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July 1, 2020

Mortality and Morbidity: The Measure of a Pandemic

Author Affiliations
  • 1Deputy Editor, JAMA
  • 2Editor in Chief, JAMA
JAMA. 2020;324(5):458-459. doi:10.1001/jama.2020.11761

By late May 2020, more than 100 000 individuals in the US died of coronavirus disease 2019 (COVID-19).1 News reports lamented the number, comparing it to the capacity of a large football stadium or a small town and noting its similarity to the number of US soldiers killed in World War I or in the Korean and Vietnam wars combined.2

Death seems like it should be an accurate measure of the pandemic’s evolution and effects—the worst outcome, an unequivocal outcome. However, the number of deaths attributed to COVID-19 in official reports is likely an underestimate of deaths caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In addition, the statistic does not incorporate deaths indirectly attributable to the virus and the measures used to contain it.

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    3 Comments for this article
    Missing Scenarios
    Carey Page, MD | UTHSCSA
    Considerations missing from the discussion are the numbers of patients dying from other causes that were also infected by SARS-CoV-2. Myocardial infarction, gun-shot wounds, auto accidents as the proximate cause of death were often (by rule) attributed to COVID-19 if the person tested positive at the time of death. There were also economic incentives to attributing the "cause of death" to COVID-19. This misappropriation may or may have not been corrected as time passed.

    Similarly absent from the analysis is the consideration of economic and social conditions that required people to venture into the "economy" in spite of
    the "shelter in place" rules. Economic distress from the shutdown and loss of income caused many to "go to the store" rather than opting for delivery. In fact, the most frequent source of person-to-person transmission is "in the home." In NYC, the most frequent source of community acquired infection was the home (≈66%).

    So; this paper does a good job as far as it goes but leaves out some really significant scenarios: some political and economic, and some real-life.
    Accurate Measurement of Mortality and Morbidity for COVID-19
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    The clear and concise editorial by the Editor-in-Chief and Deputy Editor of JAMA is concerned with the important issue of the accurate measurement of mortality and morbidity for COVID-19.

    Such accurate measurement of mortality and morbidity is essential for optimal public health policy considerations, which are affected by political considerations, especially in a Presidential election year.  

    As of 3 July 2020, almost 3 million individuals have been diagnosed as COVID-19 positive, with over 1340,000 deaths, in the USA (https://www.worldometers.info/coronavirus/).

    The estimated number of deaths that are directly attributable to COVID-19 is undeniably an underestimate as the numbers do not seem to
    include cases where individuals were not tested for the disease before or after death, as well as misdiagnosis due to overlapping and disguised factors.

    Deaths that could be indirectly attributed to COVID-19 include avoidance of care, and lack of access to medical and health care due to other socio-environmental factors such as poverty, hunger and racism, which are often found to be overlapping.

    Estimates based on "unexplained excess deaths" are aggregate measures that do not take account of mitigating factors, such as the effects of self isolation, social distancing, quarantining, lockdowns, reduced traffic accidents, domestic violence, and deaths arising from COVID-19-induced psychological stress and mental illness.

    Clear and consistent definitions across all measuring facilities, including all States, are essential to obtain accurate measures of mortality and morbidity to enable meaningful public health policy deliberations.
    Brian Reddy |
    From the excess deaths study:

    "87 001 were excess deaths, of which 56 246 (65%) were attributed to COVID-19"

    i.e. 56,246 / 87,001 = ~65%


    87,000 * 0.65 = 56,246

    Important to note, in order for COVID deaths to make up 65% of excess deaths then,

    56,246 * 1.55 = 87,001

    Excess deaths must be ~50% greater than COVID deaths. Not 35%.

    From your editorial,

    "If the same pattern continued through the end of May, there would be, as reported, 100 000 deaths attributable to COVID-19, but an estimated 135 000 total
    deaths attributable to the pandemic."

    100,000 / 135,000 = 74%

    Since 1-0.65 = 35%, I believe you thought to do 100,000 * 1.35 = 135,000

    But 100,000 * 1.5 = 150,000.

    That way,

    100,000 COVID deaths / 150,000 excess = 65% of excess deaths (for lack of a better term) directly attributable to COVID.

    So, COVID reported deaths * ~1.5 = excess deaths, that way COVID deaths make up 65% of excess deaths.