Report: COVID-19 Cannot Directly Account for Jump in All-Cause Mortality Last Year


Overall, more than half a million more people died between March 2020 and the end of the year, suggesting the pandemic may have been indirectly involved in more deaths than previously realized.

United States

The number of deaths in the United States rose sharply last year, reaching levels that cannot be fully explained by the official count of coronavirus disease 2019 (COVID-19) deaths, according to a new analysis.

The report, published in the Journal of the American Medical Association, covers the period between March 1, 2020 and Jan. 2, 2021. It is based on data from the National Center for Health Statistics and the US Census Bureau. The data cover 49 states and the District of Columbia. North Carolina was not included due to insufficient data, the report’s authors said.

During that time frame covered by the analysis, a total of 2,801,439 deaths from all causes were reported in the US. That’s 22.9% higher (522,368 deaths) than would have been expected in a normal year.

The number is notable in part because, according to the US Centers for Disease Control and Prevention (CDC), the total number of people dying from COVID-19 in the calendar year 2020 was approximately 375,000.

Corresponding author Steven H. Woolf, MD, MPH, of the Center on Society and Health at Virginia Commonwealth School of Medicine, and colleagues, explained that some of those excess deaths not reflected in the CDC count might still have been related to the pandemic.

“Excess deaths not attributed to COVID-19 could reflect either immediate or delayed mortality from undocumented COVID-19 infection, or non–COVID-19 deaths secondary to the pandemic, such as from delayed care or behavioral health crises,” they said. “Death rates from several non–COVID-19 diseases (eg, heart disease, Alzheimer disease) increased during surges.”

The new data align with an earlier report, which found that between March and July 2020, the number of actual US deaths was 20% higher than would be expected in a normal year. The similarity in the excess mortality rate suggests that, even as hospitals around the world got better at identifying and treating COVID-19, surges in cases and downstream effects on the healthcare system remained problematic.

“While we made progress in treating COVID-19, there was an extraordinary number of deaths in the summer surge and particularly during the early winter holiday period,” Woolf told Contagion. “This contributed greatly to the large increase in excess deaths for the year. And sadly, so many of these deaths were preventable.”

The investigators also found significant variance between regions. For instance, New York State had the largest relative increase in all-cause mortality, with a 38.1% increase. However, the other states populating the top 10 states in terms of excess deaths were mostly in the midwest (South Dakota, North Dakota and Ohio) and southeast (Alabama, Louisiana, and Mississippi). Woolf and colleagues noted that many of those states “weakly embraced, or discouraged, pandemic control measures and lifted restrictions earlier than other states.”

The data also revealed racial disparities. For instance, while non-Hispanic Blacks make up just 12.5% of the US population, they made up 16.9% of the excess deaths reported in the study. That data point aligns with other reports suggesting racial minorities have been hit harder by the pandemic, compared to other groups.

Woolf and colleagues noted that their data have some limitations. For instance, the report is based in part on provisional data and could also be affected by inaccurate death certificates. Such limitations, though, are part of the reason it’s important to look at excess all-cause mortality, rather than focusing simply on deaths directly linked to COVID-19.

“We need programs like [Johns Hopkins University’s] COVID Tracking Project to keep the nation informed of the number of deaths attributed to the virus, as well as case numbers and hospitalizations,” he said. “But we also need to monitor excess deaths, a measure that is agnostic about the vagaries of cause of death attribution and gives the nation a fuller sense of the death toll a crisis brings. This is true not only for pandemics but also for other natural disasters, such as earthquakes, hurricanes, etc.”

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