Since recording its first case in February, the Covid-19 pandemic has ravaged the United States and killed almost 130,000 people across the country.
But startling new research released today suggests the true number of Americans to perish from the highly infectious virus is much, much higher.
Scientists from the US and Denmark examined death records over a three-month period and their findings, published in the medical journal JAMA Internal Medicine, show there were 122,300 more deaths than normal.
Obviously, the "excess deaths" can't all be attributed to the coronavirus outbreak.
But such a sharp increase in morality in the US, at the same time as the pandemic, indicates a number of fatalities caused by the pandemic haven't been counted, the study authors said.
Between March 1 and May 30, the period examined by the scientists, which included researchers from Yale University, there were 781,000 total deaths in the US.
In that same three-month period, 95,235 deaths due to Covid-19 were recorded, meaning the number of excess deaths was 28 per cent higher.
"Efforts to track the severity and public health impact of coronavirus in the United States have been hampered by state-level differences in diagnostic test availability, differing strategies for prioritisation of individuals for testing, and delays between testing and reporting," the study said.
"Evaluating unexplained increases in deaths due to all causes, or attributed to non-specific outcomes, such as pneumonia and influenza, can provide a more complete picture of the burden of Covid-19."
The study used data from the National Centre for Health Statistics and compared it to the same period from previous years.
Limited availability of testing and the "imperfect sensitivity" of tests means "there have likely been a number of deaths caused by the virus" that aren't formally recorded.
"In several states, these deaths occurred before increases in the availability of Covid-19 diagnostic tests and were not counted in official Covid-19 death records," the study noted.
A number of major metropolitan locations were examined, including the hard-hit New York City, which was at the epicentre of coronavirus deaths in the early stages of the pandemic.
Mortality rates there rose "seven-fold above the baseline at the peak of the pandemic", the study said. There were a total of 25,100 excess deaths in New York City.
Among individual American states, the gap between the reported pandemic deaths and the estimated excess deaths varied.
In California, there were 4046 reported deaths due to Covid-19 and 6800 excess all-cause deaths. Texas and Arizona had even wider gaps, with approximately 55 per cent and 53 per cent of the excess deaths unattributed to coronavirus, respectively.
"Some of the discrepancy between reported Covid-19 deaths and excess deaths could be related to the intensity and timing of increases in testing," the study said.
"In some states (for example, Texas, California) excess all-cause mortality preceded the widespread adoption of testing for (Covid-19) by several weeks."
Epidemiologists and researchers have monitored excess death data in a bid to track influenza morality for than a century.
The team behind this new study used a similar strategy to identify the potential underestimation of Covid-19 fatalities.
Not all excess deaths potentially linked to Covid-19 would be the direct result of infection on its own, they pointed out.
"If patients with chronic conditions turn away from the health care system because of concerns about potential Covid-19 infection, there could be increases in certain categories of deaths unrelated to Covid-19," the study said.
"In the midst of a large outbreak, there is also an unavoidable delay in the compilation of death certificates and ascertainment of causes of death."