The Florida Department of Health’s count of coronavirus deaths reached a grim milestone Friday, surpassing 400 and climbing to 419.

But at least 40 additional people who had died from the virus in Florida were missing from the state’s count, the Tampa Bay Times has learned.

Those deaths are reflected in another tally that’s being kept by the state’s medical examiners. On Friday, it stood at 461, 10 percent more than the health department’s announced number.

The discrepancy underscores the difficulty in building a system to track the fast-moving disease in real time. But it also reflects choices by state health officials that could have the effect of understating the virus’ toll, the Times found.

Deaths have taken days to appear in the health department count, even after the cause has been determined by a medical examiner.

And the state health department is counting coronavirus deaths only for people who claimed residency in Florida. The medical examiners, who are legally responsible for certifying fatalities from diseases that constitute a threat to public health, are counting anyone who died in Florida, including snowbirds and visitors.

Public health experts told the Times that the state should tally all deaths that occur in Florida, which has hundreds of thousands of seasonal residents. From there, the state could break out additional statistics for its residents.

Even the higher number is nearly certain to miss some of the deaths the epidemic has caused.

Provisional figures released by the state health department show that at least 5,000 people have died from respiratory illnesses in 2020 so far. Many almost certainly died from the seasonal flu, and the state did not answer questions about what period the data covers, making it difficult to compare to prior years.

But experts and medical examiners say some were likely early casualties of COVID-19, the disease caused by the coronavirus, before testing for the virus was widespread.

“I can guarantee you that there are pneumonia deaths in Florida that aren’t being counted as COVID that are maybe COVID-related,” said Andrew Noymer, associate professor of public health at the University of California-Irvine who studies death statistics.

The state health department declined to answer detailed questions about its process for counting deaths. In a statement, the agency said it “coordinates with (the) Florida Medical Examiner Commissions, physicians, hospitals and other entities to report deaths of individuals who have tested positive for COVID-19” and provides that data to the public “as it is reported.”

The agency said it was listing deaths according to the decedent’s place of residence “so they are not inadvertently listed twice.”

Still, the disparities have complicated the task of understanding how far the epidemic has spread in specific communities. And they have caused confusion and alarm among the loved ones of the dead.

Henry Solares, who lives in Seminole, said he scanned charts and news stories for days after a relative died from the virus. But he couldn’t find anything about a 74-year-old man from Hillsborough County.

Solares said he started to question the state’s reporting system. “I mean, what’s broken down in this process?” he wondered.

His relative appeared to be listed in the state’s count Thursday — five days after his death.

Two ways of tracking

The Florida Department of Health publishes its count of coronavirus cases and deaths in twice-daily reports.

They stretch hundreds of pages and include details that aren’t being released in some parts of the country, including the age and gender of each person who has contracted the disease.

Confirmed cases and tests are broken down by residents and non-residents.

Deaths are not. Only Florida residents are included.

The information contained in those reports comes largely from the department’s offices in each of Florida’s 67 counties.

Kevin Watler, a spokesman for the Florida Department of Health in Hillsborough County, said the laboratories processing COVID-19 tests notify his office whenever a Hillsborough County resident tests positive.

Health department epidemiologists contact those people and log regular updates about them into the state’s tracking database. But it can take days to learn someone has died and verify the death, Watler said.

Medical examiners have taken a different approach. Florida law requires them to investigate suicides, homicides and accidental deaths, as well as deaths by disease that constitute a “threat to public health.”

That means they are responsible for confirming every coronavirus death that happens in Florida, said Dr. Stephen Nelson, the chief medical examiner for Polk, Hardee and Highlands counties and chairman of the state Medical Examiners Commission.

“When the governor issues an executive order for a disaster, we take on the role of counting the dead,” Nelson said.

For a death to be included in the medical examiner’s count, the person must have tested positive for the virus, Nelson said.

Medical examiners are not performing autopsies on all people who die from the disease, he said. For cases in which a person has tested positive before dying, the medical examiner will generally just review the medical history and test results.

If the person died without being tested, the medical examiner office will review the case to determine whether post-mortem testing is warranted. Only people who had symptoms associated with the coronavirus are tested.

Nelson said his colleagues around the state have their own supplies of tests and are not yet at the point of running low.

As medical examiners have been investigating cases, they have been submitting a thumbnail sketch of each coronavirus death to the state Medical Examiners Commission, which is compiling them in a spreadsheet. The spreadsheet is updated regularly, Nelson said.

It classifies deaths based on the county where the person died, not where he or she lived.

The Medical Examiners Commission is sharing the information with the state Emergency Operation Center, Nelson said.

Some death statistics on the national level are compiled based on the place where a death occurred, not where the decedent lived. And some other large states, including California and New York, are reporting both.

In its statement, the health department called reporting deaths by residency “the appropriate method utilized to calculate disease rates, which allow for a more accurate analysis of disease impacts on populations through the incorporation of demographic data.”

Watler pointed out that the health department uses a similar methodology to track deaths from other infectious diseases.

“The medical examiners have one way of doing things; we have a different way,” he said.

Local confusion

The differences have created confusion in some medical examiner offices.

At times, the two lists have been different.

On Thursday morning, the state showed nine deaths for Hillsborough County, while the medical examiner’s tally showed seven. Only five cases in the two datasets appeared to possibly match.

The Palm Beach County Medical Examiner Office also noticed that the number of deaths it had logged did not match the figure reported by the state, Paul Petrino, the office’s operations manager, told the Times.

For the first time, the state reported more deaths for Palm Beach County than what the medical examiner office had tallied. The state’s count was 73 deaths. The medical examiner’s count showed 70.

The same thing happened in the District Six Medical Examiner Office, which covers Pinellas and Pasco counties. Director of Investigations William Pellan said he reached out to the state earlier this week “because the numbers were off.”

The state was showing nine deaths for Pinellas, Pellan told the Times. “I can tell you we have handled seven,” he added.

Pellan said he was told that the state count included a person who lived in Pinellas County but was treated in Tampa and died in Hillsborough County.

The Palm Beach office’s count may also be different because the office has recorded deaths of some seasonal residents.

Petrino didn’t know an exact figure.

He said the office was concerned about the discrepancy. Death statistics are part of capturing how the epidemic unfolds in communities, Petrino said. They also help people understand why decisions like stay-at-home orders are necessary.

“If I’m a resident of Palm Beach County,” he said, “I want to know who’s dying here. I don’t care where they live.”

Andrew Lover, an infectious disease epidemiologist at the University of Massachusetts Amherst, said the residency issue is more relevant in Florida than in other states because snowbirds and part-time residents are commonplace.

He said total deaths in the state should be recorded, and from there, the state could provide a breakdown, as it does for the total number of confirmed cases.

“It would make sense to try to get a total count of all fatalities within the state of Florida and not worry about residency status so much,” he said.

A struggle to comprehend

For some people who have lost loved ones to the virus, making sense of the numbers has been a struggle.

Maria Cain, whose sister Franca Panettone died last week, was told her sister was Hernando County’s first coronavirus death. But Cain was not convinced, she told the Times.

“I don’t think the whole truth is out there,” Cain said.

Cain said that while discussing hydroxychloroquine — a malaria medication now being used to treat coronavirus patients — a doctor had told her that a man who received the treatment had died at the hospital. The hospital, Oak Hill in Brooksville, also serves residents of surrounding counties.

A spokeswoman for Oak Hill said the hospital “continues to provide appropriate reporting to the Florida Department of Health.”

Solares, whose relative died in Hillsborough County, said he wasn’t looking for or expecting the state to release names or extensive details. He just wanted fast access to basic information to help him — and the broader public — understand the trends.

“I thought we were supposed to have some transparency,” he said.

Experts agree that counting deaths is a work in progress and the number of deaths will continue to change.

They also say the actual figure is likely far larger than either count suggests.

The lack of testing across the country is a big factor in why scientists believe almost all COVID-19 death counts are an underestimate, said Noymer, the University of California-Irvine professor.

“That’s where the rub is, right?” he said. “Because there’s been all these testing problems.”

Noymer said scientists will have to look retrospectively at what happened in 2020. One strategy will be to examine all deaths and compare this year to previous years, searching for upticks in certain causes, like pneumonia.

Across the country, pneumonia is likely appearing as a single cause of death for people who were infected by the coronavirus, Noymer said. In those cases, the cause of death is not wrong, Noymer said. It’s just not specific.

“We’re actually interested in what causes the pneumonia more than the pneumonia itself,” he said.

Even with the challenges, getting as close as possible to an accurate count of deaths matters, said Lover, the University of Massachusetts epidemiologist.

Death is the worst outcome — and one of the most important to track.

“It will help calibrate how massive of a response we should be having,” he said.

Staff writer Allison Ross contributed to this report.

Read the state’s response:

The Florida Department of Health coordinates with Florida Medical Examiners Commission, physicians, hospitals and other entities to report deaths of individuals who have tested positive for COVID-19. This data is provided to the public as it is reported to DOH. The Department utilizes the testing data received from all 67 counties in the State of Florida. It is important to note that data in these reports are provisional and subject to change based on additional information gathered in the epidemiological investigation. As more data is collected and analyzed, the reports will adjust accordingly. The information at the local level is compiled into Florida’s COVID-19 Data and Surveillance Dashboard and daily report, both of which are updated twice a day. An individual who has tested positive for COVID-19 and later died, is counted as a death in the county they reside in. Per CDC, people are listed according to their place of residence, so they are not inadvertently listed twice. Only FL residents are listed in FL deaths. County Medical Examiners are the only ones who attribute the cause of death.

Responding to additional questions, the state added:

Reporting deaths by residency is the appropriate method utilized to calculate disease rates, which allow for a more accurate analysis of disease impacts on populations through the incorporation of demographic data- a critical aspect of public health planning. Population size is determined using census data, which is based on residency. CDC surveillance systems typically and historically utilize residency-based reporting regarding infectious disease outbreaks, including human immunodeficiency virus, tuberculosis and domestic arboviral diseases, which “…were reported by the jurisdiction of the person’s ‘usual residence’ at the time of disease or condition onset” based on this guidance document adopted in 2011. (https://wwwn.cdc.gov/nndss/document/11-SI-04.pdf).” It is important to note that Florida already provides, transparently and publicly, information on the deaths of Florida residents. Furthermore, the state is not underreporting in any way compared to the CDC – at this time, we have 438 deaths in Florida residents reported, while the CDC provisional data shows only 145. We will continue to follow standard protocols for disease reporting.

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