Excess mortality is defined as the difference between observed deaths and average expected deaths in the same period as reported by CDC’s National Center for Health Statistics (NCHS).12 We calculated excess mortality using the Farrington surveillance algorithm applied to death data for Puerto Rico from 2013 through the present.12 Negative values, in which the observed count fell below the NCHS threshold, were set to zero12 and were not depicted. Details about NCHS methods and excess death data associated with COVID-19 can be found elsewhere.12 We calculated a range of deaths potentially associated with COVID-19. The lower bound of the range was the sum of confirmed and probable COVID-19 deaths reported by PRDoH during March 17–July 31, 2020 (calendar weeks 12-31). The upper bound of the range of COVID-19–associated deaths was the sum of excess deaths in Puerto Rico reported by NCHS during March 2–August 2, 2020 (calendar weeks 10-31).2 We calculated 95% CIs for the sum of excess deaths using the standard error of excess deaths for the study period. This range, the difference between the lower bound and the upper bound, represents an estimate of missed deaths that likely were associated with the COVID-19 pandemic. We also depicted the excess estimates for all cases of death excluding COVID-19 deaths to visualize the gap between excess mortality and COVID-19 deaths during the study period. We did not analyze data on underlying medical conditions, symptomology, or course of clinical illness and care received because this information was missing for 171 (76%) cases.

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