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Figure.  Weekly Death Rates From January 2019 Through April 2020
Weekly Death Rates From January 2019 Through April 2020

Data refer only to underlying causes of death; COVID-19 may have been a contributing cause in an unknown number of deaths. New Jersey and New York City experienced the largest relative increases.

Table.  Excess Deaths From March 1, 2020, to April 25, 2020, Attributed and Not Attributed to Coronavirus Disease 2019 (COVID-19)a
Excess Deaths From March 1, 2020, to April 25, 2020, Attributed and Not Attributed to Coronavirus Disease 2019 (COVID-19)a
1.
Weekly counts of deaths by state and select causes, 2014-2018. National Center for Health Statistics website. Updated June 5, 2020. Accessed June 10, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/3yf8-kanr
2.
Weekly counts of deaths by state and select causes, 2019-2020. National Center for Health Statistics website. Updated June 10, 2020. Accessed June 10, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/muzy-jte6
3.
2018 American Community Survey 1-year estimates: table B01003. US Census Bureau website. Accessed May 15, 2020. https://data.census.gov/cedsci/table?hidePreview=false&tid=ACSDT1Y2018.B01003&t=Total%20population&vintage=2018
4.
QuickFacts: New York City, New York. US Census Bureau website. Accessed May 15, 2020. https://www.census.gov/quickfacts/newyorkcitynewyork
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    4 Comments for this article
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    Confounding Variable and Secondary COVID-19 Deaths
    Gary Ordog, MD, DABMT, DABEM | County of Los Angeles, Department of Health Services, Physician Specialist (retired)
    Thank you for the illuminating research publication. A major confounding variable in any current COVID-19 mortality study will be the change in definitions of the COVID-19 cause of death by the WHO and on death certifications midstream through this pandemic. I would also like to point out that there are many more what may be called 'secondary COVID-19 deaths' that are related to the conditions caused by the virus, but not directly due to infection from the virus. For example, we appear to be witnessing an increase in fatal drug overdoses and suicides during the pandemic. It may be that fatal domestic violence has also increased. COVID-19 may have more far reaching effects on our health than we initially realized. Thank you and stay safe.
    CONFLICT OF INTEREST: None Reported
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    First Do No Harm
    Ben Park, MD | Physician
    Data are and have been available on the health consequences of unemployment, loss of a small business, delay in life saving procedures, failure to vaccinate our population, and the failure to educate our children. During the COVID pandemic we have experienced all of these. Dr. Scott Atlas and his business professor co-authors suggest that we have already lost twice as many years of life from our policy as we have from COVID (1). As COVID mortality slows the adverse impact from the lockdown continues unabated.

    In another article addressing only mortality from job loss (2), authors used administrative data
    on the quarterly employment and earnings of Pennsylvanian workers in the 1970s and 1980s matched to Social Security Administration death records covering 1980–2006 to estimate the effects of job displacement on mortality. This article forecasts much greater loss of lives from the current policy than Dr. Atlas's paper.

    When we believed the mortality rate to be 3.4% closing the borders and shutting down the economy was clearly the right approach. When we got data and then failed to adjust our approach we failed our patients. We do not hesitate to change clinical practice when research shows our current approach is wrong. We must also follow this principle with regard to COVID.

    Reference

    1. https://www.iedm.org/wp-content/uploads/2020/05/lepoint092020_en.pdf
    2. The Quarterly Journal of Economics, 2009, vol. 124, issue 3, 1265-1306
    CONFLICT OF INTEREST: None Reported
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    Alzheimer/Dementia Excess Mortality
    James Gill | CT Office of the Chief Medical Examiner
    This letter reports that the five states with the most COVID-19 deaths experienced large proportional increases in deaths from non-respiratory underlying causes including Alzheimer and cerebrovascular diseases. A non-respiratory underlying cause of death does not mean that the death did not have a respiratory-related, immediate cause of death. Bronchopneumonia is a common immediate cause of death in patients with dementia and with strokes. The death certificate must include the underlying cause of death (e.g., Alzheimer-type dementia) but does not have to include the immediate cause (e.g., pneumonia). The absence of a respiratory process on the death certificate should not be assumed to mean absence of a respiratory infection. The certifying clinician may have decided not to include the immediate cause and/or attributed the respiratory component to a complication of the underlying disease (e.g., aspiration pneumonia due to dementia) as opposed to an intervening COVID-19 infection. Investigative follow-up in real-time by the medical examiner, or later by the public health department, have found and will find more COVID-19 deaths among these groups particularly in deaths at nursing homes which have many residents with dementia and stroke.
    CONFLICT OF INTEREST: None Reported
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    Possible Understatement of Excess Deaths
    Daniel Frank, MD | MedNorthwest
    This valuable paper shows a spike in mortality, both from obvious COVID-19 as well as from other causes that may have been primarily or secondarily related to SARS-CoV-2 infection. A breakdown by age might add additional information. If expected mortality among younger individuals is lower during this time, owing to fewer motor vehicle deaths for example, then we might be understating the true excess mortality in older populations at higher risk for death from COVID-19.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    July 1, 2020

    Excess Deaths From COVID-19 and Other Causes, March-April 2020

    Author Affiliations
    • 1Center on Society and Health, Virginia Commonwealth University School of Medicine, Richmond
    • 2Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond
    • 3Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
    JAMA. 2020;324(5):510-513. doi:10.1001/jama.2020.11787

    The number of publicly reported deaths from coronavirus disease 2019 (COVID-19) may underestimate the pandemic’s death toll. Such estimates rely on provisional data that are often incomplete and may omit undocumented deaths from COVID-19. Moreover, restrictions imposed by the pandemic (eg, stay-at-home orders) could claim lives indirectly through delayed care for acute emergencies, exacerbations of chronic diseases, and psychological distress (eg, drug overdoses). This study estimated excess deaths in the early weeks of the pandemic and the relative contribution of COVID-19 and other causes.

    Methods

    Weekly death data for the 50 US states and the District of Columbia were obtained from the National Center for Health Statistics for January through April 2020 and the preceding 6 years (2014-2019).1,2 US totals excluded Connecticut and North Carolina because of missing data. The analysis included total deaths and deaths from COVID-19, influenza/pneumonia, heart disease, diabetes, and 10 other grouped causes (Supplement). Mortality rates for causes other than COVID-19 were available only for underlying causes. Death data with any mention of COVID-19 on the death certificate (as an underlying or contributing cause) were used to capture all deaths attributed to the virus. Population counts for calculating mortality rates were obtained from the US Census Bureau.3,4

    Observed deaths for the 8 weeks between March 1, 2020, and April 25, 2020, were taken from provisional data released on June 10, 2020.2 Expected deaths (and 95% CIs) for these same weeks were estimated by fitting a hierarchical Poisson regression model to the weekly death counts for the period of December 29, 2013, through February 29, 2020 (assembled from final data for 2014-20181 and provisional data for January 1, 2019, through February 29, 20202). The model with the optimal fit (Supplement) used a combination of harmonic functions to capture seasonality and adjusted for annual trends with a categorical year effect. The model allowed season and time trends to vary by state.

    Excess deaths equaled the difference between observed and expected deaths and were summed across the 8 weeks to estimate total excess deaths. To explore increases in cause-specific mortality in jurisdictions overwhelmed by COVID-19, mortality trends for 14 grouped causes (4 reported here) were examined in the 5 states with the most COVID-19 deaths from March through April 2020 (Massachusetts, Michigan, New Jersey, New York, and Pennsylvania). Deaths in these states peaked in the week ending on April 11, 2020, and the proportional increase above baseline (weighted mean of weekly deaths over 9 weeks in January to February 2020) was measured. All calculations were performed using SAS, version 9.4 (SAS Institute Inc).

    Results

    Between March 1, 2020, and April 25, 2020, a total of 505 059 deaths were reported in the US; 87 001 (95% CI, 86 578-87 423) were excess deaths, of which 56 246 (65%) were attributed to COVID-19. In 14 states, more than 50% of excess deaths were attributed to underlying causes other than COVID-19; these included California (55% of excess deaths) and Texas (64% of excess deaths) (Table). The 5 states with the most COVID-19 deaths experienced large proportional increases in deaths due to nonrespiratory underlying causes, including diabetes (96%), heart diseases (89%), Alzheimer disease (64%), and cerebrovascular diseases (35%) (Figure). New York City experienced the largest increases in nonrespiratory deaths, notably those due to heart disease (398%) and diabetes (356%).

    Discussion

    These estimates suggest that the number of COVID-19 deaths reported in the first weeks of the pandemic captured only two-thirds of excess deaths in the US. Potential explanations include delayed reporting of COVID-19 deaths and misattribution of COVID-19 deaths to other respiratory illnesses (eg, pneumonia) or to nonrespiratory causes reflecting complications of COVID-19 (eg, coagulopathy, myocarditis). Few excess deaths involved pneumonia or influenza as underlying causes.

    This study has limitations, including the reliance on provisional data, potentially inaccurate death certificates, and modeling assumptions. For example, modeling epidemiologic years instead of calendar years would reduce the excess deaths estimate to 73 524.

    Large increases in mortality from heart disease, diabetes, and other diseases were observed. Further investigation is required to determine the extent to which these trends represent nonrespiratory manifestations of COVID-19 or secondary pandemic mortality caused by disruptions in society that diminished or delayed access to health care and the social determinants of health (eg, jobs, income, food security).

    Section Editor: Jody W. Zylke, MD, Deputy Editor.
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    Article Information

    Corresponding Author: Steven H. Woolf, MD, MPH, Center on Society and Health, Virginia Commonwealth University School of Medicine, 830 E Main St, Ste 5035, Richmond, VA 23298-0212 (steven.woolf@vcuhealth.org).

    Accepted for Publication: June 16, 2020.

    Published Online: July 1, 2020. doi:10.1001/jama.2020.11787

    Author Contributions: Drs Woolf and Chapman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Woolf, Chapman, Sabo, Weinberger.

    Acquisition, analysis, or interpretation of data: Chapman, Sabo, Hill.

    Drafting of the manuscript: Woolf, Chapman, Sabo, Weinberger.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Chapman, Sabo, Weinberger, Hill.

    Administrative, technical, or material support: Woolf, Chapman.

    Supervision: Woolf.

    Conflict of Interest Disclosures: Dr Weinberger reported receiving grants from Pfizer and the National Institute of Allergy and Infectious Diseases (R01AI137093) and personal fees from Pfizer, Merck, GlaxoSmithKline, and Affinivax outside the submitted work. No other disclosures were reported.

    Funding/Support: This study was partially funded by the National Center for Advancing Translational Sciences (grant UL1TR002649).

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Weekly counts of deaths by state and select causes, 2014-2018. National Center for Health Statistics website. Updated June 5, 2020. Accessed June 10, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/3yf8-kanr
    2.
    Weekly counts of deaths by state and select causes, 2019-2020. National Center for Health Statistics website. Updated June 10, 2020. Accessed June 10, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/muzy-jte6
    3.
    2018 American Community Survey 1-year estimates: table B01003. US Census Bureau website. Accessed May 15, 2020. https://data.census.gov/cedsci/table?hidePreview=false&tid=ACSDT1Y2018.B01003&t=Total%20population&vintage=2018
    4.
    QuickFacts: New York City, New York. US Census Bureau website. Accessed May 15, 2020. https://www.census.gov/quickfacts/newyorkcitynewyork
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