A technical bulletin posted on the state’s Nevada Health Response website says the number of COVID-19 deaths in Nevada may be “much higher” than reported.

“Throughout Nevada, even as COVID-19 daily deaths are being recorded in significant numbers, the true death toll is likely much higher,” says the technical bulletin, dated April 8 and written by Division of Public and Behavioral Health administrator Lisa Sherych and the state’s Chief Medical Officer Issam Assan.

The bulletin requires mandatory reporting of COVID-related deaths from all providers of health care, health care facilities, medical examiners, coroners and funeral homes.

“The official death counts have failed to capture the true number of all Nevadans dying in this pandemic. This expected undercount is mainly the result of inconsistent protocols, limited resources and a patchwork of inconsistent decision-making.”

As of Thursday, 189 deaths have been reported by the state.

A spokesman for Gov. Steve Sisolak did not respond to requests for comment about the governor’s knowledge of the underreported cases. State officials did not immediately respond to questions about the bulletin.

“A late start to this novel coronavirus testing could have hampered hospitals’ ability to detect the infection among patients with pneumonia and severe flulike symptoms in February and early March,” the bulletin says.

The revelation comes as California officials confirm the first reported COVID-19 death in the U.S. was a 57-year-old woman on February 6 in Santa Clara, not weeks later in Washington state, as previously believed. The woman’s death indicates the coronavirus was likely spreading in January.

“While it’s known to be overwhelming, the extent of the problem is not yet clear because significant numbers of COVID-19 virus-related deaths have been missed,” the bulletin says of undercounted deaths in Nevada. “As of the date of issuing this Technical Bulletin more than 50 Nevada patients with COVID-19 infection have been reported to have died due to an association with COVID-19.”

It’s unknown if the reference is to previously undetected fatal cases of COVID-19. The cumulative number of deaths reported by the state on April 8 was 90.

The bulletin says an accurate “estimation was difficult as there is no uniform standard system for reporting deaths caused by COVID-19 infection; related to and/or associated with COVID-19 infections in Nevada. Furthermore, the continued shortage of laboratory testing may continue to hinder case detection and mortality count.”