AZ deaths from June far exceed past years

Other factors may be at work besides COVID-19

Arizona saw far more deaths this June than a typical June in previous years, and well beyond the official counts for COVID-19 deaths.

In June 2020, the Arizona Department of Health Services statistics show 6,265 people died. Last June, it was 4,689. This year’s total is higher, by far, than any of the past five years.

The health department’s chart of COVID-19 deaths by date shows 952 deaths attributed to the disease in June, which is far fewer than the increased number of deaths overall in June. July’s COVID-19 death numbers so far are higher than June’s. Both June and July’s numbers of COVID-19 deaths will continue to fluctuate for several weeks.

The U.S. Centers for Disease Control and Prevention’s charts on “excess deaths,” which are deaths beyond expected levels, show Arizona has seen excess deaths throughout June and July.

Many other states, especially those that were early hotspots such as New York and New Jersey, have seen excess deaths as well.

While the exact numbers of deaths during the peak of COVID-19 cases in Arizona will take months to sort out, the high number of deaths shows the stark consequences of the pandemic on human lives.

Experts told The Arizona Republic there are a few possible explanations for the high number of deaths.

There is a lag in deaths showing up in official COVID-19 counts, which may be part of the reason the excess deaths exceed COVID-19 death counts. Some COVID-19 deaths may be misclassified as other causes and will be adjusted in the future.

And, they said, people may be avoiding care for urgent or chronic conditions because of the concern of getting COVID-19, resulting in deaths from non-COVID-19 sources that are collateral damage from the pandemic.

Suicides or drug overdoses may have increased, but investigations into those deaths often take weeks or months, and trends are harder to discern in real-time.

“It’s hard to say for sure because we’re right in the middle of this,” said

Dr. Robert Anderson, chief of the Mortality Statistics Branch of the CDC’s National Center for Health Statistics.

There may be deaths that were “basically, due to the pandemic but not directly to the virus,” he said.

Hospitals in Arizona say emergency departments are seeing lower volumes of non-COVID-19 patients and some patients are coming in later than they should for other issues, making them sicker and more difficult to treat.

Dr. Brian Hess, the medical director of emergency services for Abrazo Health in Arizona, said he spends a lot of time trying to figure out where the normal patient volume has gone and how they are getting care.

“This is conjecture because there doesn’t seem to be a lot of answers that are definitive. Anecdotally, I do hear from patients that they felt they weren’t sick enough to come in until they are seeing me at that time, which is often when their disease has spread or gotten worse than what it would have been otherwise,” Hess said.

“They are very apologetic and also very thankful for us being there, but they feel like they weren’t sick enough to come in. These are, you know, patients who fell 10 feet or what have you, and have head injuries and significant lacerations and they are apologizing for being there . ... It is concerning.”

What Arizona officials say

Dr. Cara Christ, the Arizona Department of Health Services director, said the state has seen excess deaths from COVID-19 and beyond, including those that may not yet be coded as the disease.

Deaths from COVID-19 tend to lag about two weeks to four weeks behind the peak of hospitalizations, which is what Arizona seems to be seeing now, she noted.

She’s concerned about COVID-19 deaths, but also other deaths that may be happening right now, like those from avoiding care, drug overdoses, suicides and heat-related deaths.

“We don’t want anybody to delay care because they’re afraid,” Christ said. “Doctors’ offices and hospitals have protocols in place to keep patients safe from COVID.”

Preliminary data seems to point toward increased drug overdoses and suicides, she said.

County health departments have expressed concern over potential suicide clusters to the state, she said. So far this year, there have been about 700 suicides, compared to 1,467 for the full year last year, she said. Because investigations into these deaths often take months to complete, Arizona could exceed 2019 totals this year for suicides, she said.

A few other indicators seem to point toward people avoiding hospitals. The department has seen an “uptick” in cardiac events outside of hospitals during the pandemic, Christ said. And there’s also been a decrease in orders for childhood immunizations, suggesting families aren’t going in for routine childhood visits, she said.

In Maricopa County, the five-year average for deaths in June was 2,480. This June, it was 3,321, Ron Coleman, a county spokesman, said via email.

Coleman shared graphs of cases of presumed drug-caused deaths that came into the county’s medical examiner this year, and those deaths appear to have risen in the past few months. A similar chart showing suicides appeared to decrease during that time period.

Maricopa County’s disease control division medical director, Dr. Rebecca Sunenshine, said the county has seen “significantly more deaths overall” in 2020 compared to last year, but it will take time to understand what can be attributed to COVID-19 and what may come from other causes.

In some cases, getting COVID-19 may worsen a person’s underlying condition, she said. There also may be indirect causes related to the pandemic through avoiding care, she said.

“I think it’s going to take us some time to figure out which ones are indirectly due to COVID, which ones are directly to the COVID, and if all of the increase can be attributed to COVID or if there’s something else going on as well,” Sunenshine said.

What experts say

Dr. Steven Woolf, the director emeritus of Virginia Commonwealth University’s Center on Society and Health, has studied excess deaths during the pandemic.

It’s possible some people may have died because of problems accessing medical care for emergencies, chronic diseases and emotional and substance abuse disorders, Woolf said. The opioid epidemic didn’t go away when the pandemic arrived, he noted. And the COVID-19 situation hasn’t made life easier for those with depression, anxiety or other stress.

“In time, it’ll become clear as the data come in, but right now it’s sort of an open question as to how much of this is simply COVID-19 deaths that haven’t been coded correctly, and how many of them are people without COVID-19 who aren’t getting the care that they need,” Woolf said.

At the national level, the gap in excess deaths that aren’t attributable to COVID-19 has tended to shrink over time, suggesting that early confusion over classifying these deaths has subsided a bit, he said.

But in Arizona, that gap seems to be increasing, which could signal that people are dying at home from COVID-19 complications that aren’t immediately clear, or that people are avoiding medical care for other purposes, he said.

If it is true that people are avoiding medical care, Woolf said the public should be educated about the importance of seeking help when they need it. Waiting to get care for a heart attack or stroke has dire complications, he said.

“The dangers of that far outweigh the dangers of going into an emergency room,” he said.

Anderson, of the National Center for Health Statistics, said his team is working to analyze the excess deaths from the first half of this year in hopes of better understanding what’s happening.

“I’m sure that we won’t be able to get a really solid handle on it until after all is done and we have final data,” Anderson said. “But I’m hoping that it won’t take that long to at least get a sense for what’s going on.”

A pattern of excess deaths is seen in nearly all states, said Dr. Thomas Tsai, an assistant professor in health policy and management at the Harvard T.H. Chan School of Public Health.

“There should be a relatively constant rate of strokes, heart attacks. Those things have gone down over the last several months, and it’s unclear: Where did all these patients go?” Tsai said.

Tsai said researchers are trying to determine the specific causes of the excess deaths by understanding which were the result of deferred care for what conditions, and which were misclassified COVID-19 deaths. He said quantifying the true number of COVID-19 deaths will be an ongoing process.

Hospitals and public health departments can work on messaging to explain to the public that hospitals are safe for care, based on the level of community spread, Tsai said. Medical professionals have a responsibility to actively reach out to patients and let them know about hospital precautions like staggering patient visits and controlling infection within the hospital so that patients feel comfortable coming in rather than delaying necessary care, he said.

Tsai said the excess deaths seen in Arizona and across the nation are “very concerning.”

“The deaths really bring home that these aren’t just numbers, but behind these rates and curves are individual lives and people’s family members,” Tsai said. “The fatalities really bring home — especially the excess fatalities bring home — the true cost of the pandemic in a very real way.”

What hospitals are seeing

A number of hospital systems across the state said they’ve been seeing fewer patients come in for emergency care — another possible factor in excess deaths, as patients who would typically immediately seek hospital care are either avoiding hospitals or delaying their visits.

Hospital leaders and doctors are urging Arizonans to go to emergency rooms when they need emergency medical care, as hospitals are taking infection precautions and are ready to help people. Delaying or avoiding care will have much worse outcomes, they say.

“We’re starting to hear some stories out there of people not going (to the ER) when they have chest pains, possibly having a heart attack, stroke-like symptoms, possibly having a stroke,” said Dr. Marjorie Bessel, the chief clinical officer for Banner Health, the state’s largest health care system.

Valleywise Health, which runs two emergency departments in Phoenix, has seen declines in ER visits during the pandemic. Patients who come in for heart attacks and strokes have more “delayed presentation of illness” than normal.

“Early on when we were under the stay-at-home order, we saw a precipitous decline in our number of patients that came to the ED. And then we saw it start to rise back up and it has kind of waxed and waned,” said Dr. Michael White, chief medical officer for Valleywise Health in Phoenix. “It is still under where it had been previously.”

Emergency department volume at Abrazo facilities is about 20% to 25% lower than 2019 volumes, according to Hess, the medical director. Initially, in March, volumes were down 40% to 45% and some of it has come back, but it’s still much lower than normal.

In addition to heart attack and stroke delays, other problems patients are delaying care for include people with diabetes who have worsening wounds or patients with COPD and congestive heart failure. In those cases, problems that could have been treated in a few hours are resulting in a hospital admission for two or three days, Hess said.

“People can be sick with COVID, they can be sick with a heart attack and they could be sick with a lot of other illnesses and it’s important to seek care,” Hess said. “If you are experiencing a symptom that is new or different that is affecting your ability to function in your life and you are not able to see your regular doctor, don’t delay because sometimes the ramifications of that delay can be very significant.”

Dignity Hospital, another major chain, said they’ve seen downward trends in people seeking immediate medical care in ERs. But they’ve seen an increase in patients who need “high acuity care” for conditions such as heart attacks and strokes, according to spokeswoman Abby Friedemann.

What research and data show

Two July 1 articles in the Journal of the American Medical Association seek to estimate and explain excess deaths during the pandemic.

One paper, which Woolf co-authored, estimated excess deaths from January through April, weighing deaths from COVID-19 and other causes. It explored possible explanations of delayed reporting and misattribution of COVID-19 deaths. The authors found “large increases in mortality” from heart disease, diabetes and other conditions, beyond numbers seen in years prior.

The researchers said more investigation is needed to determine whether those excess deaths are “nonrespiratory manifestations of COVID-19” or else secondary death from the pandemic because of delayed health care and issues such as job and income loss and food insecurity.

The second study sought to estimate the burden of all COVID-19-related deaths from March to May. It found that excess deaths from any cause were 28% higher than the reported number of COVID-19 deaths nationwide from March through May, meaning official COVID-19 death counts do not account for the “full increase in deaths associated with the pandemic.” Those deaths could be due to things like missed testing, classifying a COVID-19 death under another cause, or “secondary effects on mortality” like lockdown effects or avoidance of health care.

In Arizona, some excess deaths may be hiding under a pneumonia classification, when they could have actually been COVID-19 deaths, experts have suggested.

Since Feb. 1, more than 1,900 Arizonans have died from pneumonia with no recorded link to either COVID-19 or influenza, according to preliminary death certificate data compiled by the CDC.

In recent years, between 700 and 900 individuals have died from pneumonia annually, per CDC vital statistics.

In just six months, Arizona has reported more than double the number of pneumonia deaths typically seen in a whole year. Experts believe some COVID-19 deaths have been attributed to pneumonia. When reclassified the deaths boost COVID-19 death totals but lessen some of the excess non-COVID-19 deaths.

Other causes of death in weekly CDC data posted online for four weeks in June 2020 show other diseases with higher death numbers than last June. These include septicemia, heart disease, respiratory diseases, Alzheimer’s and cancer. This June’s numbers are still changing, so it’s not yet clear what conclusions could be drawn on any causes of death and whether they’re increasing.

Some of these deaths attributed to other causes could end up being COVID-19 complications, as the understanding of the various ways the disease affects body systems is still being formed, experts said.

“There are some that are arguing that the number of deaths from COVID-19 is some kind of conspiracy and that the true numbers are lower than this, and one important takeaway from multiple studies now is that it’s quite the opposite, that we’re undercounting how many deaths are occurring for the pandemic,” Woolf said.

Delays in seeking care during the pandemic can have years-long consequences.

Norman Sharpless, the director of the National Cancer Institute, for instance, said there will likely be thousands of more cancer deaths in the coming years because of delayed or avoided screenings, diagnosis and treatments for cancer during the pandemic.

“Clearly, postponing procedures and deferring care as a result of the pandemic was prudent at one time, but the spread, duration, and future peaks of COVID-19 remain unclear,” Sharpless wrote in an editorial in Science. “However, ignoring life-threatening non-COVID-19 conditions such as cancer for too long may turn one public health crisis into many others. Let’s avoid that outcome.”