Covid-19 and death rates--doctors know why numbers of people who have died are wrong

This morning the total number of deaths in the US from Covid-19 was said to be 994. That sounds kind of low, since influenza has already killed 30,000 this season. In the places where coronavirus has hit hard, it's much worse than the flu, in New York and New Orleans for instance. People are much sicker and the whole healthcare system, including emergency medical services, is stressed to breaking. We know that coronavirus is more severe and more contagious and more deadly than the flu by at least a factor of 10. Why are the numbers of deaths presently so low?

The thing that nobody is talking about with regard to Covid deaths is that our data about who has died is going to lag by weeks, months or even years and will probably fail to represent all of the deaths for which Covid is responsible. Why is this?

1. People are dying at home of Covid. How do I know this? Because 25% of people die in their own homes. People with symptoms of coronavirus are being encouraged to stay at home so some proportion of them, likely older or with disabling diseases, are dying there. When a person dies at home, unless it is a hospice death, the process of certifying their cause of death can be quite prolonged. Sometimes a coroner is involved and it can take weeks.
2. It takes a long time to die of an acute disease in the hospital. We work really hard to keep a patient alive who has been intubated and admitted to the ICU. We will try all sorts of procedures to make the lungs work and, even as the lungs get worse, we still find new machines or drugs to keep them alive with the hope that, if they survive long enough, their lungs will heal. Some of the patients in New York hospitals who are on death's door will remain there for weeks until either their bodies or their families finally give up. It could take weeks after coronavirus infections start to peak to know what percent of those infected people will die of the disease.
3. Doctors working with patients who are dying are very tired, and one of the least pressing things on their to-do list is to fill out death certificates. Some of that documentation is waiting in an exhausted physician's in-box to be completed.
4. In the busiest hospitals and most infected communities, patients with definite Covid-19 aren't being tested because there is no time and it becomes clear what is wrong with them because of their symptoms. When doctors fill out death certificates they may not list Covid-19 as the cause of death. I just recently got an email from the Idaho Death Registry telling me to put Covid as the cause of death if this is my educated opinion, even if the patient wasn't tested. It is likely that many physicians don't know this is the correct way to do it.

All of these factors are probably also affecting other countries' reported numbers of deaths. This means the numbers of the sick and dead worldwide are probably higher than we believe.

A note on why so many people die of the flu compared to how many have died of Covid-19:

Obviously, we are early in the epidemic and the numbers are rising daily. They haven't come close to peaking. But that's not even the biggest problem with this comparison.

The CDC calculates deaths of the flu in a very complex way. It is not the same way they are calculating deaths of Covid-19. With influenza CDC epidemiologists do not just count the number of people with positive influenza tests who die directly of that acute illness. They start by using the number of positive flu tests corrected for the fact that the test is insensitive (misses a significant percentage of people who are infected). They then get a bigger number by looking at the fact that most people with the flu are never tested. They also use death certificate data, but in a very nuanced way. The actual number of deaths from influenza includes people who die of other things that become fatal because of influenza, things like heart failure or chronic lung or vascular disease. On many of those death certificates, influenza will not even be listed. Some of those deaths happen weeks after an episode of the flu. It takes years to come up with an accurate death count for a particular year. 

At this point we don't, and we can't, calculate the deaths of Covid-19 the same way we do influenza. In the words on the CDC website: "Only counting deaths where influenza was recorded on a death certificate would be a gross underestimation of influenza’s true impact." To extrapolate from that, only counting deaths where Covid-19 is recorded on the death certificate will be a gross underestimate of this disease's true impact. Comparing reported numbers of people who have died of coronavirus so far to deaths from influenza is extremely misleading. Deaths due to influenza and Covid-19 are being calculated completely differently. When this epidemic is finally over, a number such as 994 on March 27 will be a point on a timeline representing the early part of America's experience, a point when we had only an inkling of what it would be like.