© Francesca Volpi for The Wall Street Journal

MILAN–—In the town of Coccaglio, an hour’s drive east of here, the local nursing home lost over a third of its residents in March. None of the 24 people who died there were tested for the new coronavirus. Nor were the 38 people who died in another nursing home in the nearby town of Lodi.

These aren’t isolated incidents. Italy’s official death toll from the virus stands at 13,155, the most of any country in the world. But that number tells only part of the story because many people who die from the virus don’t make it to the hospital and are never tested.

In the areas worst hit by the pandemic, Italy is undercounting thousands of deaths caused by the virus, a Wall Street Journal analysis shows, indicating that the pandemic’s human toll may end up being much greater, and infections far more widespread, than official data indicate.

Italy’s hidden death toll shows what could lie in store for the worst-hit areas of the U.S., Europe and many other countries in the weeks ahead if the coronavirus is not tamed fast. The burden that the pandemic puts on health-care systems can cause so many deaths that it is hard to gauge the full human cost.

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As stretched and sometimes overwhelmed hospitals fight to save their patients, many other people die unseen and uncounted, including elderly people in out-of-the-way locations. In addition, the health-care crisis can lead to a surge of deaths from other causes that would normally be treatable.



“There are many more dead than are officially declared. But this is not a j’accuse. People died and they were never tested because time and resources are limited,” Eugenio Fossati, deputy mayor of Coccaglio, says of deaths caused by the virus.

Properly tallying the number of deaths from the pathogen can help public-health officials map out a response to the pandemic, such as making sure hospitals are adequately equipped for the emergency. It can also influence how quickly and strictly governments should impose social-distancing measures, and for how long.

But collecting accurate data is challenging for Italy and many other countries, due to the speed of the pandemic and the fact that most countries’ public-health institutions are geared towards normal times.

Three weeks after Italy became the first Western democracy to place its whole population under lockdown, the rate of contagion is slowing. But in the northern region of Lombardy, where the epidemic started and remains centered, infections had already spiraled out of control before the lockdown.

The provincial cities of Bergamo and Brescia are the two worst hotspots, and have become symbols of Italy’s suffering.

In and around those two towns, the real number of deaths is probably at least double the official count of 2,060 in March for Bergamo and 1,278 for Brescia since the outbreak began in late February, according to interviews with local officials, doctors and funeral-service providers and comparisons with the numbers of deaths from past years.

People are also dying of other ailments because hospitals are too overloaded with coronavirus cases to give them the treatment they need, doctors and local officials say

Some 85 people died in the whole of last year in Coccaglio, a town near Brescia of 8,700 residents. In March of this year alone, the town’s main church bell has sounded the death knell 56 times. Only 12 of the deaths were officially attributed to the coronavirus.

“We know the real number is higher, and we mourn them, knowing full well why they died,” says Mr. Fossati, the deputy mayor. “It’s a hard truth to accept.”

Another problem is that the number of virus carriers is also vastly undercounted. Italy has reported about 111,000 confirmed cases of coronavirus, but testing is mostly limited to those who show symptoms. Many virus carriers with no symptoms aren’t tested. Officials and health experts estimate the true number of infected people at anywhere from hundreds of thousands to six million.

Slideshow by photo services

The uncertainty about the death toll and the number of infected people makes it difficult to establish the true fatality rate of Covid-19, the respiratory disease caused by the virus. Estimates by epidemiologists of the fatality rate still range widely, but it is generally thought to be between 1% and 3% of those infected.



Italy’s government-run statistical agency on Wednesday reported a nationwide jump in deaths for the first three weeks of March from a year earlier—particularly in northern Italy, where it found the number of deaths more than doubled in over half the hundreds of towns and cities it surveyed.

“If you base any policy making on these numbers, you should be very careful,” says Lucas Böttcher, a researcher at the University of California, Los Angeles, who has modelled fatality rates for Covid-19. “They can highly fluctuate during an outbreak.”

Nowhere in Italy has been harder hit than Bergamo, a city of about 120,000 people. In March 2019, 125 people died in the city. This March, 553 people died. Of these, 201 deaths were officially attributed to the virus. This leaves 352 further deaths for the period, far higher than normal.

In the wider Bergamo province, which comprises the city and more than 240 small towns and has a total population of 1.1 million, 2,060 people died in March from the virus. But some 4,500 more people died in the province in March than a year earlier, according to a new joint study by the local Eco di Bergamo newspaper and research firm InTwig that took data from 91 towns in the province.

“Other countries that have the good fortune to be seven to 14 days behind us have to use that time to erect defenses,” says Giorgio Gori, Bergamo’s mayor, who estimates the virus has spread so widely in his city that one-third of the population has been infected. “We were first, and we weren’t prepared. Any leaders looking at us and not reacting vigorously will have a lot to answer for.”

Similar situations have played out across the Lombardy region, which accounts for 58% of Italy’s official coronavirus deaths.

In towns around Lombardy, local officials and doctors say the deaths recorded in March are many times the average monthly number. Often, the monthly toll matches deaths that towns normally record over half a year.

The health-care system in the region is so overstretched that doctors can’t treat all the sick. Those who die outside the hospital usually aren’t tested for the coronavirus.

“They are not receiving post-mortem tests,” Eleonora Colombi, a family doctor based near Brescia, says of people who die outside hospitals, such as in nursing homes. “Many of those who die and aren’t tested are old, but you normally don’t have so many people all dying at the same time. It’s corona.”

At Dr. Colombi’s office, three patients who tested positive for the coronavirus have died in recent weeks. But an additional 20 people who died with symptoms associated with the virus weren’t tested.

The problem isn’t just with patients sick with Covid-19.

“We have a problem with the elderly and other sick people like cancer patients who are dying at home,” says Dr. Colombi. “The ambulance won’t come if you are 94 years old and there are 50 other people waiting.”

An added problem is that 20% of Bergamo’s family doctors have been infected—and those still working only consult with patients over the phone. The local health service has responded to the high infection rate among family doctors by instituting teams of three to four doctors that make house calls in full protective gear. But with only eight teams for all of Bergamo, and each team able to make only about eight visits a day, many people don’t receive care.

Pietro Fiore, the mayor of Castellone, a small town south of Milan, says some local residents have died because they weren’t brought to the hospital for conditions that might have been treatable because the hospitals were overwhelmed with coronavirus patients.

In Castellone, 31 people died between March 1 and March 26, compared with five in that period last year. About eight of the 31 deaths were officially attributed to the coronavirus, but about 10 more were probably caused by the virus, and a similar number by potentially treatable ailments, says Mr. Fiore.

With Italy under a strict lockdown, it isn’t only funerals that have become impossible. In Castellone, death notices aren’t being posted on billboards around the main piazza, as is often done in small Italian towns. In Castellone, where the tradition is still strong, residents normally follow up the death notices with their own notices posted around the town expressing condolences for the families of the deceased.

“People don’t even know who is dying, and there isn’t the chance to show support for the families that lose people,” says Mr. Fiore. “That’s the hardest thing.”

There are signs the lockdown that was imposed on March 8 across Lombardy and two days later on the whole of Italy is beginning to have an effect. The rate of contagion has slowed, and fewer people are being admitted to the hospital. A study by a team of epidemiologists at Imperial College London estimates that Italy’s strict social distancing measures prevented about 38,000 deaths up to the end of March.

It will take time for the number of daily deaths to come down, since many of those who are dying became infected weeks ago. For now, the sheer number of people dying is still overwhelming Italian towns. Funeral-service agencies that work with hundreds of funeral homes in Brescia and Bergamo say the number of dead they buried or cremated in March was more than twice the number in March last year. The stated cause of death is often just pneumonia, without reference to the coronavirus, they say.

In Bergamo, so many coffins were accumulating in mid-March that a convoy of army trucks came to take them away for cremation elsewhere. In Brescia, the local diocese has offered 40 empty churches to store coffins as they await their turn for cremation, which can sometimes take up to two weeks. While funerals aren’t allowed because of social-distancing requirements, priests still bless the dead.

“One of the most difficult things to accept is that unfortunately many people are dying on their own, with none of their dear ones next to them,” says Brescia Bishop Pierantonio Tremolada, who gives regular blessings over the coffins in churches. “That is something we can still do for them.”

Write to Margherita Stancati at margherita.stancati@wsj.com and Eric Sylvers at eric.sylvers@wsj.com