A small county in Missouri undercounted the number of fatalities caused by the coronavirus after a coroner agreed to remove covid-19 as a cause of death from some death certificates upon being asked by families of the deceased.

The undercount in coronavirus-linked deaths in Macon County, home to around 15,000, as a result of the coroner’s actions is relatively small. The Kansas City Star, which first broke news of the story, pegged the figure at a half-dozen or more. But it comes amid broader recognition that the number of covid fatalities in the United States is probably higher than the official tally of 614,000.

In Macon, some requests came from people who wanted to avoid being reminded of how they could not see family before their deaths because of restrictions on visits to hospitals and nursing homes. “A lot of families were upset. They didn’t want covid on the death certificates,” the county coroner, Brian Hayes, told the Star.

Hayes, a Republican elected official who is also a partner at a local funeral home, said he obliged requests to alter or omit covid as the cause of death only when there was a factual alternative that could be listed. “I won’t lie for them, it’s gotta be true, but I do what pleases the family,” Hayes said, according to the Star.

He did not immediately respond to a request for comment sent early Wednesday.

Jerris R. Hedges, a medical professor at the University of Hawaii in Manoa, wrote in an email that it was understandable for families to want to keep the cause of death private. But coroners should report both the presence of a coronavirus infection, and any associated underlying disease under the cause of death, he said, as it could help persuade those with preexisting conditions to get vaccinated.

“Although some deaths are uniquely related to covid, many, many more are where covid has pushed those with preexisting conditions into a literal death spiral,” he wrote.

It isn’t clear the extent to which a potential nationwide undercount may have been affected by intentional distortions of data or other factors, like an inability to test patients who later die of covid-19.

In January, New York State Attorney General Letitia James said the state had undercounted coronavirus-related deaths at nursing homes by as much as 50 percent.

In May, the Institute for Health Metrics and Evaluation at the University of Washington said the actual number of deaths in the United States caused by the pandemic could be over 900,000 — higher than the roughly 580,000 deaths logged at the time.

Anthony S. Fauci, the nation’s top infectious-disease expert, said on NBC’s “Meet the Press” that month that he had “no doubt” there was an undercount of coronavirus-linked deaths, though 900,000 sounded “a bit more than I would’ve thought.“

A confusing vaccination rollout in Missouri has residents signing up for multiple lists and driving long distances away from urban areas like Kansas City. (Lee Powell, James Cornsilk/The Washington Post)

The United States, which has the world’s highest official coronavirus death toll, is not the only country where an undercount in fatalities is likely. The May report from the University of Washington listed India, Mexico and Brazil among countries with likely wide variances between officially reported covid deaths and actual fatalities.