Pima County recorded 6,859 deaths in the first seven months of 2020. In the previous five years, the average was 5,730.

 Mamta Popat / Arizona Daily Star

While Arizona reached a grim milestone this weekend, surpassing more than 5,000 confirmed coronavirus deaths, some experts are now pointing to jumps in total fatalities β€” including 20% in Pima County in 2020 β€” as proof that hundreds more deaths could be indirectly attributed to the virus.

Nearly 7,000 Pima County residents died from all causes through the first seven months of 2020, representing an increase of more than 900 deaths from this point a year ago and a 20% upsurge from the average of the previous five years, according to preliminary figures released by the Arizona Department of Health Services.

That included more than 2,100 overall deaths in June and July, an increase of more than 500 from the same months in 2019 and 40% from the average of the previous five years, data shows. Pima County experienced highs in case numbers, deaths and hospitalizations during the summer months.

Statewide, more than 42,000 Arizonans died from all causes in the first seven months of 2020, representing a 25% jump from the average of the previous years. Just over 14,000 Arizonans died in June and July, a 55% increase from the average of the previous five years.

As of Saturday, the Arizona Department of Health Services had confirmed 5,007 deaths from the coronavirus, including 575 deaths in Pima County, although that does not account for a number of deaths that may be reported up to a month later through processes like death certificate matching and surveying.

Direct or indirect relation

With a large discrepancy between the number of confirmed coronavirus deaths and total deaths, experts are now connecting the dots between the two, saying that a large chunk of the difference will likely be traced back to the pandemic.

Will Humble, the executive director of Arizona Public Health Association, which published a study on all-cause mortality this month, said the death toll increase is largely pinned on those indirect causes.

He said the indirect deaths from the virus can be put into three buckets: delayed health care or people who opted not to seek medical treatment; recovery from the virus, or people who later died because of the long-lasting effects of the virus, such as a weakened immune system; and the lack of elective surgeries, where some people died after hospitals paused the surgeries to handle surges in coronavirus patients.

β€œThere is, in some circles, mainly on Facebook and other places, some that suggest that the number of deaths from COVID-19 has been exaggerated, that death certificates have been inappropriately assigned to COVID-19. Unequivocally, this virus is causing far more deaths than we would normally be seeing in an average year,” said Humble, the former state health director.

He added that β€œit will be really challenging” to go back and fully assess the total number of deaths stemming from the pandemic once it’s over.

β€œI think that many, if not most, of these unexplained deaths in 2020 will probably never be tied back,” he said, referring to those three categories of indirect deaths.

Dr. Joe Gerald, an associate professor with the University of Arizona’s Zuckerman College of Public Health, said when looking at the raw death totals, the spike in overall deaths in July is β€œobvious.”

β€œThe thinking is that when all the dust settles back in July, it’s going to really stand out as one of the ones with the highest-ever reported in death counts reported for any reason and a lot of it is going to be due to COVID-19,” he said.

In a statement, Holly Poynter, a spokeswoman for the Arizona Department of Health Services, said a β€œfuller understanding” of the death toll from the virus will come from reviewing final death certificate information and can take weeks or months to collect. She said death certificate counts tend to be lower than the counts by some surveillance definitions.

β€œDuring a public health emergency, surveillance definitions must be used for initial reporting because there is a lag collecting death certificate information in which doctors list causes of death. We need real-time data to help us understand what is happening and make the best possible public health recommendations. Death certificates are used in the final reporting,” she said.

β€œMilieu” of issues

In Pima County, excess mortality is likely proof that β€œall the milieu of different issues” surrounding the coronavirus are likely contributors, according to Dr. Francisco Garcia, the county’s chief medical officer.

β€œYes, there is excess mortality, and when all is said and done, it will probably be attributable in one way or another to the pandemic. It doesn’t mean that the actual infection was the cause of the death or a contributing factor to the death,” he said. β€œBut again there is something real here β€” it may not necessarily be an infectious process but it’s real. … I think it’s all part of this infectious milieu.”

Last month, Dr. Greg Hess, the county’s medical examiner, analyzed a spike in deaths after determining deaths reported to his office, which are only a small portion of those in the county, increased more than 27% than the average of the previous three years.

Despite speculation that coronavirus policy, including stay-home orders, could cause changes in death behaviors, that wasn’t necessarily the case. Motor vehicle deaths did not decrease, despite the expectation that less people would be driving because they were staying home. Suicide deaths did not increase after some suggested they would because of social isolation. The largest spike was in overdose deaths, a trend that had been seen before the pandemic.

The biggest takeaway from the analysis, Hess said, is that his office ended up accepting only 96 more deaths than an average year, not performing autopsies on the vast majority of deaths that were reported to the medical examiner’s office. Many of those rejected deaths are considered natural and typically would not be handled by his office in any other year.

As a result, his office has confirmed only 39 coronavirus deaths since March, as of Friday. He said a clearer picture of what’s driving the increase in deaths in Pima County will be done later, once there is more data available such as death certificates, but that it’s β€œcertainly going to be harder later to determine how accurate your numbers are.”

β€œClearly there are going to be some (coronavirus cases) that are missed β€” they’re never diagnosed, they never seek care, they are deceased in their home, they had been ill and they have other medical problems,” he said. β€œI’m sure there are going to be some of those are going to slip through the cracks.”

Counting cases depends on county

Asked whether the state has a standard in the state’s counting of deaths, Steve Elliott, a health department spokesman, said, β€œIn order to be included in the death numbers, COVID-19 must be a cause of or contributing factor to death.”

But how coronavirus deaths are counted depends on the county, according to a review by the Star.

In Pima County, cases are counted if the positive test result and vital record death information is consistent with COVID-19 complications, or if the death certificate lists COVID-19 disease of SARS-CoV-2 as a cause of death or significantly contributing to death, according to health department spokesman Aaron Pacheco.

Cases are not counted as COVID-19 deaths if there was a negative test within three days of death, or if the person had a positive result and had an unrelated death, like from an automobile crash.

Death certificate causes of death are handled by the medical provider overseeing care at the time of death, which could be the person’s primary care provider, a physician in the ER, or in a small sub-set of cases, the medical examiner.

That process differs in other nearby counties.

In Maricopa County, where 2,950 deaths have been confirmed, all positive test results within 60 days of death are initially pulled into the total. Then cases are removed of people who died from injury or poisoning, through things like car accidents, gunshots and overdoses each month. That has accounted for only seven of those deaths, as of this week.

β€œPublic Health has consistently explained that we will not have a final count of deaths caused by and associated with COVID-19 until after the pandemic,” health department spokesman Ron Coleman said.

The Cochise County Health Department, where 60 coronavirus deaths have been confirmed, is counting deaths by notification by a hospital or provider report and death certificates that list COVID-19 disease or SARS-CoV-2 as a cause of death or a significant condition contributing to death, according to epidemiologist Marthan Montano.

In Santa Cruz County, where there have been 57 coronavirus deaths, cases are counted if the decedent was a positive or a presumptive positive, based on an epidemiological link, such as potentially being exposed to a COVID-19-positive person, according to Fernando Silvas, epidemiologist of the Santa Cruz County Health Department.

He added that all of the locals that have died or been hospitalized have been transferred out of jurisdiction, so they rely on the hospital for notification of positive tests. But tracking down deaths β€œhas not been much of an issue for us” because of their small number.''

Elders and their family members can once again embrace each other through a "Hug Tunnel" constructed at the St. Luke's Home in Tucson. Linda Hollis, chief executive officer, says the idea came from a news report about a nursing home in Brazil that made a tunnel.

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Contact reporter Justin Sayers at 573-4192 or jsayers1@tucson.com. Twitter: @_JustinSayers. Facebook: JustinSSayers.