Are we overcounting COVID-19 deaths?

Most countries record every death and its cause, providing a permanent legal record. In the United Kingdom, the guidelines on how to complete the medical certificate of cause of death run to several pages.

The doctor who records the death must note the primary cause of death and any contributing factors on the death certificate. And therein lies the problem.

COVID-19 can lead to multiple problems — pneumonia, respiratory failure, blood clots, stroke, and heart attack — any of which might cause death. And most of those who die after contracting COVID-19 have one or more comorbidities.

So, how many people have died of COVID-19, and how many have died with COVID-19?

Consider the example of an 86-year-old man in a care home with late stage dementia and coronary artery disease (CAD). He contracts COVID-19 but has few symptoms. Then, he dies. What was the primary cause of death?

One doctor might record dementia as the primary cause, with CAD and COVID-19 as contributing factors. Another might decide that COVID-19 was the primary cause as, without contracting the SARS-CoV-2 virus, the man might have lived for a few more weeks with the other two conditions.

Dr. William Schaffner, professor of infectious diseases at the Vanderbilt University Medical Center in Nashville, TN, agreed that the actual cause of death can be hard to determine. “Deaths are, to a degree, imprecise,” he said to MNT. “A physician must make a judgment of cause of death.”

Whether the man died of COVID-19 or with COVID-19 is open to interpretation. And this is why some dispute the official figures.

The World Health Organization (WHO) defines a death from COVID-19 as “a death resulting from a clinically compatible illness in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID-19 disease, e.g., trauma.”

The U.S. attributes death to COVID-19 where this disease, or the coronavirus that causes it, appears as a cause or contributing cause of death on the death certificate.

The U.K. records any death that occurs within 28 days of a positive PCR test for SARS-CoV-2 as a COVID-19 death. The official U.K. COVID-19 death toll is now about 159,000.

However, a video that people have widely shared on social media has stated that the true number of COVID-19 deaths in the U.K. is 17,000 — just over one-tenth of the official number. This is the number of people for whom COVID-19 was the only recorded cause of death. Some people believe that this is the number that the government should publicize.

Similarly, in the U.S., CDC data showed that COVID-19 was the sole cause of only about 5{cfdf3f5372635aeb15fd3e2aecc7cb5d7150695e02bd72e0a44f1581164ad809} of listed COVID-19 deaths. These data led to the former U.S. president, Donald Trump, claiming on social media that the published figures were greatly exaggerating the severity of COVID-19.

When doctors determine that COVID-19 is not the sole cause of death, they record other causes on the death certificate. In the U.S., at least 90{cfdf3f5372635aeb15fd3e2aecc7cb5d7150695e02bd72e0a44f1581164ad809} of such recorded deaths had COVID-19 as the underlying cause of death rather than a contributing cause.

So although we could say that all of these people died with COVID-19 and not of COVID-19, the disease almost certainly played a role in their deaths.

One way of avoiding this issue is to record excess deaths during the pandemic and attribute these to COVID-19, rather than looking at how many people had COVID-19 on their death certificate. However, this approach has its own problems.

Experts calculate the excess death rate by comparing figures for a given period with the average for that same period over several previous years. So, a person looking for excess deaths in January 2022 might compare the deaths in that month with the January average for, say, the past 10 years.

The problem with counting excess deaths, though, is that it does not take into account changes in populations. In many countries, populations are getting older.

In 2000, over-65s accounted for approximately 1 in 8 people in both Europe and the U.S. By 2020, more than one-fifth of Europeans were over the age of 65 years, and people in this age bracket made up one-seventh of the U.S. population. And these numbers are increasing rapidly.

As populations get older, more people die. So, comparing the death rates in 2021 with those from previous years might give a skewed perspective. Some of those excess deaths would have occurred without the pandemic.

In addition, deaths from some causes, such as infectious diseases, have decreased during the COVID-19 pandemic due to lockdowns and physical distancing. This will affect the excess deaths figure.

Despite misgivings from some quarters, most experts believe that COVID-19 deaths are not being overcounted. Indeed, many think that undercounting is more likely, particularly in the early months of the pandemic.

“Early on, there was not widespread testing, so we underestimated the deaths. Now, the death data are more reliable. There may be some plus or minus, but death data are pretty accurate.”

– Dr. William Schaffner

Dr. Arturo Casadevall, a distinguished professor and chair of molecular microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health in Baltimore, echoed this view.

“My view is that the current number of COVID-19 deaths is an undercounting simply because those deaths reflect the ones we know about, and not every death caused by this disease was recorded or diagnosed as such,” he told MNT.

Higher income countries record all deaths, noting the causes on the death certificate. This is not the case worldwide.

The problem of unrecorded deaths is particularly acute in low and middle income countries. When a death is unrecorded, only those who witness the death may know its cause.

In India, the WHO has recorded more than 500,000 deaths due to COVID-19, but household surveys and statistical models suggest that the number could be as much as 10 times higher. Without good data on deaths and births, the COVID-19 death toll can never be certain.

The true death toll of COVID-19 may not be known for many years. Many experts also believe that the final numbers should also include those who died not with COVID-19 but because of it.

“The number of deaths attributed to COVID-19 does not include other deaths associated with the pandemic, such as those caused by the absence of proper care for other conditions because the healthcare system was focused on COVID-19, and much routine care such as cancer screening was slowed or postponed.”

– Dr. Arturo Casadevall

While the pandemic continues, it will be difficult to get a true figure for global deaths. “Death data are a lagging indicator. They are pretty reliable, but it takes longer for people to die and the data to be collected,” Dr. Schaffner cautioned.

However long it takes for the true figures to emerge, the COVID-19 pandemic has inflicted, and continues to inflict, an appalling global death toll. And it is becoming clear that the figures are almost certainly underreported, as Dr. Casadevall explained:

“I think that in coming years, we will see revisions to this number with higher estimates of total deaths as we come to better understand the toll of this calamity.”

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