Italy recorded almost 50 percent more fatalities in March than usual, according to new official data showing that the real coronavirus death toll could be far higher than the 29,000 reported.
The new data suggest that the death toll from the day the country's first infection was reported on February 20 to March 31 could be nearly double the official figure.
The Italian government has struggled to determine how many people have actually died from an illness that forced the nation of 60 million to shut down over the first half of March.
The data were released on the day Italy eased nine weeks of confinement. Italians were allowed to stroll freely in parks and visit their relatives even while many small stay shut for another two weeks.
Prime Minister Giuseppe Conte hopes a drop in infections and a gradual return to business can help the economy start recovering from what might be its worst downturn since the 1930s.
But Conte's government still does not know how many people have died of COVID-19 -- a grim reality that makes planning for the months ahead even harder.
Italy's civil protection services had attributed 12,428 fatalities to the virus by the end of March.
But the state statistics agency ISTAT and the ISS public health institute said nearly 11,700 extra deaths needed to be accounted for in that span.
The number was derived by comparing Italy's total number of deaths between February 20 to March 31 to the statistical average for that period in the preceding five years.
"For the month of March, the national average shows an increase in deaths from all causes of 49.4 percent," ISTAT and the ISS said in a joint statement.
The statement referred to the nearly 11,700 unaccounted for fatalities as "excess deaths".
It said deaths among men in their 70s rose by a factor of 2.3 nationally -- and among men in their 80s by 2.2 times -- in that span.
These were "the most significant excess deaths", the two state organisations said.
- Three causes -
Italy became the global epicentre of the pandemic after its toll from the illness surpassed the official one reported by China on March 19.
The Mediterranean country recorded more than a third of all coronavirus deaths registered across the world that month.
Yet local officials at the centre of the outbreak in northern provinces around Milan viewed Italy's official figures with suspicion.
Some were reporting fatality rates in March that exceeded usual figures by a factor of five or six.
Those deaths did not appear to be registering in the official figures being released daily by Italy's civil protection service.
Italy's official death toll rose by 195 on Monday to 29,079 -- second only to the United States.
But the figure is almost entirely comprised of hospital deaths.
Few of the elderly in care homes have been tested and the number of deaths from the virus in the community is unknown.
ISTAT and the ISS said in a joint statement that there were three possible explanations for the 11,700 additional fatalities.
One is that these people were never tested for the virus but actually had it when they died.
There could also be "an indirect effect of the virus" in which COVID-19 exacerbates an existing condition such as kidney or other organ dysfunction.
A third factor is the negative impact "of an excessive stress on the healthcare system, especially in the more affected areas," the statement said.
Italy also reported 15,539 coronavirus deaths in April. ISTAT and the ISS had insufficent data for that month.