© Susan Stocker / South Florida Sun Sentinel/South Florida Sun Sentinel/TNS Police monitor traffic going into a free coronavirus drive-thru testing site at Amelia Earhart Park in Hialeah on April 2, 2020. Those who are 65 or older and are experiencing symptoms of COVID-19 can get tested at the park by appointment only Monday through Saturday from 9a.m. to 5 p.m. by calling 305-268-4319.

Florida’s death count from COVID-19 likely stands significantly higher than the official number, indicating the disease is taking a more severe toll than thought, according to interviews with experts and information from local officials.

The number of dead in Florida stood at 144 Thursday, according to the Florida Department of Health.

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But medical examiners in Broward, Miami-Dade and Palm Beach counties, who represent the hardest-hit part of Florida, have flagged 59 additional deaths that may have resulted from the disease and for which they’re awaiting test results. Although a few of these may have been included in the Thursday evening death count, this figure represents a significant backlog that is certain to raise the total.

© Susan Stocker / South Florida Sun Sentinel/South Florida Sun Sentinel/TNS Drivers are checked in at a free coronavirus drive-thru testing site at Amelia Earhart Park in Hialeah on April 2, 2020. Those who are 65 or older and are experiencing symptoms of COVID-19 can get tested at the park by appointment only Monday through Saturday from 9a.m. to 5 p.m. by calling 305-268-4319.

In addition, a lag of two or three days in reporting confirmed cases keeps the official number below the true one. And many deaths from the disease may not ever be recognized for what they are, experts say, because the victim might have appeared to die from some underlying condition, such as heart disease.

Horrific as the official numbers may be, they understate the disease’s real impact on Florida. Along with the shortage of test kits, the absence of an accurate death count makes it harder to track the disease’s assault, to see what areas have taken the hardest hit and to plan the most effective response.

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“This could be an important problem in not getting the full picture,” said Natalie Dean, assistant professor of biostatistics at the University of Florida, who has studied Ebola, Zika and other infectious diseases. “We use deaths to get a sense of the larger scale of the epidemic, and if we’re missing something, then we’re underestimating the size of the epidemic."

The number of deaths with pending COVID-19 tests Thursday afternoon stood at nine in Broward County, 11 in Miami-Dade County and 39 in Palm Beach County, according to the medical examiner’s offices in each county. Palm Beach registered a spike of deaths over the past few days, suddenly becoming the Florida county with the most fatalities, with 27. The day-by-day delivery of results from this running backlog of pending tests could have accounted for some of the increase.

Dr. Wendolyn Sneed, the Palm Beach County medical examiner, said deaths with pending test results are typically elderly people with underlying medical conditions.

Dr. David Aronoff, director of the Division of Infectious Diseases at the Vanderbilt University School of Medicine, said it’s common with diseases such as the flu to miss a significant number of deaths.

“People attribute the cause of death to something like a heart attack or a pulmonary embolism, which is a blood clot that goes to the lungs, that are actually complications of an underlying infectious disease,” he said. “In COVID, for example, people may have pre-existing heart disease, may die of a heart attack or heart arrhythmias, and there’s a risk, particularly if they didn’t get tested for COVID, that their death could be misattributed.”

One factor in missing deaths from the new coronavirus is a lack of testing, which he said would account for authorities missing fatalities.

“I’m certain there are going to be people with COVID-19 who don’t get tested or their test is a false negative or they do test positive but they die of something that seems like it’s not COVID," he said. "And so that ends up being marked as the cause of death, whether it’s a blood clot in the lung or a heart attack or even that they fall out of bed. So I think that’s a risk.”

Even for confirmed deaths, it can take days for them to show up in the state tally.

Broward County Medical Examiner Dr. Craig Mallak, for example, confirmed on March 26 that 67-year-old Dr. Alex Hsu had died and tested positive for COVID-19. Yet there was no listing of a 67-year-old Broward man on the state’s official list until two days later.

And on March 26, the Sun Sentinel had confirmed seven coronavirus deaths in Broward County, but only three could be seen in the state tally.

The Florida Department of Health declined to answer questions about its methodology or process for recording coronavirus deaths, other than to issue a statement saying the department’s list includes every person known to have died and tested positive.

“When the state reports COVID-19 related deaths, this does not necessarily mean COVID-19 was the cause of death,” the statement read. “When the state reports a death, it means the individual tested positive for COVID-19.”

Dr. Sneed, the Palm Beach County medical examiner, said she was concerned about missing some coronavirus fatalities entirely, largely those involving people with underlying medical conditions who die at home.

She said she’s fairly confident of getting coronavirus information on those who die in hospitals or those who die unexpectedly so someone calls 911, since law enforcement or rescue workers keep her office in the loop. But she asked families to make sure to contact her office in cases of death from illness, if no coronavirus test had already been done. Her office has performed 10 post-mortem COVID-19 tests, she said.

However many deaths are missed, the number of confirmed deaths has been rising sharply and is expected to continue to go up.

Florida's death count exceeds projections by the University of Washington's Institute for Health Metrics and Evaluation, which produces closely watched forecasts of death tolls at the state and national levels. That model, which is being used by the White House, projected there would be 121 deaths in Florida by Thursday. As of 11 a.m. that day, Florida had reported 128 deaths.

The latest projection shows about 175 Floridians will die a day at the epidemic’s peak on May 5, reaching a total of 6,897 deaths by August. The Washington model is considered conservative because it assumes people will slow the spread of the virus by fully complying with social-distancing measures.

David Fleshler can be reached at dfleshler@sunsentinel.com or 954-356-4535. Skyler Swisher can be reached at sswisher@sunsentinel.com, 561-243-6634 or @SkylerSwisher.

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