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Editorial
December 17, 2020

Deaths From COVID-19

Author Affiliations
  • 1Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2Harvard Kennedy School, Cambridge, Massachusetts
JAMA. 2021;325(2):133-134. doi:10.1001/jama.2020.25381

In any year, keeping track of new health trends can be difficult. But this year, the dynamic nature of coronavirus disease 2019 (COVID-19) has made clarity almost impossible. Declines in mortality, after daily COVID-19–related deaths peaked last spring, initially fueled hope that the worst was over. But following a summer increase in deaths, trends have accelerated even faster. This fall, a million new cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which previously had increased monthly, began appearing weekly; as of December 13, cumulative infections totaled more than 16 million in the United States.1 Meanwhile, the media regularly report a flood of statistics that can be difficult to contextualize.

In this issue of JAMA, the simple, yet powerful, analysis by Woolf et al2 puts these numbers into perspective. Ranking the once unfamiliar threat of COVID-19 against more familiar illnesses, they compare US mortality from COVID-19 (March-October 2020) to leading causes of death 2 years prior to the pandemic (March-October 2018). The analysis,2 combined with their prior research on death and life expectancy trends,2-4 suggest 4 major conclusions.

First, COVID-19 ranks as a leading cause of death; at certain times, it is the leading cause of death. Compared with leading causes of death from the same period in 2018, novel COVID-19 was the third leading cause of death for children and adults (697.5 deaths/million), ranking only behind heart disease (1287.7 deaths/million) and cancer (1219.8 deaths/million).2 No age group has been spared, although COVID-19 was not the leading cause of death for the younger age groups. These figures probably underestimate true excess mortality by at least 20%, due, in part, to the indirect effects of the pandemic on non–COVID-19 deaths2 including the death risk that lethal communicable diseases pose to others.

Woolf et al note that the rapidly rising death rates this fall will exceed spring death rates when COVID-19 was the leading cause of death. Between November 1, 2020, and December 8, 2020, the 7-day average for daily COVID-19 deaths nearly tripled—826 to 2226 deaths per day.2 Daily deaths in the first 13 days of December averaged 2381 per day,1 already well exceeding the 1900 average daily deaths during the initial peak from April 15 to May 15.1 On December 9, 2020, deaths reached a record high of 3411,1 more than 2 per minute and roughly 400 more than the September 11, 2001, attack.2 Such numbers elevate COVID-19 as a cause of death higher than heart disease and cancer, which, for decades, accounted for 1700 and 1600 deaths per day, respectively.2

Cumulative COVID-19 deaths in the United States just surpassed 300 000 on December 14.1 The United States, which constitutes 4% of the globe’s population, ranks first in the world in total pandemic deaths (19% of the global total), with the 12th worst (as of December 14) COVID-19 cumulative mortality rates of all countries.5 The rising deaths have come despite heroic efforts by frontline health care professionals, advances in hospital-based COVID-19 care, and therapeutic agents newly authorized by the US Food and Drug Administration such as monoclonal antibody treatments, remdesivir, and dexamethasone. Notably, mortality statistics fail to capture the full devastation of COVID-19–related morbidity, involving not only physical health but also the emotional, social, and spiritual dimensions of well-being.

The fall surge in COVID-19 mortality reflects previously unseen omnipresent disease. Although the spring surge generated deaths largely in New York, parts of New England, Louisiana, and Georgia, the fall surge is widespread nationally, with hot spots in rural states and on both coasts. Notably, people of color have about twice the death rate as White people; 1 in 875 Black persons and 1 in 925 Indigenous persons have died compared with 1 in 1625 White persons.6 Other at-risk groups include essential workers, prisoners, and prison staff.

Second, risk of COVID-19 death is highest among the oldest and lowest among the youngest populations. Age makes a major difference in mortality risk. Compared with those aged 18 through 29 years, people between the ages of 75 and 84 years and those 85 years or older have 200 times and 630 times greater average death rates, respectively.7 Nursing home and long-term care facility residents and staff are at high risk, representing only 5% of the population but 38% of deaths,8 with people in about 28 000 long-term care facilities accounting for more than 106 000 deaths.8 In 14 states, at least half of deaths have been linked to nursing homes; in 6 states, the percentage is more than 60%; in 3, 70% or more.8

In contrast, for people younger than 35 years, Woolf et al found that deaths from drug overdoses, transport accidents (eg, motor vehicle fatalities), and suicide exceeded deaths from COVID-19.2 Recent 2020 data show record overdose deaths with more than 40 states reporting increased mortality.9 Suicide rates, particularly among youth, continue rising.9

For children and youth, the relative risk of COVID-19 death is lower still. A joint report from the American Academy of Pediatrics and the Children's Hospital Association notes that as of December 3, 154 children, of more than 1.4 million diagnosed with COVID-19, have died.10 Although children can serve as a vector for illness, school transmission rates have not been as high as initially feared in communities with low background rates. All these emerging data have recently prompted the Centers for Disease Control and Prevention (CDC) to recommend that schools should be the last to close and first to reopen during these times.

Third, COVID-19 will further prolong stagnant US life expectancy trends. In earlier research, Woolf et al documented that while US life expectancy increased rapidly in the 1970s, it advanced more slowly starting in the 1980s, peaked in 2014, and then declined annually for the 3 years after that.4 Their current study results2 suggest that COVID-19 will only further deter chances of reversing this trend, especially because excess 2020 US mortality has resulted not only from infection but also from conditions (such as heart disease and Alzheimer disease) that possibly went undetected or untreated during the pandemic, as documented in another prior study by Woolf et al.3

Fourth, many, if not most, COVID-19–related deaths could have been prevented, showing that critical public health strategies must remain a major societal focus for the present and future. A national plan for a pandemic response must include robust federal coordination of testing capacity so that supply can meet ever-growing demand, better contact tracing, more robust supplies of personal protective equipment, and heightened emphasis on social distancing that includes travel precautions for the ongoing holiday season. With only 37 states currently having statewide facial covering mandates, President-elect Biden has announced his intention to ask all US residents to wear a mask for his first 100 days in office.

So far, one vaccine candidate has received FDA Emergency Use Authorization with more likely in the coming days. The CDC Advisory Committee on Immunization Practices has just recommended prioritizing frontline health care workers and residents in nursing homes and long-term care facilities. Because widespread vaccine availability may not be possible for months, the next phase could include prioritizing older individuals with chronic conditions and essential workers. This should be combined with dedicated outreach to regain the trust required to reach communities of color, which have historically had lower vaccination rates. Meanwhile, broad public health precautions cannot be relaxed.

Ultimately, containing the pandemic will require national coordination of federal, state, and local leaders; dedicated resources for overwhelmed health care workers and hospitals; renewed support for underresourced state and local public health officials; and a coronavirus stimulus package that aids struggling schools and businesses, as well as the millions of people on the brink of eviction.

The year 2020 ends with COVID-19 massively surging, as it was in the spring, to be the leading cause of death. The accelerating numbers of deaths fall far short of fully capturing each devastating human story: every death represents untold loss for countless families. Ending this crisis will require not only further advances in treatment but also unprecedented commitment to all aspects of prevention, vaccination, and public health. Only by doing so can future years see this illness revert back to the unfamiliar and unknown condition it once was.

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Article Information

Corresponding Author: Howard K. Koh, MD, MPH, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 401, Boston, MA 02115 (hkoh@hsph.harvard.edu).

Published Online: December 17, 2020. doi:10.1001/jama.2020.25381

Conflict of Interest Disclosures: Dr Koh reported receiving grants 77667 from the Robert Wood Johnson Foundation, UL1TR002541 from the National Institutes of Health National Center for Advancing Translational Science, 5U48 DP006376-02 from the Health Promotion and Disease Prevention Research Centers, 61075 from the Templeton Foundation, and 1085 from the JPB Foundation. Dr VanderWeele reported receiving grants 61075 and 61907 from the John Templeton Foundation and personal fees from Aetna Inc, and Flerish Inc. Mr Geller reported receiving compensation as a contributor to UptoDate. No other disclosures were reported.

Disclaimer: The opinions expressed herein represent the authors’ personal views and do not reflect the beliefs of Harvard University. Any reference to a business, product, or service does not represent endorsement.

Additional Contributions: We thank Kirk Vanda, MBA, and Chelsea Heberlein, MPH, of the Harvard T.H. Chan School of Public Health for their assistance on this article, neither of whom were compensated for their contributions.

References
1.
Trends in number of COVID-19 cases and deaths in the US reported to CDC, by state/territory. Centers for Disease Control and Prevention. Published December 14, 2020. Accessed December 14, 2020. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases
2.
Woolf  SM, Chapman  DA, Lee  JH.  COVID-19 as the leading cause of death in the United States.   JAMA. Published online December 17, 2020. doi:10.1001/jama.2020.24865Google Scholar
3.
Woolf  SH, Chapman  DA, Sabo  RT, Weinberger  DM, Hill  L, Taylor  DDH.  Excess deaths from COVID-19 and other causes, March-July 2020.   JAMA. 2020;324(15):1562-1564. doi:10.1001/jama.2020.19545PubMedGoogle ScholarCrossref
4.
Woolf  SH, Schoomaker  H.  Life expectancy and mortality rates in the United States, 1959-2017.   JAMA. 2019;322(20):1996-2016. doi:10.1001/jama.2019.16932PubMedGoogle ScholarCrossref
5.
COVID-19 virus pandemic. Worldometer. Published December 14, 2020. Accessed December 14, 2020. https://www.worldometers.info/coronavirus/?utm_campaign=homeAdvegas1
6.
COVID-19 deaths analyzed by race and ethnicity. APM Research Lab. Accessed December 2, 2020. https://www.apmresearchlab.org/covid/deaths-by-race
7.
COVID-19 hospitalization and death by age. Centers for Disease Control and Prevention. Published February 11, 2020. Updated August 18, 2020. Accessed December 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html
8.
More than 100,000 US coronavirus deaths are linked to nursing homes. New York Times. Published December 4, 2020. Accessed December 14, 2020. https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html
9.
Issue brief: reports of increases in opioid- and other drug-related overdose and other concerns during COVID Pandemic. American Medical Association; 2020. Updated December 9, 2020. Accessed December 3, 2020. https://www.ama-assn.org/system/files/2020-11/issue-brief-increases-in-opioid-related-overdose.pdf
10.
American Academy of Pediatrics, Children’s Hospital Association. Children and COVID-19 state data report. Published December 6, 2020. Accessed December 10, 2020. https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%2012.3.20%20FINAL.pdf
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    5 Comments for this article
    EXPAND ALL
    This May Turn Out to Be a Successful Pandemic from the Public Health Perspective.
    Gary Ordog, MD, DABMT, DABEM | County of Los Angeles, Department of Health Services, (retired)
    This pandemic is developing as predicted based upon projections from the 1918 Pandemic. In March of this year, at an estimated 3% mortality rate, 10 million Americans we projected to die of COVID-19 within two years, without an effective treatment or vaccine. The US death total is over 300,000 currently, and probably will be 500,000 by the time maximum vaccine effectiveness in the US is achieved. The vaccine produced by Operation Warp Speed will probably save the lives of > 9 million Americans alone, let alone those that will be saved in the rest of the world due to these innovations that will be passed on. Those saved in world total could approach 300,000,000 if all goes well. So, thanks to the vaccine, and the Public Health directives, the final death rate may be only one twentieth of what was expected compared to the 1918 pandemic. This will then be considered a tremendous success. Those who succumbed to COVID-19 will be missed, but it could have been a lot worse. This operation has been a tremendous scientific and medical contribution to humanity. Thank you and in the meantime, please stay safe.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Seeking Clarity
    Gerald Griffin, MD, PharmD | University of the Pacific, School of Pharmacy&Health Sciences
    I would separate actual deaths from Covid-19 from those with Covid-19 - those whose actual cause of death may be a non-Covid cause for whom Covid-19 or sepsis or hypoxemia may be a secondary line on the death certificate.
    CONFLICT OF INTEREST: None Reported
    Excess COVID-19 Mortality and Other Causes
    Giuliano Ramadori, Professor of Medicine | University Clinic, Internal Medicine, Göttingen, Germany
    The attempt of Wolf and collegues to determine excess mortality during the COVID-19 pandemic, comparing the mortality causes registered in the USA in the period 2015-2019 with those of March-July 2020 (1,2) and those of the period March-oOctober 2020 with those of the same period of the year 2018 (3) is based on data from death certificates.The death certificates are used by the National Center for Health Statistics. For calculation of mortality rates population counts are obtained from the US Census Bureau (1-3). According to the diagnoses of the death certificates a large part of the registered excess deaths was attributed to COVID-19, which is always underestimated not only in Bergamo (4) but an increase of deaths is also attributed to heart disease and to Alzheimer (1,2).

    As happens every year heart disease is not specified, suggesting that quite often the cause of death is given as a naturally occurring cardiac arrest which could be due to underling metabolic diseases, to the multitude of drugs administered to aged people, or even to simple dehydration.This is even more understandable if we consider that in the western world old people die at home or in Skilled Nursing Facilities.Therefore a general discussion about this statistical „mantra“ is overdue as not only preventive public health strategies „must remain a major societal focus“ as clearly stated by Koh et al (5) but in addition structural changes should be undertaken. Reintroduction of infectious disease wards accompanied by redirecting research funds more toward transmissible diseases, defence mechanisms against them, and new drug development have to become a priority.

    The second surprising finding mentioned by Wolf at al (1,2) is that there has been an increase of death by Alzheimer disease, as Alzheimer disease, from a rare histology-based disease, has now become a synonym for widespread dementia.This is somehow misleading and should be taken into account when filling out the death certificates.

    REFERENCES

    1. Wolf SH et al.JAMA, 2020;324(5) August 4.
    2. Wolf SH et al.JAMA, 2020;324(15) October 20
    3. Wolf SH et al.JAMA,2020; December 17
    4. Camilli A,Internazionale (http://intern.az/1CbZ)2020,16 giugno
    5. Koh HK et al. editorial JAMA,2020; December 17
    CONFLICT OF INTEREST: None Reported
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    Misleading Narrative
    Patricia Schwerdtle, Dr.Sci.Hum. MPH. | Monash University, Australia
    Good article but I am concerned about your analysis by race/ethnicity (reference 6 in the article). Check the original research and methodology. Essentially they have conducted a univariate analysis and overlook the multitude of other factors that influence a person's risk of contracting & dying from COVID19, most importantly, SES. APM essentially picks up wealth inequality, which is well known to be the most important social determinant of health - the social gradient. This is problematic because making it about race misleads the public and policymakers. Other factors not depicted in the APM analysis are occupation, living circumstances, health insurance, geographical location, the prevalence of NCDs & health-seeking behavior. You only have to look at the policies for vaccine rollout to see the real story - elderly people and people with underlying medical conditions are being prioritized as are frontline workers with increased exposure. This type of commentary portrays a simplistic narrative that is fueling divisive political rhetoric. This can lead to false solutions, more deaths, & further frustration.
    CONFLICT OF INTEREST: None Reported
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    Wanted: Interpretable Mortality Analyses
    Peter Morfeld, PhD | Institute and Policlinic for Occupational Medicine, Environmental Medicine and Prevention Research, University Hospital of Cologne, Kerpener Str. 62, 50969 Cologne, Germany
    Koh et al refer to “the simple, yet powerful, analysis by Woolf et al" to put deaths from COVID-19 and excess deaths into context (1, 2). Yet this simple approach suffers from a conceptual mismatch of etiologic deaths and excess deaths: the number of deaths due to COVID-19 can actually be larger than the number of excess deaths (even if there are no biases and no imprecision) (3).

    Interpretable mortality analyses are important to understand potential effects of the COVID train in front of us. As long as that train rolls, we need mortality analyses to monitor and understand its carriages,
    namely, surges of infection and deaths. Yet, to achieve this end, research into mortality and burden of disease must avoid simplistic methodology and interpretation (4).

    Peter Morfeld – Philip Lewis – Thomas C. Erren

    REFERENCES
    1. Koh HK, Geller AC, VanderWeele TJ. Deaths From COVID-19. JAMA. 2021;325(2):133-134. doi:10.1001/jama.2020.25381
    2. Woolf SH, Chapman DA, Sabo RT, Weinberger DM, Hill L. Excess Deaths From COVID-19 and Other Causes, March-April 2020. JAMA. 2020;324 (15):1562-1564. doi:10.1001/jama.2020.19545.
    3. Hammitt JK, Morfeld P, Tuomisto JT, Erren TC. Premature Deaths, Statistical Lives, and Years of Life Lost: Identification, Quantification, and Valuation of Mortality Risks. Risk Analysis. 2020;40(4):674-695. doi: 10.1111/risa.13427
    4. Morfeld P, Erren TC. Mortality and Attributable Fraction in COVID-19 Analysis: Avoiding Research Waste and Negligence. American Journal of Public Health. 2020;110(11):1644-1645. doi: 10.2105/AJPH.2020.305887
    CONFLICT OF INTEREST: None Reported
    READ MORE
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