COVID-19-associated Deaths Significantly Undercounted

JAMA study estimates that 35% of excess deaths during pandemic's early months were tied to causes other than COVID-19.

Overall death rates in the United States rose significantly this spring in the first three months of the coronavirus pandemic.

However, COVID-19 accounts for only two-thirds of the estimated 87,000 excessive deaths tracked across the nation between March 1 and May 30, according to a research letter published Wednesday in JAMA Network.

In 14 states, including — California and Texas — more than half of the excess deaths were tied to an underlying cause other than COVID-19, said lead author Steven Woolf, MD, director emeritus of Virginia Commonwealth University's Center on Society and Health.

Woolf said the data suggest that the official COVID-19 death counts – currently surpassing 129,000 lives nationwide – underestimate the true death toll of the pandemic in the U.S.

"There are several potential reasons for this under-count," said Woolf, a professor in the Department of Family Medicine and Population Health at VCU School of Medicine. "Some of it may reflect under-reporting; it takes a while for some of these data to come in. Some cases might involve patients with COVID-19 who died from related complications, such as heart disease, and those complications may have been listed as the cause of death rather than COVID-19.

"But a third possibility, the one we're quite concerned about, is indirect mortality — deaths caused by the response to the pandemic," Woolf said. "People who never had the virus may have died from other causes because of the spillover effects of the pandemic, such as delayed medical care, economic hardship or emotional distress."

Deaths from causes other than COVID-19 spiked in Massachusetts, Michigan, New Jersey, New York — particularly New York City — and Pennsylvania, the regions that also had the most COVID-19 deaths in March and April.

At COVID-19's peak for March and April, diabetes deaths in those five states rose 96% above the expected number of deaths when compared to the weekly averages in January and February of 2020. Deaths from heart disease (89%), Alzheimer's disease (64%) and stroke (35%) in those states also spiked.

New York City's death rates rose 398% from heart disease and 356% from diabetes, the study found.

Woolf said some of these deaths were likely indirectly caused by the pandemic among people suffering acute emergencies, such as a heart attack or stroke, who may have been afraid to go to a hospital.

Those who did seek emergency care may not have been able to get the treatment they needed, such as ventilator support, if the hospital was overwhelmed by the surge, he said.