An official Palestinian tally of deaths in Israel’s war in Gaza likely undercounted the toll by 41 percent in the first nine months of the conflict as the Gaza Strip’s healthcare infrastructure unravelled, according to a study.

The peer-reviewed statistical analysis published in The Lancet journal on Thursday was conducted by academics at the London School of Hygiene and Tropical Medicine, Yale University and other institutions.

Using a statistical method called capture-recapture analysis, the researchers sought to assess the death toll from Israel’s air and ground campaign in Gaza between October 2023 and the end of June 2024.

Up to June 30 last year, the Palestinian Ministry of Health in Hamas-run Gaza reported a death toll of 37,877 in the war.

However, the new peer-reviewed study used data from the ministry, an online survey and social media obituaries to estimate that there were between 55,298 and 78,525 deaths from traumatic injuries in Gaza by that time.

The study’s best death toll estimate was 64,260, which would mean the Health Ministry had underreported the number of deaths to that point by 41 percent.

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The study estimated that 59.1 percent of those killed were women, children and people over the age of 65. It did not provide an estimate of Palestinian fighters among the dead.

That toll represented 2.9 percent of Gaza’s pre-war population, “or approximately one in 35 inhabitants,” the study said.

The toll was only for deaths from traumatic injuries, so did not include deaths from a lack of healthcare or food, or the thousands of missing believed to be buried under rubble.

Israel’s war in Gaza has killed at least 46,006 Palestinians and wounded 109,378 since October 7, 2023, the territory’s Health Ministry says.

The war began on October 7 2023, after Hamas-led attacks across the border with Israel killed at least 1,139 people and led to more than 200 people being taken captive.

In the first months of the war, the official Health Ministry death count was based entirely on bodies that arrived in hospitals.

It later came to include other methods, including distributing an online survey to Palestinian people inside and outside the Gaza Strip, who were asked to provide data on their ID numbers, names, age at death, sex, location of death, and reporting source.

The Lancet study noted that the Palestinian Health Ministry’s capacity for maintaining electronic death records had previously proven reliable, but has currently deteriorated under Israel’s military campaign, which has included raids on hospitals and other healthcare facilities and disruptions to digital communications.

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On Thursday, Gaza health officials said the Al-Aqsa, Nasser and European hospitals are at risk of imminent closure, after repeated Israeli attacks and blockades of supplies. The Kamal Adwan, Indonesian and al-Awda hospitals have already been forced to close.

Al Jazeera’s Hani Mahmoud, reporting from Al-Aqsa Hospital in Deir el-Balah, central Gaza, said that many deaths were going unreported in the north of the Gaza Strip, with bodies being buried in the yards of homes or in the streets, as victims from a renewed Israeli offensive in the area cannot be brought to besieged hospitals.

“The entire healthcare system in the northern part of the Strip is out of service, without any proper mechanism for recording the number of casualties in the area,” he said.

“It is increasingly difficult to keep track of mass killings during Israel’s relentless attacks.”

He said the Al-Aqsa Hospital was now being overwhelmed by a recent influx of injured civilians, many of them women and children.

“Doctors are reporting an acute shortage of basic supplies, including surgical tools, antibiotics and painkillers,” he said.

Reporting from Deir-el Balah on Friday, Al Jazeera’s Tareq Abu Azzoum said the Israeli military is escalating its attacks on residential areas.

“Medical teams in al-Awda Hospital continue to report that the Israeli army is going on with bulldozing all residential homes in the vicinity of the hospital amid more deterioration taking place among medical cases left there, and it could be a sign of further Israeli escalation taking place within the coming days,” he said.

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Israel has repeatedly said it goes to great lengths to avoid civilians deaths and accuses Hamas of using hospitals as cover for its operations, which the group has denied.