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Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in Biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control and has worked in both pediatric and adult acute care facilities.

Understanding Excess Deaths in the Wake of COVID-19

When we look back at the coronavirus 2019 (COVID-19) pandemic, many things will be evaluated–cases, mortality, long-term implications, number of tests, etc. A critical aspect of understanding how severe and impacting the pandemic is means also looking at the damage it inflicted, such as economic. One piece to this awareness is evaluating excess deaths associated with the pandemic. 
Understanding mortality is tricky though, especially as testing availability posed a huge challenge in the early months of the outbreak. Mortality burden is not just those who have died due to COVID-19, but also those who avoided seeking medical care due to fear, stressed healthcare systems, or a number of other reasons.  A new research study sought to discuss this in the JAMA Internal Medicine.
The research team worked to understand all-cause mortality in the first few months of the COVID-19 pandemic within the United States. The authors pulled data due to any cause each week then compared “these estimates of excess deaths with the reported numbers of deaths due to COVID-19 in different states and evaluate the timing of these increases in relation to testing and pandemic intensity.”
Data regarding deaths due to influenza, pneumonia, and COVID-19 was pulled from the National Center for Health Statistics and stratified by state and week. The observation period was March 1 through May 30, 2020. By estimating the number of deaths in a COVID-19 free world, they then subtracted the expected number of deaths each week from the observed number of deaths. The authors did include adjustments for reporting delays.
After this work, their findings were quite eye-opening. The 781000 deaths that occurred during the study time were higher than expected during that time of year. During the study timeframe, there were 95235 deaths that were officially contributed to COVID-19 and 122300 excess deaths. The number of excess all-cause deaths was 28% higher than those of COVID-19 deaths. They noted that,“the deaths officially attributed to COVID-19 accounted for 78% of the excess all-cause deaths, leaving 22% unattributed to COVID-19. The proportion of excess deaths that were attributed to COVID-19 varied between states and increased over time.”
In terms of mortality varying by state, the researchers found that all-cause mortality actually increased by a 7-fold increase from the baseline when the epidemic was at its peak in New York City. Other states had varying findings–California reported 4,046 COVID-19 related deaths and 6,800 all-cause excess deaths, meaning that 41% of excess deaths were unattributed to COVID-19. In two states currently experiencing massive spikes, the authors noted, “Texas and Arizona had even wider gaps, with approximately 55% and 53% of the excess deaths unattributed to COVID-19, respectively.”
Ultimately, these findings point to several things. First, monitoring excess deaths is an important piece in understanding the toll of the COVID-19 pandemic and its rippling effects.  Second, there are serious implications for testing capacity and availability. Third, as the authors noted that deaths due to any cause increased by 122000 (28% higher than those reported COVID-19 deaths), which emphasizes that there is a larger burden of deaths that extend beyond COVID-19. Access to care or avoidance of medical settings for fear all contribute to increased mortality and point to a desperate need to address this moving forward. Outreach and communication is critical during this time.
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