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Southern states have higher rates of unreported COVID-related deaths than other regions of the country, according to a new study.

The study, led by Andrew Stokes, a professor of global health at Boston University School of Public Health, analyzed deaths in 787 U.S. counties that had more than 20 COVID fatalities from Feb. 1 to Oct. 17, 2020. Georgia accounted for more than 50 of the counties studied. (Georgia has a high number of counties — second most among the states.)

In the new study, the term “excess deaths’’ compares fatalities to recent population benchmarks.

Excess deaths can include both those that are directly attributed to COVID-19, and those without that direct link but either indirectly related to the pandemic or misclassified as other causes.

The researchers estimated that 31 percent of excess deaths attributable to the COVID-19 pandemic were not reported as COVID on death certificates.

The results were first reported by STAT on Monday. The study, which has not been peer-reviewed, has been submitted to PLOS Medicine.

In the past two weeks, the Georgia Department of Public Health has reported record single-day numbers of COVID deaths.

The study found that rural counties, counties with low median incomes and less formal education, and counties in the South reported high numbers of excess deaths not assigned to COVID compared to those directly attributed to the virus. These findings suggest that COVID mortality may be especially undercounted in these areas.

In some cases, unreported deaths can be indirectly related to the pandemic, such as from suicide, drug overdoses or inadequate health care services, Stokes told GHN on Monday. In rural areas, there may be less access to COVID tests, he added.

The researchers found that a substantial fraction of the deaths of individuals with pre-existing health conditions who caught COVID and died as a result were attributed to a pre-existing condition. Excess mortality not attributed to the virus was higher in counties with higher levels of smoking, obesity, and diabetes, the study found.

Counties with more African-American residents, who are already at high risk of COVID death based on direct counts, also reported more excess deaths not assigned to the virus, according to the study.

The state Department of Public Health, asked to comment on the study Monday, said that it’s difficult to compare how states and regions report COVID deaths ”due to a lack of a national definition.”

“For example, Georgia DPH includes any death where COVID is listed on the death certificate, but we also include some deaths where COVID isn’t listed but we have a recent positive result and indication from the medical records/case investigation that COVID contributed to death,” said a Public Health spokeswoman, Nancy Nydam. “Other states may do things differently, although we’re all doing what we consider scientifically sound.”

Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, which provided funding for the study, said Monday that the research “raises questions and doesn’t necessarily answer them.’’

One factor in the uncounted deaths could have come early in the pandemic, when testing was scarce, said Hempstead, who also was a researcher on the study.  “As terrible as the death toll from COVID is, we’re undermeasuring it. We’re undermeasuring it more in some areas than others.”

The system for recording deaths in the United States is fragmented, STAT pointed out. Though most deaths are declared by a doctor, when a patient dies at home and isn’t under the care of a doctor, either a medical examiner or a coroner will typically be called on to declare the death.

The study found that counties with coroners had higher rates of excess COVID deaths than counties with medical examiners. Coroners are elected officials who are not required to be medical professionals, while medical examiners are appointed and must be medical professionals.

Many coroners may not have enough information to fill death certificates accurately, Hempstead said. “Medical examiners tend to have more resources.’’

Georgia has coroners in 154 of its 159 counties, with five heavily populated metro Atlanta counties having medical examiners instead.

Mark Savage, president of the Georgia Coroners Association, said Monday that he bases his death certificate analysis on test results and medical documentation when COVID is suspected.

“For the most part, we coroners try to put accurate information on the death certificate,’’ said Savage, who is the coroner of Banks County in northeast Georgia. “This COVID has put a physical and mental stress on everybody.’’