing immediate, accurate information, which is critical for informing policy decisions on when to loosen restrictions on businesses and social activities.

This expectation has been complicated by limited testing and the lengthy process for investigating deaths, which can take weeks or even months. And in many states, data tracking systems are out of date and have been underfunded for years.

“To keep up with a disease that moves with the speed and intensity of COVID-19, we absolutely need data modernization,” Hamilton said.

Most states still rely on mail, phone and fax for disease surveillance, and a handful of states use paper systems for death certificates. These two systems, which can help states count deaths with more certainty, don’t typically talk to each other. So certain public health staff, already overtasked during the pandemic, have to reconcile differences manually.

A growing number of states regularly report probable deaths along with lab-confirmed deaths. Other states track probable deaths internally but do not yet include them in public reports.

Probable deaths are a small share of total deaths in the states that report them, most commonly about 5% to 10%. The range varies from less than 1% in some states up to about one-quarter of total deaths in others. Many probable deaths involve outbreaks at nursing homes, where some residents get tested and some do not.

Even if states chose to not report probable deaths, or need more time to do so, most of these deaths will be counted in the death certificate data that states send to the CDC’s National Center for Health Statistics, mortality statisticians have said.

The center is using its COVID-19 death counts along with total deaths from all causes to determine the number of excess deaths during the pandemic, which will offer a better picture of COVID-19’s death toll. Experts say it is unrealistic to expect an exact tally for any disease. It is widely accepted that the seasonal flu is underreported on death certificates, which is why the CDC reports annual flu deaths as a broad range.

But the federal government could be doing more to help the country better understand COVID-19’s death toll, said Charles Rothwell, a former director of the National Center for Health Statistics. Rothwell said that front-line workers, like clinicians and medical certifiers, need upgraded reporting systems so that health records, vital records, disease tracking and federal guidance are connected.

“This is all very possible and not that expensive,” said Rothwell. “This is a doable moment.”

© 2020 The New York Times Company