U.S. COVID-19 Death Toll May Only Be ‘Tip of the Iceberg,’ Says CDC Adviser


As the COVID-19 pandemic continues across the U.S., obtaining an accurate tally of cases and deaths has become a growing challenge.

Death counts may be underestimated due to several factors. Staff shortages and bureaucratic red tape around accessing death records in certain states have also reportedly added to the issue, causing delays in reporting the latest state figures to the U.S. Centers for Disease Control and Prevention (CDC).

But many potentially infected people have been dying at home. These deaths are currently unaccounted for because of a lack of testing before they died.

Several metropolitan areas of states with some of the highest death tolls in the country have reportedly seen a spike in fatalities at home that may have been from COVID-19.

Speaking to Newsweek, Mark Hayward, an expert on mortality statistics who is a member of a CDC advisory council on vital statistics, said: “The biggest challenge in obtaining an accurate tally of COVID-19 deaths is to [be able to] implement widespread testing. Locales that lack testing and where populations are rural, reside in nursing homes, or people live alone are likely to be major contributors to the undercount; note that these are not mutually exclusive categories.”

He added: “There are also varying standards (and timing of rollouts) of testing by state. Cause-of death classification schemes have also been evolving and it’s not always straightforward in assigning COVID-19 as a cause of death. I think the biggest barrier, though, is the lack of testing.”

As of Thursday, nearly 3,263,000 people in the U.S. have been tested for the virus. This is less than 1 percent of the total population.

So the current reported U.S. death toll may only be “the tip of the iceberg,” Hayward told ProPublica.

But just how underreported are the death counts across the U.S.? Hayward told Newsweek: “I do not have an actual figure of underreporting and this will vary over time as testing becomes more widespread. The degree of under-reporting will vary across localities in the U.S. and over time. The geographic and temporal variability are tightly linked because of the geographic differences in testing.”

He added: “It’s also hard to use other countries as standards to gauge underreporting, given differences in vital registration systems.”

Getting an accurate account of deaths is vital for mitigation purposes, especially for identifying any potential hotspots and sending resources to those areas before there is an explosion of cases and deaths. That’s according to the chief of the CDC’s mortality statistics branch, Robert Anderson.

“One of the reasons we count deaths is to allocate resources to where they need to go. It becomes a little more time-sensitive when you’re dealing with something like a pandemic,” Anderson told ProPublica.

New York City, the country’s most populous city with nearly 8.4 million residents, reported around 200 people a day were dying at home, a spokesperson for the medical examiner’s office, Aja Worthy-Davis, told Gothamist last week.

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An untold number of deaths were said to have been unconfirmed and the medical examiner’s office does not test dead bodies for the virus.

A spokesperson for the city’s health department, Michael Lanza, told Gothamist that the city only includes confirmed novel coronavirus deaths in official figures. “Every person with a lab-confirmed COVID-19 diagnosis is counted in the number of fatalities,” he said.

“While undiagnosed cases that result in at-home deaths are connected to a public health pandemic…not all suspected COVID-19 deaths are brought in for examination by OCME [Office of Chief Medical Examiner], nor do we provide testing in most of these natural at-home deaths.”

a person sitting on a bed: Medics wearing personal protective equipment (PPE), prepare to intubate a gravely ill patient with COVID-19 symptoms at his home on April 06, 2020 in Yonkers, New York.© Getty Images Medics wearing personal protective equipment (PPE), prepare to intubate a gravely ill patient with COVID-19 symptoms…

Nearly 2,192 deaths at home (equating to about 130 deaths a day) were also recorded by the Fire Department of the City of New York between March 20 and April 5.

The figure was reported to be a nearly 400 percent increase from the same period last year, when the department received 453 calls for cardiac arrest patients who died.

The graphic below, provided by Statista, shows the number of confirmed COVID-19 cases, the disease caused by the new strain of coronavirus, in a selection of states.

a screenshot of a cell phone: A chart provided by Statista shows the cumulative number of confirmed COVID-19 cases in New York, Washington and California from March 16 through April 15. New York alone accounts for a third of the confirmed cases of the United States' COVID-19 outbreak, the world's worst on record. Statista© Statista A chart provided by Statista shows the cumulative number of confirmed COVID-19 cases in New York, Washington and California from March 16 through April 15. New York alone accounts for a third of the confirmed cases of the United States’ COVID-19…

Health officials in Massachusetts were said to have reported around 317 at-home deaths in March. The figure is reportedly a 20 percent increase from the same period over the past three years.

Officials in Detroit reported 150 “dead person observed” calls were received from April 1 to April 10. The number was said to be at nearly 40 during the same period for the past three years, according to city 911 call data.

It is hoped the quality of the figures will improve with further expansion of testing across the country. Hayward told Newsweek: “The CDC is responding to the need to accurately count COVID-19 deaths.”

The CDC recently issued new guidelines for counting cases and deaths, which have been in effect from April 14.

“As of April 14, 2020, CDC case counts and death counts include both confirmed and probable cases and deaths,” the CDC states on its website.

“State and local public health departments are now testing and publicly reporting their cases. In the event of a discrepancy between CDC cases and cases reported by state and local public health officials, data reported by states should be considered the most up to date,” it adds.

Hayward noted: “The new guidelines in essence help identify probable COVID-19 deaths in the absence of testing – which is important.”

The COVID-19 virus, which was first reported in Wuhan, China, has infected more than two million people across at least 185 countries and regions. Over 139,400 have died, while nearly 528,300 have recovered from infection, according to the latest figures from Johns Hopkins University.

The graphic below, provided by Statista, illustrates the spread of COVID-19 across the U.S.

a close up of a map: The number of confirmed novel coronavirus cases in the United States. Statista© Statista The number of confirmed novel coronavirus cases in the United States. Statista

Data on COVID-19 cases is from Johns Hopkins University unless otherwise stated.

Centers for Disease Control and Prevention Advice on Using Face Coverings to Slow Spread of COVID-19

  • CDC recommends wearing a cloth face covering in public where social distancing measures are difficult to maintain.
  • A simple cloth face covering can help slow the spread of the virus by those infected and by those who do not exhibit symptoms.
  • Cloth face coverings can be fashioned from household items. Guides are offered by the CDC. (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html)
  • Cloth face coverings should be washed regularly. A washing machine will suffice.
  • Practice safe removal of face coverings by not touching eyes, nose, and mouth, and wash hands immediately after removing the covering.

World Health Organization advice for avoiding spread of coronavirus disease (COVID-19)

Hygiene advice

  • Clean hands frequently with soap and water, or alcohol-based hand rub.
  • Wash hands after coughing or sneezing; when caring for the sick; before, during and after food preparation; before eating; after using the toilet; when hands are visibly dirty; and after handling animals or waste.
  • Maintain at least 1 meter (3 feet) distance from anyone who is coughing or sneezing.
  • Avoid touching your hands, nose and mouth. Do not spit in public.
  • Cover your mouth and nose with a tissue or bent elbow when coughing or sneezing. Discard the tissue immediately and clean your hands.

Medical advice

  • Avoid close contact with others if you have any symptoms.
  • Stay at home if you feel unwell, even with mild symptoms such as headache and runny nose, to avoid potential spread of the disease to medical facilities and other people.
  • If you develop serious symptoms (fever, cough, difficulty breathing) seek medical care early and contact local health authorities in advance.
  • Note any recent contact with others and travel details to provide to authorities who can trace and prevent spread of the disease.
  • Stay up to date on COVID-19 developments issued by health authorities and follow their guidance.

Mask and glove usage

  • Healthy individuals only need to wear a mask if taking care of a sick person.
  • Wear a mask if you are coughing or sneezing.
  • Masks are effective when used in combination with frequent hand cleaning.
  • Do not touch the mask while wearing it. Clean hands if you touch the mask.
  • Learn how to properly put on, remove and dispose of masks. Clean hands after disposing of the mask.
  • Do not reuse single-use masks.
  • Regularly washing bare hands is more effective against catching COVID-19 than wearing rubber gloves.
  • The COVID-19 virus can still be picked up on rubber gloves and transmitted by touching your face.
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