Why the real Covid-19 death toll will have to wait for pandemic to end

Every day brings with it another grim milestone in the coronavirus wave. Infections and deaths keep ticking up on Covid trackers Worldometer and John Hopkins University coronavirus resource centre. At the time of writing, 2,214,327 people were infected with the virus which has killed more than 148,000.

But do we really know how many people have died of this disease? The short answer is no, and experts say it is impossible to know the number of fatalities amid the pandemic. We have to wait for it to end, before annual death rates can be compared with 2020, if the pandemic comes to a close within this year.

Data collected from Italy, Spain, Ireland, Belgium and France by the London School of Economics found 42 to 57 percent of all Covid-19 deaths linked to the virus were among care home residents who are left out as some of these countries count only hospital deaths.

France is one of the few countries in Europe which made an adjustment on April 2 to include Covid-19 deaths in care homes in its official statistics. 

Spain, Italy and England only count deaths in hospital in their official coronavirus death tolls.

In central Spain's Castilla-La Mancha region, health authorities recorded 965 coronavirus deaths during March, while authorities issued 3,319 burial licenses, The Local reported.

In March 2018, authorities had issued 1,826 burial licenses and 1,691 in 2019. 

Licences issued in 2020 clearly showed a surge in deaths amid the Covid-19 pandemic, a discrepancy justice authorities only picked up on later.

"Similar discrepancies are emerging in regions across Spain," the news website reported, suggesting many Covid-19 victims remained unaccounted for.

Incomplete official data

Italy has the most deaths in the world after the US, 22,170 deaths from 168,941 infections.

Its Lombardy region has 10 million people and 11,142 officially registered Covid-19 deaths.

Officials say the shortage of swab tests means that Lombardy is only testing those most clearly showing symptoms and therefore those least likely to survive.

"In addition, Lombardy has not tested the elderly in retirement homes, where the virus has circulated a lot," Milan's Vita-Salute San Raffaele University professor Roberto Burioni said.

This means that Italy still does not know how many people have really died of coronavirus.

According to Matteo Villa, a researcher at the Italian Institute for Political Studies and author of a new study Coronavirus: Lethality in Italy, between appearance and reality, Italy's cases and number of dead is higher than what's being recorded by the government.

The study, published on March 27, estimated that the real number of people who would test positive in Italy are in the order of 530,000, compared with about 55,000 official "active cases".

"The difference between this realistic figure and the 'out of scale' one is attributable to the number of people who have been infected, but not subjected to the swab, to verify their test results," Villa said.

Italian officials concede their Covid-19 data is incomplete because deaths that occurred outside of hospitals are not counted. The official toll does not include those who died from the disease but were not tested which applies to people who died in nursing homes.  

One such official is the mayor of Bergamo Giorgio Gori, who recently said the real death toll in his province may be higher than current figures.

He tweeted a newspaper analysis suggesting that the toll there was "between 4,500 and 5,000, and not the 2,060" officially reported.

'Deaths are underestimated'

Other officials, such as Silvio Brusaferro, the head of national health institute ISS, believes the number of deaths from coronavirus in Italy could be underestimated in the official figures.

"It is plausible that deaths are underestimated. We report deaths that are signaled with a positive swab. Many other deaths are not tested with a swab," Brusaferro said last month.

Around 50 percent of Covid-19 deaths are occurring in care homes, according to a new study on data from five European countries.

Every New Yorker 'gets counted'

In the US, the death tally quickly soared after the US Centers for Disease Control and Prevention (CDCP) said it was now adding "probable" cases of coronavirus in its counting, as well.

"As of April 14, 2020, CDCP case counts and death counts include both confirmed and probable cases and deaths," it said.

A confirmed case or death, according to CDCP, is defined by meeting confirmatory laboratory evidence for Covid-19. A probable case or death is defined by meeting clinical criteria and epidemiologic evidence with no confirmatory laboratory testing performed for Covid-19.

On Wednesday, using CDCP guidelines, New York City drastically increased its estimate of people killed by Covid-19 to 10,367 after including some 4,000 probable victims who had not been tested.

"Behind every death is a friend, a family member, a loved one. We are focused on ensuring that every New Yorker who died because of Covid-19 gets counted," said the city's health commissioner, Dr Oxiris Barbot.

"While this data reflects the tragic impact that the virus has had on our city, they will also help us to determine the scale and scope of the epidemic and guide us in our decisions."

All this points to the fact that it is hard to ascertain which countries, if any, have an accurate death toll since a number of factors, including testing rates, health protocols and capabilities and resources, influence the tallies.

Deaths mostly unreported in India

In the case of developing countries like India, which has reported 420 deaths and over 12,700 cases so far, experts say "only around a fifth of India’s deaths are actually certified and recorded".

"India has a really weak surveillance system for reporting diseases even in the best of times ... so, we won’t actually get to observe rural deaths or rural cases because if someone who is poor in a village is dying of respiratory distress, it won’t record," Ramanan Laxminarayan, an epidemiologist and economist who directs the Center for Disease Dynamics, Economics and Policy in Washington, DC, told The New Yorker.

"It won't show up in any sort of death statistic; only around a fifth of India's deaths are actually certified and recorded. The remainder have no official cause of death."

China revises death toll

China is in fact one current example of how death tolls will be adjusted after the virus stops circulating in such high numbers and officials across the world have a chance to recount, re-tally and recalibrate.

On Friday, Wuhan city has raised its number of Covid-19 fatalities by 1,290, or 50 percent of earlier reported cases.

State media said the earlier undercount had been due to the insufficient admission capabilities at overwhelmed medical facilities at the peak of the outbreak.

Wuhan's revised death toll of 3,869 is the most in China. Numbers of total cases in the city of 11 million were also raised by 325 to 50,333, accounting for about two-thirds of China’s total 82,367 announced cases.

Scepticism about China’s numbers was initially fuelled by official efforts to quash bad news in the early days and a general distrust of the government which was accused of covering up the SARS outbreak.

Long lines of people waiting to collect the ashes of loved ones at funeral homes last week revived the debate.

"The number of confirmed cases of Covid-19 by country appears like a grim league table and draws the attention of many," said Hsu Li Yang, who heads the infectious diseases programme at the National University of Singapore.

"However, it is important to understand that these numbers –– be it from China, Italy, Singapore or the USA –– are all inaccurate, and they are all underestimates, to varying degrees, of the actual number of infections.

Reporting in censor-heavy countries 

In countries such as Russia where information shared with the media is highly controlled and often punishable, speculation is rife about cover-ups.

But the Russian government's critics say the official 28,000 tally and 232 death toll, according to the Russian coronavirus crisis response centre, is being underreported and that the government is faking official statistics about the number of cases.

"It's impossible to know the real situation, but one thing we know for sure: the state is ready to manipulate medical statistics for political purposes," Anastasia Vasilyeva, the head of the independent Doctors Alliance trade union, told The New Yorker earlier this month.