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How accurate is the US coronavirus death count? Some experts say it's off by 'tens of thousands'
To get an accurate picture of the pandemic, US needs to test more of the dead.
1 May 2020, 04:56
coronavirus has already claimed the lives of more than 61,000 Americans. But experts fear that number could be far higher at this point in the outbreak -- perhaps by tens of thousands -- once the pandemic subsides enough for officials to go back and make a true reckoning of the dead.
Experts are urging leaders to take measures right now to preserve data and medical specimens so that science has the chance to determine the precise number of people who succumbed during one of the most severe global pandemics in memory.
"Under-counting deaths in this particular epidemic is happening all over," said Dr. Daniel Lopez-Acuna, an epidemiologist and former top World Health Organization official, who spent 30 years at the organization. "It’s almost inevitable."
Tune into ABC at 1 p.m. ET and ABC News Live at 4 p.m. ET every weekday for special coverage of the novel coronavirus with the full ABC News team, including the latest news, context and analysis.
Calculating the precise number of COVID-19 deaths is remarkably complicated for a number of reasons. But leading epidemiologists, pathologists, medical examiners, medical history professors and local, state, federal and global health officials told ABC News that more testing is the single most important factor in determining an accurate national death count.
"We need to have the testing available because the big question now with COVID-19 is the denominator -- of anything," said Dr. Alex Williamson of the College of American Pathologists. "How many people get it? How many people recover? How many are hospitalized? How many died? We don't know the true denominator. More testing is the most important thing we need to do."
MORE: Coronavirus death toll in US likely worse than numbers say
MORE: When each state's stay-at-home order lifts
California’s first known COVID-19 death to date was Patricia Cabello Dowd, 57, in Santa Clara County. Dowd died on Feb. 6 of heart complications, which were later determined to have been unleashed by the COVID-19 virus. Dowd's death -- in which an autopsy obtained by the San Francisco Chronicle listed a heart rupture "due to Covid-19 infection" -- came three weeks before the earliest previously identified American coronavirus-related death.
New data on cardiac arrest emergency calls reviewed by ABC News suggests that New York City’s catastrophic outbreak likely began in close-knit neighborhoods in Queens and Brooklyn as far back as mid-February.
MORE: In the 'epicenter of the epicenter,' were early heart attacks a missed coronavirus warning?
Harvard University study which concluded last week that the U.S. needs to be testing 5 million people a day in June and up to 20 million by July in order to safely re-open the country.
"We don’t believe those estimates are accurate, nor are they reasonable, " Giroir said.
Yet either way, that testing is still mostly focused on the living. Experts told ABC News that an accurate death toll is not only important to later get a better picture of what happened, but if possible, real-time or near real-time death counts can also help public health officials in their battle to contain the virus now.
History: A chilling guide
Researchers retrospectively calculate overall deaths from a pandemic by studying excess deaths year-to-year in a given region. But that’s a difficult figure to gauge until a pandemic is over.
Previous studies of other recent virus outbreaks suggest the actual number of COVID-19 deaths to date is very likely dramatically higher than the more than 60,000 deaths currently reported.
A Centers for Disease Control and Prevention (CDC) analysis of the H1N1 swine flu virus outbreak in the U.S. in 2009 and 2010 concluded two years later that the actual tally was likely 15 times higher than the officially recorded figures. A 2013 study by the U.S. National Institutes of Health determined the figure was seven times higher than the official count.
What to know about coronavirus:
"I’ve never – none of us have ever – seen an infection like COVID-19, that literally stopped the world," said Williamson.
While most news organizations rely on the Johns Hopkins University figures, which are pulled directly from state and local government websites and are considered more timely picture of the problem, the National Center for Health Statistics, a branch of the CDC, is the primary agency responsible for U.S. health statistics, which are compiled by collecting data on births, deaths and health surveys.
Due to the lack of a uniform U.S. system, the NCHS system lags about two weeks behind in reporting said, Dr. Robert Anderson, chief of mortality statistics.
Daniel Weinberger, an epidemiologist from the Yale School of Public Health, analyzed NCHS death count data to estimate how many COVID-19 deaths may have gone uncounted during the five-week period from March 1 to April 3.
He concluded the official death toll in the U.S. is "probably a substantial underestimate of the true number by tens of thousands."
in a press briefing last week. When France added nursing homes to its tally, the nation’s death count spiked 40%, according to The Wall Street Journal.
While the U.S. is not currently counting nursing home deaths nationally, it’s estimated that thousands have died from or with COVID-19 complications in these facilities across the U.S. Last week ABC News reported that based on the reporting of 28 states, the death toll in long-term care facilities has already surged past 10,000.
Yet it was also only last week that the CDC began the laborious process of preparing to incorporate nursing home deaths into its overall death count. The agency issued a notification saying it would soon begin requiring that nursing homes report communicable disease deaths promptly to federal authorities. It’s unclear when the U.S. will begin including those figures in its national death count.
On April 14, the CDC directed all U.S. states and territories to begin counting suspected as well as lab-confirmed COVID-19 deaths.
Officials in some states have said they’ll adhere to the new CDC guidelines, but "each state has their own laws, which sometimes takes time," said Janet Hamilton, executive director Council of State and Territorial Epidemiologists (CSTE).
In mid-April, New York City released its first death count to include suspected -- not just lab-confirmed -- cases. That metric accounted for at-home deaths. The revised city figures, which added 3,700 deaths, drove up the nationwide death count by 17%.
Last week, scientists at Yale School of Public Health published a scholarly paper, which has yet to be peer-reviewed, that estimated that the actual death count in New York and New Jersey could be up to three times higher than the official tally of confirmed COVID-19 deaths or deaths that would be expected normally this time of year with respiratory diseases.
"Some states, such as Florida and Pennsylvania, might have missed deaths early on and might be under-counting deaths by a substantial degree currently," the Yale scientists concluded. "Other states, like Washington, have an accurate estimate of the mortality burden of the pandemic virus due to intense testing," the paper said. "And in states that have been hit hard by the pandemic virus, such as New Jersey and New York, the total excess mortality burden is 2-3 times that ascribed to COVID-19 in official statistics."
’The golden question’
Many U.S. states remain too overwhelmed by the outbreak or too short on supplies to perform postmortem COVID-19 testing.
Yet experts say localities’ inclusions of suspected cases in their death counts is vital going forward.
"It is critical to include both the probable and the confirmed cases so we have the full picture of the impact," said Hamilton, of CSTE. Failure to do so, she said, "would be a failure of our public health system."
Even those areas that can include probable and suspected COVID-19 deaths face challenges due to how little we yet understand about the disease, and how long the dead may carry it.
"Post-mortem, we don't know how long the [COVID-19 diagnostic] test is valid for after death," said CAP’s Williamson. "If a person is not found in their house for five days, does the COVID-19 test still work? We don't really know the answer to that."
There are two main types of death investigations in the U.S.: medical examiner autopsies and hospital-based autopsies.
formal guidance on April 3, but the guidance will take time to take root nationwide, experts said.
Beyond a shortage of testing that is forcing hospital officials to prioritize testing of live patients over the deceased, many hospital pathologists remain wary of conducting autopsies during the pandemic because of all that is still unknown about the coronavirus, according to ABC News interviews around the nation.
Even swabbing the nose of a corpse could potentially re-introduce the virus into the air surrounding the body, pathologists said -- urging their colleagues to only conduct such testing in the proper settings.
One pathologist who spoke with ABC News on the condition of anonymity said a recurring theme online among prominent U.S. academic pathologists is that due to a limited, evolving understanding of how the virus spreads, shortages of personal protective equipment and limited autopsy rooms with appropriate precautions in hospitals, many pathologists "are scared to do the autopsies" for fear of being infected.
Yet postmortem samples and tissue can be preserved until more testing is available.
"You can freeze the nasal pharyngeal swabs and test them later," Aiken said. "And medical examiners and coroner's draw blood for toxicology. Eventually that blood could be used for antibody testing. So even though the lab tests are limited now, in the long run, they may be able to determine if deaths are COVID-19 related."
The final factor that undermines a complete COVID-19 death count, according to experts, is that many if not most of the people who have died had at least one additional underlying chronic medical condition that contributed to the deaths – particularly obesity, diabetes and hypertension.
But which factor actually caused the death?
"That’s the golden question: who died with COVID-19, and who died of COVID-19," Williamson concluded. "That’s what we still don’t know."
ABC News' Josh Margolin and Lee Ferran contributed to this report.
To get an accurate picture of the pandemic, US needs to test more of the dead.
1 May 2020, 04:56
coronavirus has already claimed the lives of more than 61,000 Americans. But experts fear that number could be far higher at this point in the outbreak -- perhaps by tens of thousands -- once the pandemic subsides enough for officials to go back and make a true reckoning of the dead.
Experts are urging leaders to take measures right now to preserve data and medical specimens so that science has the chance to determine the precise number of people who succumbed during one of the most severe global pandemics in memory.
"Under-counting deaths in this particular epidemic is happening all over," said Dr. Daniel Lopez-Acuna, an epidemiologist and former top World Health Organization official, who spent 30 years at the organization. "It’s almost inevitable."
Tune into ABC at 1 p.m. ET and ABC News Live at 4 p.m. ET every weekday for special coverage of the novel coronavirus with the full ABC News team, including the latest news, context and analysis.
Calculating the precise number of COVID-19 deaths is remarkably complicated for a number of reasons. But leading epidemiologists, pathologists, medical examiners, medical history professors and local, state, federal and global health officials told ABC News that more testing is the single most important factor in determining an accurate national death count.
"We need to have the testing available because the big question now with COVID-19 is the denominator -- of anything," said Dr. Alex Williamson of the College of American Pathologists. "How many people get it? How many people recover? How many are hospitalized? How many died? We don't know the true denominator. More testing is the most important thing we need to do."
MORE: Coronavirus death toll in US likely worse than numbers say
MORE: When each state's stay-at-home order lifts
California’s first known COVID-19 death to date was Patricia Cabello Dowd, 57, in Santa Clara County. Dowd died on Feb. 6 of heart complications, which were later determined to have been unleashed by the COVID-19 virus. Dowd's death -- in which an autopsy obtained by the San Francisco Chronicle listed a heart rupture "due to Covid-19 infection" -- came three weeks before the earliest previously identified American coronavirus-related death.
New data on cardiac arrest emergency calls reviewed by ABC News suggests that New York City’s catastrophic outbreak likely began in close-knit neighborhoods in Queens and Brooklyn as far back as mid-February.
MORE: In the 'epicenter of the epicenter,' were early heart attacks a missed coronavirus warning?
Harvard University study which concluded last week that the U.S. needs to be testing 5 million people a day in June and up to 20 million by July in order to safely re-open the country.
"We don’t believe those estimates are accurate, nor are they reasonable, " Giroir said.
Yet either way, that testing is still mostly focused on the living. Experts told ABC News that an accurate death toll is not only important to later get a better picture of what happened, but if possible, real-time or near real-time death counts can also help public health officials in their battle to contain the virus now.
History: A chilling guide
Researchers retrospectively calculate overall deaths from a pandemic by studying excess deaths year-to-year in a given region. But that’s a difficult figure to gauge until a pandemic is over.
Previous studies of other recent virus outbreaks suggest the actual number of COVID-19 deaths to date is very likely dramatically higher than the more than 60,000 deaths currently reported.
A Centers for Disease Control and Prevention (CDC) analysis of the H1N1 swine flu virus outbreak in the U.S. in 2009 and 2010 concluded two years later that the actual tally was likely 15 times higher than the officially recorded figures. A 2013 study by the U.S. National Institutes of Health determined the figure was seven times higher than the official count.
What to know about coronavirus:
- How it started and how to protect yourself: Coronavirus explained
- What to do if you have symptoms: Coronavirus symptoms
- Tracking the spread in the U.S. and worldwide: Coronavirus map
"I’ve never – none of us have ever – seen an infection like COVID-19, that literally stopped the world," said Williamson.
While most news organizations rely on the Johns Hopkins University figures, which are pulled directly from state and local government websites and are considered more timely picture of the problem, the National Center for Health Statistics, a branch of the CDC, is the primary agency responsible for U.S. health statistics, which are compiled by collecting data on births, deaths and health surveys.
Due to the lack of a uniform U.S. system, the NCHS system lags about two weeks behind in reporting said, Dr. Robert Anderson, chief of mortality statistics.
Daniel Weinberger, an epidemiologist from the Yale School of Public Health, analyzed NCHS death count data to estimate how many COVID-19 deaths may have gone uncounted during the five-week period from March 1 to April 3.
He concluded the official death toll in the U.S. is "probably a substantial underestimate of the true number by tens of thousands."
in a press briefing last week. When France added nursing homes to its tally, the nation’s death count spiked 40%, according to The Wall Street Journal.
While the U.S. is not currently counting nursing home deaths nationally, it’s estimated that thousands have died from or with COVID-19 complications in these facilities across the U.S. Last week ABC News reported that based on the reporting of 28 states, the death toll in long-term care facilities has already surged past 10,000.
Yet it was also only last week that the CDC began the laborious process of preparing to incorporate nursing home deaths into its overall death count. The agency issued a notification saying it would soon begin requiring that nursing homes report communicable disease deaths promptly to federal authorities. It’s unclear when the U.S. will begin including those figures in its national death count.
On April 14, the CDC directed all U.S. states and territories to begin counting suspected as well as lab-confirmed COVID-19 deaths.
Officials in some states have said they’ll adhere to the new CDC guidelines, but "each state has their own laws, which sometimes takes time," said Janet Hamilton, executive director Council of State and Territorial Epidemiologists (CSTE).
In mid-April, New York City released its first death count to include suspected -- not just lab-confirmed -- cases. That metric accounted for at-home deaths. The revised city figures, which added 3,700 deaths, drove up the nationwide death count by 17%.
Last week, scientists at Yale School of Public Health published a scholarly paper, which has yet to be peer-reviewed, that estimated that the actual death count in New York and New Jersey could be up to three times higher than the official tally of confirmed COVID-19 deaths or deaths that would be expected normally this time of year with respiratory diseases.
"Some states, such as Florida and Pennsylvania, might have missed deaths early on and might be under-counting deaths by a substantial degree currently," the Yale scientists concluded. "Other states, like Washington, have an accurate estimate of the mortality burden of the pandemic virus due to intense testing," the paper said. "And in states that have been hit hard by the pandemic virus, such as New Jersey and New York, the total excess mortality burden is 2-3 times that ascribed to COVID-19 in official statistics."
’The golden question’
Many U.S. states remain too overwhelmed by the outbreak or too short on supplies to perform postmortem COVID-19 testing.
Yet experts say localities’ inclusions of suspected cases in their death counts is vital going forward.
"It is critical to include both the probable and the confirmed cases so we have the full picture of the impact," said Hamilton, of CSTE. Failure to do so, she said, "would be a failure of our public health system."
Even those areas that can include probable and suspected COVID-19 deaths face challenges due to how little we yet understand about the disease, and how long the dead may carry it.
"Post-mortem, we don't know how long the [COVID-19 diagnostic] test is valid for after death," said CAP’s Williamson. "If a person is not found in their house for five days, does the COVID-19 test still work? We don't really know the answer to that."
There are two main types of death investigations in the U.S.: medical examiner autopsies and hospital-based autopsies.
formal guidance on April 3, but the guidance will take time to take root nationwide, experts said.
Beyond a shortage of testing that is forcing hospital officials to prioritize testing of live patients over the deceased, many hospital pathologists remain wary of conducting autopsies during the pandemic because of all that is still unknown about the coronavirus, according to ABC News interviews around the nation.
Even swabbing the nose of a corpse could potentially re-introduce the virus into the air surrounding the body, pathologists said -- urging their colleagues to only conduct such testing in the proper settings.
One pathologist who spoke with ABC News on the condition of anonymity said a recurring theme online among prominent U.S. academic pathologists is that due to a limited, evolving understanding of how the virus spreads, shortages of personal protective equipment and limited autopsy rooms with appropriate precautions in hospitals, many pathologists "are scared to do the autopsies" for fear of being infected.
Yet postmortem samples and tissue can be preserved until more testing is available.
"You can freeze the nasal pharyngeal swabs and test them later," Aiken said. "And medical examiners and coroner's draw blood for toxicology. Eventually that blood could be used for antibody testing. So even though the lab tests are limited now, in the long run, they may be able to determine if deaths are COVID-19 related."
The final factor that undermines a complete COVID-19 death count, according to experts, is that many if not most of the people who have died had at least one additional underlying chronic medical condition that contributed to the deaths – particularly obesity, diabetes and hypertension.
But which factor actually caused the death?
"That’s the golden question: who died with COVID-19, and who died of COVID-19," Williamson concluded. "That’s what we still don’t know."
ABC News' Josh Margolin and Lee Ferran contributed to this report.
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