The death toll from the coronavirus in Texas came into sharper focus this past week, as health officials added several hundred more fatalities to a tally that now exceeds 6,500.

The jump came as the Texas Department of State Health Services shifted to death certificates listing COVID-19 as the cause of death as a data source, instead of local health reports. State officials said the move provides a more accurate picture of the disease’s human toll.

But the lag time in receiving death certificates — up to 10 days after a person dies — offers a delayed account of the number of fatalities on a given day. That initial incomplete death tally can hinder the work of policymakers responding to the virus and epidemiologists studying it.

The switch also has led state officials to subtract deaths from counties’ tallies. In Nueces and Travis counties, for example, the move initially made it appear that there were fewer deaths in both counties than had previously been reported.

Annette Rodriguez, health director for the Corpus Christi-Nueces County Public Health District, said she’s concerned that the change will sow confusion.

The state health department on July 25 reported 97 total deaths in Nueces County by using death certificates, according to data pulled Friday. That’s 32 fewer deaths than had been previously reported by local officials.

“There’s always been a lag,” Rodriguez said of reports using death certificates. “I think this just causes a lot more confusion. We’re doing our best to report the right numbers.”

The change decreased Travis County’s COVID-19 total death count by about 13 people. An Austin Public Health spokesperson said the county was aware of the change and would continue to report deaths to its public dashboard “as we receive and verify them.”

In announcing the shift, the state health department noted that such gaps will close as deaths are notched on earlier days.

For example, according to the state’s tally as of Friday, four people have died in Texas from the coronavirus on Wednesday, but that number is all but certain to rise as more death certificates are filed over the next week.

The fatalities chart on our #COVID19TX dashboard reflects the improved fatalities data from death certificates.

The chart shows fatalities by the date of death instead of when the death was reported. This change provides a clearer picture of Texas COVID-19 fatalities over time. pic.twitter.com/7wf3P3cGiF

— Texas DSHS (@TexasDSHS) July 29, 2020

However, national experts agree that, despite the lag, death certificates give the most complete picture of fatalities in a pandemic.

Chris Van Deusen, spokesman for the Department of State Health Services, said the large increase in COVID-19 deaths came because the agency was able to report some deaths sooner than local health authorities.

“This isn’t meant to replace the fatality investigations and information gathered at the local level but to supplement it by providing a more complete picture of fatalities across the state,” he said Friday.

In other counties, death certificates showed a much higher toll. State officials added more than 200 deaths to Bexar County’s tally using death certificates. More than 550 people have died in that county from the coronavirus, according to the new count.

Van Deusen said he was not sure why there was such a big increase in Bexar County deaths using the new method.

Two methods

Dr. Bob Anderson, chief of mortality statistics at the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics, said tracking COVID-19 fatalities using death certificates is a “tried and true” method, but using both death certificates and local reports would paint the most accurate picture of the virus’ toll.

“It’s important to be using both, but ultimately, it’s going to be the death certificate count that’s going to be the official count,” Anderson said. “I view the case surveillance part as a very quick and maybe a little dirty way of counting things, and then the death certificate is there to clean things up.”

Case surveillance reporting is how health departments count cases of COVID-19 or any disease, Anderson said. Local health providers count each case and note whether the person died from the virus. The reports are then sent to the state, and the state sends them to the CDC.

“It can be turned around very fast and can be turned around very quickly,” he said. “Generally, it works very well.”

The COVID Tracking Project, a volunteer-run effort at The Atlantic, notes that using death certificates “generates the most epidemiologically accurate data for modeling pandemic severity.”

“The downside of this method is that it takes on average, one to two weeks to produce and review death certificates, which means death reporting using this method significantly lags behind testing and hospitalization data,” the project blog said. “This makes the method less helpful for understanding how many people are dying, and where, in an ongoing outbreak.”

Meanwhile, death counts based on case data are most useful in understanding the pandemic’s real-time status, but they are less accurate because they can include some people who died while infected with COVID-19, but not because of COVID-19, according to the tracking project.

The project found that there is no clear guidance from the federal government on the best way to report deaths, and only two states, Colorado and North Dakota, record deaths using both methods.

Death certificates also provide demographics for every COVID-19 death, revealing more fully how Latinos are disproportionately stricken by the virus.

On Friday, the state health department reported that nearly half of those who have died of the virus in Texas are Latino. Roughly 40% of Texans are Latino, according to the Census Bureau.

Dr. Howard Koh, former assistant health secretary under President Barack Obama, said Texas should expect those numbers to rise.

“I wouldn’t be surprised if the death numbers in communities of color rose with the assessment of hopefully more accurate information,” Koh said. “The nation has taken too long to understand its impact. It’s not unexpected, but it’s completely unacceptable.”

Public distrust

Rodriguez in Nueces County remains concerned that public distrust will only grow with the methodology change.

“I don’t know that that’s good enough for some people,” she said. “That’s how you get the community to be like ’Well, somebody’s not being transparent.’ They think we’re overreporting.”

The Department of State Health Services has dealt with a number of changes to its data in recent weeks. Two days after the switch to death certificates, the health department removed roughly 225 fatalities from its total count.

“A manual quality check revealed the issue late Wednesday, and the counts were corrected in time for today’s update,” the agency said in a statement Thursday.

Hospitalization totals also were incomplete last week because of a transition to a new federal reporting system that sidesteps the CDC.

And earlier this month, the state health department removed more than 3,000 positive COVID-19 cases because they were “probable” cases found through antigen tests rather than “confirmed” cases through the more commonly used molecular coronavirus tests.

Dr. Amesh Adalja, an infectious disease physician and a senior scholar at the Johns Hopkins Center for Health Security, said it’s normal for data to shift, especially in a pandemic.

“There’s always this tension and balance between having accurate numbers and getting numbers in real time,” Adalja said, adding that there is some public distrust in the data, especially in a pandemic that has been so highly politicized. “It’s just important to enunciate it all — what the benefits may be and what the drawback might be and be very clear about what’s going on.”

Koh agreed, adding that the state and country likely won’t have the most accurate data until well after the pandemic, making regular press briefings from Gov. Greg Abbott and public health officials even more important to help quell concerns. (In recent weeks, Abbott has been granting near-daily interviews, mostly on local TV news stations around the state, but he gives infrequent coronavirus press briefings.)

“We always have to accept some level of uncertainty,” Koh said. “In my view, that’s the only way to do it.”