State Covid look-back report raises questions about how Alaska counted pandemic deaths

By SUZANNE DOWNING

A new Alaska Department of Health epidemiology report reviewing four years of Covid-19 data offers a technical retrospective of the pandemic’s toll and a headline grabbing number that got the attention of the mainstream media.

But key methodological choices in the Dec 9 report leave unanswered questions about how many Alaskans died from the virus versus with it, and why certain ethnic and racial populations were hit harder.

The report, Covid-19 in Alaska: A Five-Year Retrospective, summarizes cases, hospitalizations, deaths, vaccination status, and racial and ethnic disparities from 2020 through 2024. It concludes that Covid-19 was associated with roughly one out of every 500 deaths in Alaska over that period, a statistic that drew media attention.

But a closer reading shows that the report itself cautions against strong causal conclusions, cautions that were largely absent from headline coverage.

One of the most consequential methodological choices in the report is how it defines a Covid-19 death.

Rather than counting only deaths where Covid was the underlying cause, the report includes deaths where the virus was listed either as the underlying cause or as a contributing factor on the death certificate, a distinction that matters.

A contributing cause can include cases where a person died primarily from cancer, heart disease, dementia, trauma, multiple organ failure, or another serious condition, but also tested positive for Covid or had a detectable infection at the time of death.

The report does not break out how many deaths fall into each category, making it impossible to determine how many Alaskans died directly because of Covid versus how many died with Covid listed alongside other serious illnesses.

Later in the report, when Covid is compared to other leading causes of death, the methodology quietly changes. For those comparisons, only deaths where Covid was the underlying cause are counted, so each death can be assigned to a single category.

Both approaches are defensible for different purposes, but the report does not clearly flag that shift for readers. Without the context, the public may assume all mortality figures refer to the same definition, even though they do not.

Much of the media coverage focused on the report’s claim that roughly one in 500 Alaskans died from Covid during the pandemic years.

That figure is technically accurate under the report’s broad definition, but it relies on death certificate attribution that evolved significantly over time.

Early in the pandemic, limited testing likely led to undercounting of Covid-related deaths. Later, widespread and routine testing, including testing of patients admitted for unrelated reasons, increased the likelihood that Covid would be listed as a contributing factor even when it was not the primary cause of death.

The report acknowledges that surveillance systems and reporting practices changed over time, but it does not attempt to quantify how those changes affected mortality counts.

Nor does it conduct an excess-mortality analysis, a method epidemiologists can use to estimate how many deaths exceeded historical norms regardless of cause coding.

Without that analysis, the report cannot fully answer whether Covid increased overall mortality beyond what would have occurred absent the virus, particularly among older and medically fragile populations.

Then there are the racial disparities: The report also states that Alaska Native people and Pacific Islanders experienced higher Covid-associated death rates than other groups.

What it does not do is examine why those disparities exist.

The analysis does not explore underlying health conditions, obesity rates, diabetes prevalence, cardiovascular disease, household crowding, access to care, or long-standing socioeconomic factors — all of which are known to influence Covid outcomes nationally.

Pacific Islanders, in particular, have some of the highest rates of obesity and metabolic disease in the United States, factors strongly associated with severe Covid illness. The report mentions none of this, leaving readers with the impression of disparity without context. For all the reader knows, the virus was racist.

Identifying disparities without examining root causes limits the usefulness of the findings for prevention or policy. The report stops short of tackling those difficult questions.

The report includes tables comparing Covid-associated death rates among vaccinated and unvaccinated Alaskans and concludes that a majority of Covid-associated deaths occurred among those who had not completed a primary vaccine series.

However, the vaccination analysis has notable limitations.

Vaccination status is defined narrowly, without accounting for booster doses, time lapsed since last vaccination, prior infection, or immune compromise. The analysis adjusts for age but does not control for comorbidities, long-term care residence, or health status, which are factors that heavily influence mortality risk.

Vaccination rates also changed dramatically over time. Early in the pandemic, vaccines were unavailable. Later, they were prioritized for older and medically vulnerable Alaskans, while younger and healthier populations were more likely to remain unvaccinated. The report does not fully disentangle how those shifting demographics affect mortality comparisons.

As a result, the vaccination findings are descriptive rather than causal, a distinction that is not always clear in public discussion.

To be clear, the all-cause death rate in Alaska spiked higher during the 2020–2022 Covid period compared to pre-pandemic years. Alaska experienced substantial excess deaths during this time, with nearly 2,000 more deaths than expected across 2020 and 2021 combined (approximately 500 excess in 2020 and 1,400 in 2021), according to the Centers for Disease Control and Prevention. Some of these may have been the result of indirect pandemic effects, such as the strained healthcare systems or reduced preventive care for other diseases. Total reported deaths rose sharply:

So then, what is the takeaway?

The Department of Health describes the report as a high-level summary rather than a detailed causal analysis, and many of its methodological choices are standard in public health surveillance.

There is a the blending of different death definitions, and the absence of deeper analysis into comorbidities and excess mortality leave significant questions unanswered.

The report documents how Covid intersected with Alaska’s population over five years.

But it does not fully explain how or why those outcomes occurred, or how much certainty policymakers and the public should place on headline-grabbing mortality figures that were drawn from changing interpretations and definitions.

Note: In full disclosure, this writer is not a medical professional and completed only one college-level course in epidemiology.