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We should definitely care about the number of people infected, the hospitalizations and those who have been sick for weeks, but tracking deaths is the starkest way to measure COVID-19′s toll on humanity.
That hasn’t been as easy as some would expect. And talking about death counts often opens up a whole line of questioning.
How many more people are dying now than otherwise would in a more normal year? Because the virus attacks the elderly and those with preexisting conditions, would those deaths have happened anyway?
As of Saturday, 139 people have died of the virus in Utah, according to the Utah Department of Health’s tallies, and more than 115,000 nationwide. How accurate are those counts?
Finally, we know that the disease has made an impact on nearly every aspect of society. Some of those can be deadly: people may put off going to the hospital fearing they would contract the virus there, people might die by suicide at a higher rate because of the isolation caused by social distancing, traffic accidents and homicides might have gone up or down in these unusual times.
I’ve wanted to dig into these questions since March, but haven’t felt really confident in the data until this week. That’s when the Centers for Disease Control and Prevention uploaded its latest death reports, which include weekly death tallies separated by cause through May. With that, and a few other sources, we can get an early picture of how this pandemic has really impacted deaths in Utah and nationwide.
First, the caveats: most of the data in this article comes from CDC “provisional” reports. That means the data hasn’t been double-checked yet, and much of the data from recent weeks is unknown. In addition, we should note that the CDC typically estimates that 20% to 30% of death certificates are filled out incorrectly or incompletely.
Still, the CDC’s data confirms information we already have and new stats to consider. So with this in hand, let’s take a shot at answering those questions.
How are coronavirus deaths tracked?
Every time someone dies in America, a physician, coroner or medical examiner has to fill out a death certificate. For example, here’s how the CDC recommends a doctor fill out the death certificate for someone who experienced pneumonia for 10 days as a result of COVID-19.
The highest line item is the “immediate cause of death.” And in this case, the doctor would put acute respiratory distress syndrome, which the person suffered from for two days. That’s the condition that caused the person to take their last breath. But the thing that first caused the sequence of events is called the “underlying cause of death,” and typically, that’s the thing we care about most. If someone is stabbed, bleeds out and dies, we typically chalk the death up to “stabbing” and not “loss of blood.” When COVID-19 is listed on a death certificate, 95% of the time it is listed as the underlying cause of death.
Doctors can put COVID-19 on the form without a positive test, if that’s their best guess. For example, if someone had significant exposure to a confirmed COVID-19 case, then died of COVID-19 symptoms, doctors are instructed to put “Probable COVID-19” on the form. These are usually tallied with the confirmed coronavirus deaths. In Utah, public health leaders say they test people after they die in an attempt to catch all cases of the virus.
Then, doctors must list any significant conditions that played a role in the death in Part II of the form. That is where heart disease, diabetes, hypertension, or any other contributing factors are placed. Any number of conditions can be put here, but only the ones that played a role in the death in the doctor’s informed opinion.
These certificates are sent to the National Center of Health Statistics. Because these stats rely on manual entry, they typically lag a few weeks behind the daily coronavirus reports we hear from the counties and states. Some states even take a couple of months to report their data, but Utah is generally relatively quick about it.
How many excess deaths have occurred in Utah and the U.S.?
With the death certificates, the CDC can count the number of deaths in any given week and in any given state and compare them to how many deaths they expected to see — the difference is called excess deaths. The CDC uses a well-established method called Farrington’s algorithm to estimate death counts using data from recent years to provide an average guess, as well as a 95% confidence interval for that guess.
Overall, there have been a huge number of excess deaths in the United States. From Feb. 1 to May 30, there were an estimated 140,023 extra deaths in the nation.
In Utah, the situation is significantly better than it is in most states. According to the CDC’s data, Utah’s total number of deaths over the same timeframe was 252 more than expected. However, that number is just inside the confidence interval’s margin of error: it is possible, but unlikely, that the extra deaths are a result of a misestimate of the expected number. Only 11 states had a lower excess death number.
Utah’s overall death rate is also very low compared to the rest of the nation, ranking 45th in terms of deaths per capita. In terms of case fatality rate, the number of deaths divided by the number of positive cases, Utah is No. 1: only 1% of Utahns who tested positive have died so far. As we’ve discussed before, Utah has had a higher testing rate than many other states, and its population is younger and healthier than most, which likely plays a big role in a lower death rate.
How many of those excess deaths are due to COVID-19?
The CDC separates the underlying causes of natural death into these categories: cancer, heart diseases, stroke, diabetes, Alzheimer’s disease, influenza and pneumonia, chronic lower respiratory diseases, kidney diseases, COVID-19, and an “other/unknown” category.
In the U.S. as a whole, the CDC estimates that between 20,665 and 45,955 of these extra deaths between Feb. 1 and May 30 were caused by something other than COVID-19. Yet, most of these were in the states hardest hit by the pandemic. For example, New York City saw heart attack deaths spike: it is likely that people experiencing a heart attack were less likely to rush to the hospital, and so drastically more of them died.
The good news is that there isn’t evidence of similar spikes in the Utah data. Typically, 77 people die every week of “diseases of the heart” in Utah, according to the CDC, but during the pandemic, 79 people died every week. It wasn’t a major difference.
The same is true for other common causes of death, like cancer, diabetes, Alzheimer’s and strokes. Even for pneumonia or chronic lower respiratory diseases, conditions you can imagine a coroner substituting for COVID-19, the death counts haven’t changed in Utah — the pre- and post-pandemic averages are extremely close, within one or two deaths per week.
What accounts for the other deaths?
Through May 30, Utah had 112 COVID-19 deaths. That explains a big chunk of the 252-ish excess deaths found in the CDC data, but not all of them. If other causes aren’t spiking, what explains the rest of the increase?
Utah does have a bunch of deaths from April 12 to May 30 in that “other/unknown” category — 169, in fact. In typical times, these unknown deaths are usually updated later to be either deadly accidents requiring investigation or drug overdoses requiring toxicology reports. However, because each death involving COVID-19 has to be manually entered, it’s possible that some of these are related to the virus. It’s also possible that they will be assigned to other causes, and there has just been a delay in categorizing them. In the coming months, we’ll have to watch to see where these deaths get distributed.
Each death is also labeled “Natural” or not — the latter category including homicides, suicides, and accidents. The vast majority of deaths are natural. In the early part of the pandemic, Utah’s rate of non-natural deaths declined from 43 per week on average to 36 per week on average.
Some expect a big leap in suicides in Utah, but I don’t see evidence of it in this data. For one, suicides are rarely even temporarily labeled as “unknown” in the death certificate system: they’re reflected in the non-natural data quickly.
And with other aspects of non-natural deaths, we didn’t see much change. Crime rates in Utah didn’t really decrease during the pandemic compared to the past couple of years, so there’s not much change in homicide. And interestingly, car accident fatalities have actually been up this year in Utah, despite having fewer cars on the road. If total non-natural deaths have fallen or stayed stagnant, and other large components have either stayed stagnant or risen a little, it’s hard to argue that one unknown component, suicides, have risen significantly.
There’s also been no big jump in non-natural deaths nationwide in the past three months, even with deaths from unknown causes potentially taken into account.
Who is dying?
In Utah, the average age of those who have died from the coronavirus is 73.9 years, according to the Utah Department of Health. So far, 72.7% of deaths have been from those over 65 years old; 82% of the dead have had at least one preexisting condition. Utah’s male to female split hasn’t been very wide: 54% of Utah’s deaths have been male, 46% have been female.
Understandably, people see these numbers, compare them to life expectancy numbers — the average life expectancy in the U.S. is 78 years — and figure that COVID-19 is largely killing those who were near death anyway. But most old people have one preexisting condition or another, and once people make it to their 70s, most live quite a while longer. Remember that life expectancy is driven down by people who die when they are relatively young.
One University of Glasgow study took into account the age and preexisting conditions of the dead in the United Kingdom and found that, on average, coronavirus deaths were cutting 13 years off of the life of male victims and 11 years of life off female ones.
The other interesting disparity is that while 51% of Utah’s coronavirus cases have come in Salt Lake County so far, 66% of the deaths have come in the county. There’s no disparity in percentage of elderly in Salt Lake County compared with the rest of the state, nor in the numbers of those with preexisting conditions, so it’s not immediately clear why the death count would be higher in Salt Lake County. However, there have been well-documented outbreaks in some of Salt Lake County’s long-term care facilities in particular, which might explain the difference.
So yes, there are still questions to be answered, with more concrete data to come. But now three months into this crisis, we’re starting to get a clearer picture on the total effect the virus has had on people’s lives — and unfortunately, the end of them.