Undercount of COVID-19 deaths means full effects on Georgia unknown

Twice each day, Georgia’s public health agency updates the bleakest of statistics: the state’s ever-rising death toll from the novel coronavirus.

On March 25, the deaths totaled 25. On April 1, 125. On April 10, 425. And on Friday, the agency said the coronavirus has now killed 668 Georgians.

But those figures, as grim as they sound, may significantly understate the number of lives lost in Georgia to COVID-19, the disease caused by the coronavirus.

Officials acknowledged Friday that, until this week, they had counted only deaths in which COVID-19 diagnoses were confirmed by laboratory tests. By omitting symptomatic people who died before they could be tested, the state has fought the virus without a true picture of its impact.

The 668 deaths on the official list represented an increase of 51 since Thursday. More than 17,000 people statewide had tested positive by Friday, up by about 1,000 from a day earlier.

Just as unsettling, the state announced that 250 residents of nursing homes and other long-term facilities have died from the virus. A report just two days earlier showed just 89 deaths in those facilities, which are considered incubators for the virus with mostly elderly, frail residents living in close quarters.

Seven facilities reported 10 or more deaths, including PruittHealth-Palmyra in Albany, where 16 residents have died. At Palmyra, 106 residents have tested positive, more than at any other facility in the state.

In all, more than 1,600 residents of nursing homes, assisted living communities and personal care homes have tested positive for the virus. More than 800 staff members also have confirmed diagnoses. The listing by the state Department of Community Health did not include facilities with fewer than 25 residents.

Medical workers, wearing masks to protect against the novel coronavirus, cross the campus of Emory University Hospital Midtown in Atlanta on Friday, April 17, 2020. JOHN SPINK/JSPINK@AJC.COM

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A complete count of deaths is a critical data point as Gov. Brian Kemp prepares to restart the state’s economy, which has been devastated by stay-at-home orders intended to contain the virus. The Atlanta Journal-Constitution reported Friday that Kemp has begun conferring with business and political leaders about how soon he could safely rescind social-distancing measures.

The tension between restoring the economy and controlling the virus came into sharp focus Friday when the Monroe County Commission became the first local governmental body in Georgia to formally ask Kemp to lift restrictions on business and other activities by April 30. On that day, Kemp’s shelter-at-home mandate is scheduled to expire, but he could extend it into May.



Until midweek, the state Department of Public Health reported only the deaths of people who had tested positive for the virus. That methodology left out others who died with significant symptoms. They may have died at home rather than in a hospital, or in a hospital before they could be tested and a laboratory analysis confirmed the diagnosis.

Georgia is now following new death-reporting guidelines from the federal Centers for Disease Control and Prevention. The CDC told states to count not just confirmed cases but also probable cases, based on a patient’s symptoms before death, exposure to people with confirmed COVID-19 diagnoses, and other factors.

“Because COVID-19 was new, there were many, many things that were not known about it at the outset,” said Nancy Nydam, a spokeswoman for the public health agency. “Now that we have learned a great deal more about COVID-19 and have more definitive information about clinical presentation and its effects on individuals, we don’t necessarily need a lab test to confirm a death as being caused by COVID-19.”

The missed deaths reflect the lack of robust testing in Georgia, which has lagged behind almost every other state in tests per capita. In the absence of tests, little coordinated effort went into determining the cause of death of people whose coronavirus diagnoses had not been confirmed.

Democratic state Sen. Donzella James speaks at a press conference near the Arbor Terrace at Cascade senior care facility in Atlanta on Friday, April 17, 2020. Behind her, on the left, is Fulton County Commissioner Joe Carn. COVID-19, the disease caused by the novel coronavirus, has ravaged Arbor Terrace, sparking a protest. STEVE SCHAEFER / Special to the AJC

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The state medical examiner’s office, a division of the Georgia Bureau of Investigation, does not look into a majority of suspected coronavirus deaths. In cases it accepts, a forensic pathologist decides whether to conduct post-mortem coronavirus testing based on the person’s “clinical and social history,” said Nelly Miles, a spokeswoman for the GBI.

In other cases, Miles said, “the coroner or local health officials may perform COVID-19 testing at their discretion.”

The medical examiner’s office does not keep track of those cases.

Dr. Jonathan Eisenstat, the chief medical examiner, has told county coroners and law enforcement officials that bodies can be tested for the virus for at least 72 hours after death.

But some hospitals have chosen not to dip into their limited supply of test kits to take specimens from deceased patients.

At Augusta University Medical Center, for example, doctors believe the coronavirus tests are not necessarily accurate on corpses.

“Testing post-mortem is not fully evaluated,” a hospital spokeswoman, Christen Engel, said in an email.

Asked if that means deceased patients who had not been tested are not counted as victims of the coronavirus, Engel replied, “Correct.”

For now, state officials do not plan to reexamine recent deaths attributed to respiratory ailments other than COVID-19, said Nydam, the spokeswoman for the state public health agency.

“It’s possible that down the road and depending on resources, there would be some retroactive review, but it would not likely make a significant change in the numbers,” Nydam said. “And in some instances the numbers might actually go down if further review of a medical record indicated another possible cause of death unrelated to COVID-19, regardless of whether a lab test was done.”