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Figure.  Excess Deaths From March to July 2020 in Selected States
Excess Deaths From March to July 2020 in Selected States

The figure plots weekly excess deaths for the 10 states with the largest number of excess deaths during March-July 2020. Reopening dates refer to the lifting of broad coronavirus disease 2019 restrictions, as reported by the New York Times.6

Table.  Excess Deaths From March 1, 2020, to August 1, 2020, US and Selected States
Excess Deaths From March 1, 2020, to August 1, 2020, US and Selected States
Video. What States Have Had the Highest Rate of Excess Deaths During the COVID-19 Pandemic?

The animation shows the number of excess deaths (per 100 000 people) that occurred in the US between March and July 2020. Excess deaths are deaths that surpass what is expected based on historical norms. The states with the highest rates of excess deaths have changed from week to week but were generally concentrated in the northeast in the spring and across the sunbelt in the summer. Calculations are based on death counts obtained on September 9, 2020.

1.
Woolf  SH, Chapman  DA, Sabo  RT, Weinberger  DM, Hill  L.  Excess deaths from COVID-19 and other causes, March-April 2020.   JAMA. 2020;324(5):510-513. doi:10.1001/jama.2020.11787PubMedGoogle ScholarCrossref
2.
Weinberger  DM, Chen  J, Cohen  T,  et al.  Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020.   JAMA Intern Med. Published online July 1, 2020. doi:10.1001/jamainternmed.2020.3391PubMedGoogle Scholar
3.
Centers for Disease Control and Prevention. Weekly counts of deaths by state and select causes, 2014-2018. Accessed June 10, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/3yf8-kanr
4.
Centers for Disease Control and Prevention. Weekly counts of deaths by state and select causes, 2019-2020. Accessed September 9, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/muzy-jte6
5.
US Census Bureau. American Community Survey: table B01003. Accessed May 15, 2020. https://data.census.gov/cedsci/table?q=b01003&g=0100000US.04000.001&tid=ACSDT1Y2018.B01003
6.
Lee JC, Mervosh S, Harvey B, Matthews AL. See how all 50 states are reopening (and closing again). New York Times. Accessed September 11, 2020. https://www.nytimes.com/interactive/2020/us/states-reopen-map-coronavirus.html
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    2 Comments for this article
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    Correlation and Causation
    Ben Park, MD | Physician Medical Group
    As scientists we are taught that correlations are important but we need to be careful about assigning causation to correlated metrics. There have been several articles recently looking at "excess deaths" during the COVID pandemic. These articles argue that we are undercounting COVID deaths.

    As scientists we are obligated to look at other possibilities. One that deserves an analysis is the impact of unemployment, substance abuse and social isolation. We have ample actuarial data showing a correlation between unemployment and increased mortality. We also know that substance abuse, predominantly alcohol and opiates, is associated with excess mortality. Isolation and
    the associated loneliness is also associated with excess mortality.

    We went from the best economy of the last 50 year to significant levels of unemployment and business failures with high levels of social isolation and skyrocketing substance abuse levels. These factors are responsible for large numbers of excess deaths, something recently recognized by WHO.

    A recent study found that "unemployment does increase the risk of premature mortality by 63 percent" per Eran Shor, a member of the study's research team and a sociology professor at McGill University (1).

    If we did the opposite study and started with expected deaths from unemployment, substance abuse and social isolation and subtracted that from total deaths how many deaths would we have? Could it be that we have categorized some deaths as COVID that were not, instead of undercounting COVID deaths?

    I do not know the answer, but the question is worth asking if we are truly scientists.

    Reference

    1. Social Science & MedicineVolume 72, Issue 6, March 2011, Pages 840-854

    CONFLICT OF INTEREST: None Reported
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    Numbers
    Ben McCay, D.C. |
    The "excess death" calculation hinges solely on the expected number of deaths, which was stated to be 1,111,031. This number is arguably in error. The death rate trend has been increasing consistently since 2008 with a sharper incline since 2013. In 2019, the death rate was 8.782 per 1000. Based on the uptrend since 2013, the death rate in 2020 was expected to be 8.88 per 1000 (1). In 2020, there is estimated to be 331 million people in the United States (2). At a rate of 8.88 per 1000, the expected death rate would be 2,939,280 in 2020 (or 244,940 per month). Thus, in a five-month period, we would expect 1,224,700 deaths. 

    Further, the article did indicate that the 1,111,031 figure was a "seasonally adjusted" figure. But if we look at the data from the CDC, the seasonal death numbers from March-July of 2019 were approximately equivalent to the overall monthly average for the entire year (Jan-Dec monthly average of 238,000 versus Mar-Jul monthly average of 236,200 is a difference of less than 1% and not statistically significant) (3). 

    In conclusion, using the figure 1,224,700 expected deaths (and assuming the observed death count was accurate at 1,336,561), then the excess deaths from March-July would more accurately be 111,861 (much lower than the published figure of 225,530). 

    References

    1) https://www.macrotrends.net/countries/USA/united-states/death-rate
    2) https://www.worldometers.info/world-population/us-population  
    3) https://www.cdc.gov/nchs/nvss/vsrr/provisional-tables.htm
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    October 12, 2020

    Excess Deaths From COVID-19 and Other Causes, March-July 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(15):1562-1564. doi:10.1001/jama.2020.19545

    Previous studies of excess deaths (the gap between observed and expected deaths) during the coronavirus disease 2019 (COVID-19) pandemic found that publicly reported COVID-19 deaths underestimated the full death toll, which includes documented and undocumented deaths from the virus and non–COVID-19 deaths caused by disruptions from the pandemic.1,2 A previous analysis found that COVID-19 was cited in only 65% of excess deaths in the first weeks of the pandemic (March-April 2020); deaths from non–COVID-19 causes (eg, Alzheimer disease, diabetes, heart disease) increased sharply in 5 states with the most COVID-19 deaths.1 This study updates through August 1, 2020, the estimate of excess deaths and explores temporal relationships with state reopenings (lifting of coronavirus restrictions).

    Methods

    Death data for 2014-2020 and population counts for the 50 states and the District of Columbia were obtained from the National Center for Health Statistics3,4 and US Census Bureau,5 respectively. Death counts from March 1, 2020, through August 1, 2020, were taken from provisional, unweighted data released on September 9, 2020.3 Connecticut and North Carolina were excluded due to missing data. A hierarchical Poisson regression model, described elsewhere,1 was used to predict expected deaths based on historic norms. COVID-19 deaths included those in which COVID-19 was cited as an underlying or contributing cause. Data for deaths not attributed to COVID-19 were only available for underlying causes of death, including Alzheimer disease, heart disease, and 10 other grouped causes, defined elsewhere.1 Reopening dates were obtained from the New York Times.6

    To confirm the validity of observed increases in non–COVID-19 deaths, the Joinpoint regression program (version 4.8.0.1; Statistical Research and Applications Branch, National Cancer Institute) was used to specify the weeks (joinpoints) when slopes changed (as measured by the annual percentage change [APC]) and their statistical significance (2-sided test, .05 threshold). To estimate dispersion in the epidemic curve for each state, the number of consecutive weeks during which 90% of excess deaths occurred (ED90) was calculated. All calculations were performed in SAS (version 9.4; SAS Institute) and R (version 3.6.1; The R Foundation).

    Results

    Between March 1 and August 1, 2020, 1 336 561 deaths occurred in the US, a 20% increase over expected deaths (1 111 031 [95% CI, 1 110 364 to 1 111 697]). The 10 states with the highest per capita rate of excess deaths were New York, New Jersey, Massachusetts, Louisiana, Arizona, Mississippi, Maryland, Delaware, Rhode Island, and Michigan. The states with the highest per capita rate of excess deaths changed from week to week (Video). The increase in absolute deaths in these states relative to expected values ranged from 22% in Rhode Island and Michigan to 65% in New York (Table). Three states with the highest death rates (New Jersey, New York, and Massachusetts) accounted for 30% of US excess deaths but had the shortest epidemics (ED90 < 10 weeks). States that experienced acute surges in April (and reopened later) had shorter epidemics that returned to baseline in May, whereas states that reopened earlier experienced more protracted increases in excess deaths that extended into the summer (Figure).

    Of the 225 530 excess deaths, 150 541 (67%) were attributed to COVID-19. Joinpoint analyses revealed an increase in deaths attributed to causes other than COVID-19, with 2 reaching statistical significance. US mortality rates for heart disease increased between weeks ending March 21 and April 11 (APC, 5.1 [95% CI, 0.2-10.2]), driven by the spring surge in COVID-19 cases. Mortality rates for Alzheimer disease/dementia increased twice, between weeks ending March 21 and April 11 (APC, 7.3 [95% CI, 2.9-11.8]) and between weeks ending June 6 and July 25 (APC, 1.5 [95% CI, 0.8-2.3]), the latter coinciding with the summer surge in sunbelt states.

    Discussion

    Although total US death counts are remarkably consistent from year to year, US deaths increased by 20% during March-July 2020. COVID-19 was a documented cause of only 67% of these excess deaths. Some states had greater difficulty than others in containing community spread, causing protracted elevations in excess deaths that extended into the summer. US deaths attributed to some noninfectious causes increased during COVID-19 surges. Excess deaths attributed to causes other than COVID-19 could reflect deaths from unrecognized or undocumented infection with severe acute respiratory syndrome coronavirus 2 or deaths among uninfected patients resulting from disruptions produced by the pandemic. Study limitations include the reliance on provisional data, inaccuracies in death certificates, and assumptions applied to the model.

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

    Accepted for Publication: September 15, 2020.

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

    Published Online: October 12, 2020. doi:10.1001/jama.2020.19545

    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: All authors.

    Drafting of the manuscript: Woolf, Sabo.

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

    Statistical analysis: All authors.

    Administrative, technical, or material support: Chapman.

    Supervision: Woolf, Chapman.

    Conflict of Interest Disclosures: Dr Weinberger reported receiving personal fees from Pfizer, Merck, Affinivax, and GlaxoSmithKline outside the submitted work and being the principal investigator for a research grant from Pfizer to Yale University. No other disclosures were reported.

    Funding/Support: Drs Woolf and Chapman and Ms Hill received partial funding from grant UL1TR002649 from the National Center for Advancing Translational Sciences. Drs Woolf and Chapman also received partial funding from grant R01AG055481 from the National Institute on Aging. Dr Weinberger was funded by grant R01AI137093 from the National Institute of Allergy and Infectious Diseases.

    Role of the Funder/Sponsor: The funders 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.

    Additional Contributions: We thank Cassandra Ellison, MFA, art director for the Virginia Commonwealth University Center on Society and Health, for her assistance with graphic design; she was not compensated beyond her salary.

    References
    1.
    Woolf  SH, Chapman  DA, Sabo  RT, Weinberger  DM, Hill  L.  Excess deaths from COVID-19 and other causes, March-April 2020.   JAMA. 2020;324(5):510-513. doi:10.1001/jama.2020.11787PubMedGoogle ScholarCrossref
    2.
    Weinberger  DM, Chen  J, Cohen  T,  et al.  Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020.   JAMA Intern Med. Published online July 1, 2020. doi:10.1001/jamainternmed.2020.3391PubMedGoogle Scholar
    3.
    Centers for Disease Control and Prevention. Weekly counts of deaths by state and select causes, 2014-2018. Accessed June 10, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/3yf8-kanr
    4.
    Centers for Disease Control and Prevention. Weekly counts of deaths by state and select causes, 2019-2020. Accessed September 9, 2020. https://data.cdc.gov/NCHS/Weekly-Counts-of-Deaths-by-State-and-Select-Causes/muzy-jte6
    5.
    US Census Bureau. American Community Survey: table B01003. Accessed May 15, 2020. https://data.census.gov/cedsci/table?q=b01003&g=0100000US.04000.001&tid=ACSDT1Y2018.B01003
    6.
    Lee JC, Mervosh S, Harvey B, Matthews AL. See how all 50 states are reopening (and closing again). New York Times. Accessed September 11, 2020. https://www.nytimes.com/interactive/2020/us/states-reopen-map-coronavirus.html
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