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December 17, 2020

COVID-19 as the Leading Cause of Death in the United States

Author Affiliations
  • 1Center on Society and Health, Virginia Commonwealth University, Richmond
  • 2Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond
JAMA. 2021;325(2):123-124. doi:10.1001/jama.2020.24865

The current exponential increase in coronavirus disease 2019 (COVID-19) is reaching a calamitous scale in the United States, potentially overwhelming the health care system and causing substantial loss of life. The news media dutifully report each day’s increase in new cases and deaths, but putting these numbers in perspective may be difficult. The daily US mortality rate for COVID-19 deaths is equivalent to the September 11, 2001, attacks, which claimed 2988 lives,1 occurring every 1.5 days, or 15 Airbus 320 jetliners,2 each carrying 150 passengers, crashing every day.

A helpful approach to put the effects of the pandemic in context is to compare COVID-19–related mortality rates with the leading causes of death that, under ordinary circumstances, would pose the greatest threat to different age groups.3 The conditions listed in the Table include the 3 leading causes of death in each of the 10 age groups from infancy to old age. Using data from the Centers for Disease Control and Prevention, the Table shows mortality rates for these conditions during the period of March through October 20184 (the most recent year for which detailed cause-of-death data are available) with COVID-19 mortality rates during March through October 2020.5

Table.  Age-Specific Mortality Rates (per Million) for COVID-19 (March-October 2020) and Other Leading Causes of Death (March-October 2018)a
Age-Specific Mortality Rates (per Million) for COVID-19 (March-October 2020) and Other Leading Causes of Death (March-October 2018)a

The Table shows that by October 2020 COVID-19 had become the third leading cause of death for persons aged 45 through 84 years and the second leading cause of death for those aged 85 years or older. Adults 45 years or older were more likely to die from COVID-19 during those months than from chronic lower respiratory disease, transport accidents (eg, motor vehicle fatalities), drug overdoses, suicide, or homicide. In contrast, for individuals younger than age 45 years, other causes of death, such as drug overdoses, suicide, transport accidents, cancer, and homicide exceeded those from COVID-19.

Especially for older adults, the threat from COVID-19 may be even greater, for 3 reasons. First, the Table presents the aggregate 8-month mortality rate for COVID-19, not the current mortality rate, which has been increasing rapidly. Between November 1, 2020, and December 13, 2020, the 7-day moving average for daily COVID-19 deaths tripled, from 826 to 2430 deaths per day, and if this trend is unabated will soon surpass the daily rate observed at the height of the spring surge (2856 deaths per day on April 21, 2020).6 As occurred in the spring, COVID-19 has become the leading cause of death in the United States (daily mortality rates for heart disease and cancer, which for decades have been the 2 leading causes of death, are approximately 1700 and 1600 deaths per day, respectively4). With COVID-19 mortality rates now exceeding these thresholds, this infectious disease has become deadlier than heart disease and cancer, and its lethality may increase further as transmission increases with holiday travel and gatherings and with the intensified indoor exposure that winter brings.

Second, the reported number of COVID-19 deaths underestimates the excess deaths produced by the pandemic. Due to reporting delays and miscoding of COVID-19 deaths and an increase in non–COVID-19 deaths caused by disruptions produced by the pandemic, excess deaths are estimated to be 50% higher than publicly reported COVID-19 death counts.7 Third, COVID-19 is unlike other causes of death in the Table because it is communicable; individuals who die from homicide or cancer do not transmit the risk of morbidity or mortality to those nearby. Every COVID-19 death signals the possibility of more deaths among close contacts.

The failure of the public and its leaders to take adequate steps to prevent viral transmission has made the nation more vulnerable, allowing COVID-19 to become the leading cause of death in the United States, particularly among those aged 35 years or older. Much of this escalation was preventable, as is true for many deaths to come. The prospect of a vaccine offers hope for 2021, but that solution will not come soon enough to avoid catastrophic increases in COVID-19–related hospitalizations and deaths. The need for the entire population to take the disease seriously—notably to wear masks and maintain social distance—could not be more urgent.

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Article Information

Published Online: December 17, 2020. doi:10.1001/jama.2020.24865

Correction: This article was corrected online December 28, 2020, to change the percentage of excess deaths to 50% and on March 28, 2022, to correct the diagnostic code for malignant neoplasms in the Table footnote.

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 (steven.woolf@vcuhealth.org).

Conflict of Interest Disclosures: None reported.

Funding/Support: Drs Woolf and Chapman received partial funding from grant UL1TR002649 from the National Center for Advancing Translational Sciences.

Role of the Funder/Sponsor: The National Center for Advancing Translational Sciences had no role in preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Anderson  RN, Miniño  AM, Fingerhut  LA, Warner  M, Heinen  MA.  Deaths: injuries, 2001.   Natl Vital Stat Rep. 2004;52(21):1-86.Google Scholar
Airbus 320 seat map. United Airlines. Accessed November 27, 2020. https://www.united.com/ual/en/us/fly/travel/inflight/aircraft/airbus-320.html
10 leading causes of death by age group, United States—2016. Centers for Disease Control and Prevention. Accessed December 8, 2020. https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2016-508.pdf
About underlying cause of death, 1999-2018. CDC WONDER online database. Accessed November 20, 2020. https://wonder.cdc.gov/ucd-icd10.html
Provisional COVID-19 death counts by sex, age, and week. Centers for Disease Control and Prevention. Updated December 9, 2020. Accessed December 9, 2020. https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-W/vsak-wrfu
CDC COVID data tracker: trends in number of COVID-19 cases and deaths in the US reported to CDC, by state/territory. Centers for Disease Control and Prevention. Accessed December 13, 2020. https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases
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.2020.19545 PubMedGoogle ScholarCrossref
9 Comments for this article
Regional Infections
John Kugler, PhD Leadership for K-12 | Chicago Teachers Union
Appreciate the effort to collect and disseminate data in real time. My comment is more of a containment concern. Are we looking into regional infection variables over time, so we can understand and possibly try to find the reasons the virus is spreading across the nation, thereby mitigating risk to non-infected individuals?
Misleading Title
Geraldo Cury, PhD | Full Professor of Federal University of Minas Gerais, Brazil
The article title is misleading because the data presented show that the leading cause of death in the USA is heart disease. According to the data presented, COVID -19 is the third leading cause of death in the period analyzed.
Getting the Scale Right
Bill Kinsey, PhD | Leiden University
The daily mortality rates are interesting, but the comparison with 9/11 mortality or the equivalent number of Airbus crashes may fail to give the needed perspective. So how about this? The number of Covid deaths in the US in some 10-11 months of 2020 already exceeds the total number of US military deaths in the nearly four years of the Second World War. Very shortly, Covid deaths will exceed all US military deaths in all the combined wars -- WWII, Korea, Vietnam and the Middle East -- since 1940.
Simple, Scientific & Disciplined Action Needed
Dr Narayan Bahadur Basnet, MBBS, MPA, PG Ped., Ph.D. | Children’s Medical Diagnosis Center (CMDC), Chabahil, Kathmandu
Thank you for publishing the alarming situation of COVID-19 especially in a scientifically advanced nation such as the US. I am very sad to read these data, and suggest immediately that people try to follow endless best efforts that we already know control this virus particle. Universal use of masking, physical distancing, and handwashing are already known to be effective measures of controlling this menace (1). Always mind everybody’s face hygiene since face, specially nose and mouth, are the home of this virus!  Regarding this pandemic we must follow simple, scientific, universal voice and action at all strata of society. A disciplined lifestyle may be very useful until we find the combination of intervention to control spread of the virus!

1. Basnet NB. http://www.inquestpublications.com/pdf/ajfmph-v1-1001.pdf
Compare to 1918 flu?
Timothy Bukowski |
How does this compare to 1918 flu ?
Title of the article misrepresents the data
Erik Peper, PhD | San Francisco State University
The title misrepresents the data. COVID-19 according to the data in the table is the third leading cause of death not the first. In addition, it misrepresents the data since the table does not include the death rate of 2020 upper respiratory infections. If those went down then they are partly embedded in the COVID-19 death rate.
Unrelated Comparison
Zhong Zhao, MD, PhD | Southwest Health Care
JAMA as a major medical journal has played a very important role in scientific research. However, I was quite concerned after reading the article about Covid-19 as the leading cause of death in the US. I don't disagree with data and facts. However comparing these data with death numbers from unrelated events carries very strong political implications. Maybe the author intends to compare the current Covid-19 situation to the tragic events that hurt Americans the most so that people will be more serious about it. I am afraid such comparison could add unintended consequence. 

I don't think the
author had thought about this potential side effect before publishing the article.
Jason Gagliano, PhD | Technical School
Thanks for the paper. It makes several good points to consider.

I would like to see a few clarifications:

1) As others have stated, how does the data support the title? Maybe the authors meant to write "...as A Leading Cause" rather than "...the Leading Cause"?

2) How were the totals calculated in the table?

Perhaps the CDC's data on tobacco can also be included. According to the CDC, ~500,000 people die annually from tobacco use. This along with cancer and heart disease (in the table) are clearly higher than current COVID-related deaths. Of
course, one would need to subtract out the number of deaths for tobacco-related cancer and heart disease (e.g. ~160,000 each) and recalculate the numbers. Interestingly, tobacco use relates to your good point on 'the transmission of morbidity and mortality', since second-hand smoke can also be deadly.

Best Wishes
In Whom is Covid-19 a Leading Cause of Death?
Carol Cancelliere, MPH, PhD | Ontario Tech University
Covid-19 is the 3rd leading cause of death at the time of this article. Are other stratifications possible other than age, e.g., sex, race, co-morbidity status, geographic region, education level? In other words, if Covid-19 is a leading cause of death, in whom is it a leading cause of death?