Nonetheless, despite an effective response, in early April as cases began to increase rapidly, the health system began to experience pressures similar to those in other countries, and the government declared a state of emergency ( 19). The early and comprehensive response to the COVID-19 pandemic in Japan probably enabled the country to avoid the severe epidemics experienced in Europe as of September 2, 2020, a total of 68,392 COVID-19 cases and 1,296 related deaths had occurred in Japan ( 18). For example, excess-death methods have been used to quantify formal underestimation of the mortality burden of COVID-19 in many heavily affected countries ( 10– 17). This approach can be applied to specific causes of death directly related to the pathogen, such as for pneumonia or other respiratory diseases, or to other categories of death that are directly or indirectly affected by a pandemic. When comprehensive testing is lacking, the mortality burden of a new pandemic is commonly estimated by an increase in the number of deaths that is greater than would be expected under normal circumstances (e.g., in the absence of a pandemic)-the so-called excess-death approach ( 8, 9).

The cause of death, especially among elderly persons in care homes or living alone, may not be adequately diagnosed or even recorded during a pandemic situation ( 7). Access to hospitals for elective surgery may also be hampered by the collapsing medical system associated with the increased number of COVID-19 patients ( 6). Lockdown measures are in place in many countries and regions around the world, but such measures can lead to reduced access to health services, exacerbating chronic diseases and delaying response to acute diseases ( 5).

data, ) it is generally accepted that many deaths caused by COVID-19 have not yet been recorded ( 4). Globally, accurate figures on deaths caused by coronavirus disease (COVID-19) have been difficult to obtain because of limited availability and quality of virus testing ( 2, 3) (Y. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first appeared in December 2019 in Wuhan, China, and has rapidly led to a global pandemic ( 1).

Cdc 2020 death totals