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COVID-19 deaths in the US continue to be undercounted, research shows, despite claims of ‘overcounts’

Taking into consideration the number of excess deaths caused by COVID-19 compared with pre-pandemic years is critical to getting an accurate accounting…

An accurate count of COVID-19 deaths is critical both scientifically and politically. Douglas Rissing/iStock via Getty Images Plus

Since the COVID-19 pandemic was declared in March 2020, a recurring topic of debate has been whether official COVID-19 death statistics in the U.S. accurately capture the fatalities associated with SARS-CoV-2, the virus that causes COVID-19.

Some politicians and a few public health practitioners have argued that COVID-19 deaths are overcounted. For instance, a January 2023 opinion piece in The Washington Post claims that COVID-19 death tallies include not only those who died from COVID-19 but those who died from other causes but happened to have COVID-19.

Most scientists, however, have suggested that COVID-19 death tallies represent underestimates because they fail to capture COVID-19 deaths that were misclassified to other causes of death.

We are part of a team of researchers at Boston University, University of Minnesota, University of California San Francisco and other institutions who have been tracking COVID-19 deaths since the beginning of the pandemic. A major goal for our team has been to assess whether the undercounting of COVID-19 deaths has occurred, and if so in which parts of the country.

Examining excess deaths

One way to examine the issue is to look at what population health researchers call excess mortality. It’s a measure which, in this case, compares the number of deaths that occurred during the pandemic to the number of deaths that would have been expected based on pre-pandemic trends.

Excess mortality captures deaths that arose from COVID-19 directly or through indirect pathways such as patients avoiding hospitals during COVID-19 surges. While determining a cause of death can be a complex process, recording whether or not someone died is more straightforward. For this reason, calculations of excess deaths are viewed as the least biased estimate of the pandemic’s death toll.

As a general rule of thumb – with some important caveats that we explain below – if there are more COVID-19 deaths than excess deaths, COVID-19 deaths were likely overestimated. If there are more excess deaths than COVID-19 deaths, COVID-19 deaths were likely underestimated.

In a newly released study that has not yet been peer-reviewed, our team found that during the first two years of the pandemic – from March 2020 to February 2022 – there were between 996,869 and 1,278,540 excess deaths in the U.S. Among these, 866,187 were recognized as COVID-19 on death certificates. This means that there were between 130,682 and 412,353 more excess deaths than COVID-19 deaths. The gap between excess deaths and COVID-19 deaths was large in both the first and second years of the pandemic. This suggests that COVID-19 deaths were undercounted even after the pandemic’s chaotic early months.

A stirring video demonstrating excess deaths from COVID-19 in the first year of the pandemic.

Major studies have also concluded that excess deaths exceeded COVID-19 deaths at the national level during the first two years of the pandemic. And preliminary analyses by our team have found that the gap between excess deaths and COVID-19 deaths has persisted into the third year of the pandemic. This suggests that COVID-19 deaths are still being undercounted.

Making sense of the discrepancy

Explaining the discrepancy between excess deaths and reported COVID-19 deaths is a more challenging task. But several threads of evidence support the idea that the difference largely reflects uncounted COVID-19 deaths.

In a recent study, we found that excess deaths peaked immediately before spikes in reported COVID-19 deaths. This was the case even for excess deaths associated with causes like Alzheimer’s disease that are unlikely to rapidly change due to patients avoiding hospitals or other changes in behavior during the pandemic.

This finding aligns with the observation that COVID-19 deaths may go unrecognized – and be misclassified to other causes of death – at the beginning of COVID-19 surges. At this time, COVID-19 testing may be less frequent in the community, among medical providers and among death investigators. If excess deaths were not caused by COVID-19, they would instead either remain relatively constant during COVID-19 surges or they would peak afterwards when hospitals were overcrowded and deaths may have resulted from health care interruptions.

Excess deaths related to external causes of death such as drug overdose also increased during the pandemic. However, a preliminary study found that the scale of this increase was small relative to the overall increase in excess deaths. So deaths from external factors alone cannot explain the gap between excess and COVID-19 deaths.

This evidence is worth considering in light of the prominent opinion piece in the Washington Post mentioned earlier, which suggests that the U.S.‘s tally of COVID-19 deaths is a substantial overcount. The author argues that in some hospitals, widespread COVID-19 testing has led patients with COVID-19 who died of other causes to still have COVID-19 included as a cause on their death certificate. There is a fundamental misunderstanding, however, in generalizing these hospital deaths to the entire country.

One reason this overgeneralization is flawed is because hospital deaths are distinct from out-of-hospital deaths. In out-of-hospital settings, COVID-19 testing is often lacking and death investigators have less training and less information about the deceased. In fact, our research suggests that COVID-19 deaths are largely undercounted in out-of-hospital settings.

Investigative reporting among coroners in rural areas has also revealed significant variability in out-of-hospital cause of death assignment. Some coroners have even gone on record to state that they do not include COVID-19 on death records if it contradicts their own political beliefs or if families wish for it to be omitted.

The other problem with the overgeneralization is geographic. Our preliminary study demonstrates that excess deaths exceeded COVID-19 deaths in the vast majority of counties across the U.S. In particular, counties in the South, the Rocky Mountain states and rural areas had many more excess deaths than COVID-19 deaths. This suggests that COVID-19 deaths were likely undercounted in these areas.

The idea that COVID-19 deaths are sometimes overreported is, to a very limited extent, supported by our analyses. A select number of large and medium-sized metro areas in New England and the mid-Atlantic states have had more COVID-19 deaths than excess deaths. But most of the country has not followed the patterns of this small group of counties.

While it is possible that some deaths assigned to COVID-19 in New England and the mid-Atlantic states were not actually caused by COVID-19, other explanations are also possible. First, COVID-19 mitigation efforts could have prevented deaths in these areas via pathways unrelated to COVID-19, reducing excess deaths. For example, some people living in wealthy, urban counties had the privilege to work from home and avoid household crowding, which may have reduced their risk of dying from flu. Flu is typically responsible for as many as 50,000 deaths each year.

In fact, the 2020-2021 flu season was minimal, likely because of social distancing. Another possible explanation is that later in the first two years of the pandemic, there may have also been fewer deaths than expected in some areas because some of the least healthy people in the area had already died of COVID-19. These alternative explanations imply that, even in those New England and mid-Atlantic counties where more COVID-19 deaths were recorded than estimated excess deaths, many COVID-19 deaths may still have occurred even as other kinds of deaths decreased.

Why it matters

Ultimately, figuring out how many people have died as a result of the COVID-19 pandemic is a major scientific undertaking that has significant political importance. Knowing how many people died and where these deaths occurred has widespread implications for informing how current pandemic response resources are allocated and for preparing for future public health emergencies.

As a result, in our view, it is critical that the scientific community carefully reviews the rigor of the science behind the counting of COVID-19 deaths. Given the intense politicization of the pandemic, claims of overcounting or undercounting need to be made cautiously.

Finally, research by our team and investigative reporting conducted in partnership with our team has found that the undercounting of COVID-19 deaths is significantly more common in Black, Hispanic and Native American communities as well as low-income areas. Claims that COVID-19 deaths have been overcounted undermine efforts to reconcile the undercounts in these communities and to ensure resources are being allocated to those most affected. For example, if a person does not have COVID-19 assigned as a cause on their death certificate, their family is ineligible for pandemic social programs such as the FEMA funeral assistance program.

To understand where the U.S. public health system has succeeded and fallen short during the pandemic, a full accounting of deaths caused by COVID-19 is needed. More than that, families, friends and loved ones of those who have died so far also deserve to know the true toll that COVID-19 has taken.

Andrew Stokes receives funding from the Robert Wood Johnson Foundation, the W.K. Kellogg Foundation, and the National Institute on Aging.

Dielle Lundberg receives funding from the Agency for Healthcare Research and Question through grant number T32HS013853. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Elizabeth Wrigley-Field receives funding from the Minnesota Population Center, funded through a grant from the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD, grant number P2CHD041023).

Yea-Hung Chen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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Federal Food Stamps Program Hits Record Costs In 2022

Federal Food Stamps Program Hits Record Costs In 2022

In early January, The Wall Street Journal Editorial Board warned that one peril of a…

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Federal Food Stamps Program Hits Record Costs In 2022

In early January, The Wall Street Journal Editorial Board warned that one peril of a large administrative state is the mischief agencies can get up to when no one is watching.

Specifically, they highlight the overreach of the Agriculture Department, which expanded food-stamp benefits by evading the process for determining benefits and end-running Congressional review.

Exhibit A in the over-reach is the fact that the cost of the federal food stamps program known as the Supplemental Nutrition Assistance Program (SNAP) increased to a record $119.5 billion in 2022, according to data released by the U.S. Department of Agriculture...

Food Stamp costs have literally exploded from $60.3 billion in 2019, the last year before the pandemic, to the record-setting $119.5 billion in 2022.

In 2019, the average monthly per person benefit was $129.83 in 2019, according to the U.S. Department of Agriculture. That increased by 78 percent to $230.88 in 2022.

Even more intriguing is the fact that the number of participants had increased from 35.7 million in 2019 to 41.2 million in 2022...

All of which is a little odd - the number of people on food stamps remains at record highs while the post-COVID-lockdown employment picture has improved dramatically...

Source: Bloomberg

If any of this surprises you, it really shouldn't given that 'you, the people' voted for the welfare state. However, as WSJ chided: "abuse of process doesn’t get much clearer than that."

In its first review of USDA, the GAO skewered Agriculture’s process for having violated the Congressional Review Act, noting that the “2021 [Thrifty Food Plan] meets the definition of a rule under the [Congressional Review Act] and no CRA exception applies. Therefore, the 2021 TFP is subject to the requirement that it be submitted to Congress.” GAO’s second report says “officials made this update without key project management and quality assurance practices in place.”

Abuse of process doesn’t get much clearer than that. The GAO review won’t unwind the increase, which requires action by the USDA. But the GAO report should resonate with taxpayers who don’t like to see the politicization of a process meant to provide nutrition to those in need, not act as a vehicle for partisan agency staffers to impose their agenda without Congressional approval.

All of this undermines transparency and accountability for a program that provided food stamps to some 41 million people in 2021. The Biden Administration is using the cover of the pandemic to expand the entitlement state beyond what Congress authorized.

The question now is, will House Republicans draw attention to this lawlessness and use their power of the purse to stop it to the extent possible with a Democratic Senate.

And don't forget, the US economy is "strong as hell."

Tyler Durden Sat, 01/28/2023 - 09:55

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Spread & Containment

A Royal Caribbean Cruise Line Adult Favorite Has Not Come Back

The cruise line has almost fully returned to normal after the covid pandemic, but one very popular activity hasn’t been brought back.

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The cruise line has almost fully returned to normal after the covid pandemic, but one very popular activity hasn't been brought back.

In the early days of Royal Caribbean Group's (RCL) - Get Free Report return from its 15-month covid pandemic shutdown, cruising looked a lot different. Ships sailed with limited capacities, masks were required in most indoor areas, and social distancing was a thing.

Keeping people six feet apart made certain aspects of taking a cruise impossible. Some were made easier by the lower passenger counts. For example, all Royal Caribbean Windjammer buffets required reservations to keep the crowds down, but in practice that system was generally not needed because capacities were never reached.

Dance parties and nightclub-style events had to be held on the pool decks or in larger spaces, and shows in the big theaters left open seats between parties traveling together. In most cases, accommodations were made and events more or less happened in a sort of normal fashion.

A few very popular events were not possible, however, in an environment where keeping six feet between passengers was a goal. Two of those events -- the first night balloon drop and the adult "Crazy Quest" game show -- simply did not work with social-distancing requirements.

One of those popular events has now made its comeback while the second appears to still be missing (aside from a few one-off appearances).

TheStreet

The Quest Is Still Mostly Missing

In late November, Royal Caribbean's adult scavenger hunt, "The Quest," (sometimes known as "Crazy Quest") began appearing on select sailings. And at the time it appeared like it was coming back across the fleet: A number of people posted about the return of the interactive adult game show in an unofficial Royal Caribbean Facebook group.

It first appeared during a Wonder of the Seas transatlantic sailing.

Since, then its appearances continue to be spotty and it has not returned on a fleetwide basis. This might not be due to any covid-related issues directly, but covid may play a role.

On some ships, Studio B, which hosts "The Quest," has been used for show rehearsals. That has been more of an issue with the trouble Royal Caribbean has had in getting new crew members onboard. And while that staffing issue has been improving, some shows may not have had full complements of performers, so using the space for rehearsal has been a continuing need.

In addition, while covid rules have gone away, covid has not, and ill cast members may force the need for more rehearsals.

Royal Caribbean has not publicly commented on when (or whether) "The Quest" will make a full comeback

Royal Caribbean Balloon Drops Are Back   

Before the pandemic, Royal Caribbean kicked off many of its cruises with a balloon drop on the Royal Promenade. That went away because it forced people to cluster as music was performed and, at midnight, balloons fell from the ceiling.

Now, the cruise line has brought back the balloon drop, albeit with a twist. The drop itself is appearing on activity schedules for upcoming Royal Caribbean cruises. Immediately after it, however, the cruise line has added something new: "The Big Recycle Balloon Pickup."

Most of the dropped balloons get popped during the drop. Previously, crewmembers picked up the used balloons. Now, the cruise line has made it a "fun" passenger activity.

"Get environmentally friendly as you help us gather our 100% biodegradable balloons in recycle baskets," the cruise line shared in its app. 

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Spread & Containment

What’s Still Missing on Royal Caribbean Cruises Post Covid

The cruise line has almost fully returned to normal after the covid pandemic, but one very popular activity hasn’t been brought back.

Published

on

The cruise line has almost fully returned to normal after the covid pandemic, but one very popular activity hasn't been brought back.

In the early days of Royal Caribbean Group's (RCL) - Get Free Report return from its 15-month covid pandemic shutdown, cruising looked a lot different. Ships sailed with limited capacities, masks were required in most indoor areas, and social distancing was a thing.

Keeping people six feet apart made certain aspects of taking a cruise impossible. Some were made easier by the lower passenger counts. For example, all Royal Caribbean Windjammer buffets required reservations to keep the crowds down, but in practice that system was generally not needed because capacities were never reached.

Dance parties and nightclub-style events had to be held on the pool decks or in larger spaces, and shows in the big theaters left open seats between parties traveling together. In most cases, accommodations were made and events more or less happened in a sort of normal fashion.

A few very popular events were not possible, however, in an environment where keeping six feet between passengers was a goal. Two of those events -- the first night balloon drop and the adult "Crazy Quest" game show -- simply did not work with social-distancing requirements.

One of those popular events has now made its comeback while the second appears to still be missing (aside from a few one-off appearances).

TheStreet

The Quest Is Still Mostly Missing

In late November, Royal Caribbean's adult scavenger hunt, "The Quest," (sometimes known as "Crazy Quest") began appearing on select sailings. And at the time it appeared like it was coming back across the fleet: A number of people posted about the return of the interactive adult game show in an unofficial Royal Caribbean Facebook group.

It first appeared during a Wonder of the Seas transatlantic sailing.

Since, then its appearances continue to be spotty and it has not returned on a fleetwide basis. This might not be due to any covid-related issues directly, but covid may play a role.

On some ships, Studio B, which hosts "The Quest," has been used for show rehearsals. That has been more of an issue with the trouble Royal Caribbean has had in getting new crew members onboard. And while that staffing issue has been improving, some shows may not have had full complements of performers, so using the space for rehearsal has been a continuing need.

In addition, while covid rules have gone away, covid has not, and ill cast members may force the need for more rehearsals.

Royal Caribbean has not publicly commented on when (or whether) "The Quest" will make a full comeback

Royal Caribbean Balloon Drops Are Back   

Before the pandemic, Royal Caribbean kicked off many of its cruises with a balloon drop on the Royal Promenade. That went away because it forced people to cluster as music was performed and, at midnight, balloons fell from the ceiling.

Now, the cruise line has brought back the balloon drop, albeit with a twist. The drop itself is appearing on activity schedules for upcoming Royal Caribbean cruises. Immediately after it, however, the cruise line has added something new: "The Big Recycle Balloon Pickup."

Most of the dropped balloons get popped during the drop. Previously, crewmembers picked up the used balloons. Now, the cruise line has made it a "fun" passenger activity.

"Get environmentally friendly as you help us gather our 100% biodegradable balloons in recycle baskets," the cruise line shared in its app. 

Read More

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