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March 31, 2021

The Leading Causes of Death in the US for 2020

Author Affiliations
  • 1National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
  • 2National Center for Health Statistics, Mortality Statistics Branch, Division of Vital Statistics, Hyattsville, Maryland
JAMA. 2021;325(18):1829-1830. doi:10.1001/jama.2021.5469

Vital statistics data provide the most complete assessment of annual mortality burden and contribute key measurements of the direct and indirect mortality burden during a public health pandemic. While mortality statistics have historically been produced annually, the COVID-19 pandemic introduced a pressing need for the National Center for Health Statistics (NCHS) National Vital Statistics System (NVSS) to rapidly release reliable provisional mortality data. Provisional estimates indicate a 17.7% increase in the number of deaths in 2020 (the increase in the age-adjusted rate was 15.9%) compared with 2019, with increases in many leading causes of death.1 The provisional leading cause-of-death rankings for 2020 indicate that COVID-19 was the third leading cause of death in the US behind heart disease and cancer.1

Mortality Data From the NVSS

The NVSS collects, processes, tabulates, and disseminates vital statistics based on death certificates filed in the 50 states and the District of Columbia. Causes of death on death certificates are coded according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.2,3 Cause-of-death data are based on the underlying cause of death, which is the disease or condition responsible for initiating the chain of events leading to death. Mortality statistics presented here are provisional, based on currently available death certificate data from the states to the NCHS as of March 21, 2021. Final mortality data will be available approximately 11 months after the end of the data year.

Shifting Trends in Mortality

The provisional number of deaths occurring in the US among US residents in 2020 was 3 358 814, an increase of 503 976 (17.7%) from 2 854 838 in 2019 (Table). Historic trends in mortality show seasonality in the number of deaths throughout the year, with the number of deaths higher in the winter and lower in the summer. The eFigure in the Supplement shows that death counts by week from 2015 to 2019 followed a normal seasonal pattern, with higher average death counts in weeks 1 through 10 (n = 58 366) and weeks 35 through 52 (n = 52 892) than in weeks 25 through 34 (n = 50 227). In contrast, increased deaths in 2020 occurred in 3 distinct waves that peaked during weeks 15 (n = 78 917), 30 (n = 64 057), and 52 (n = 80 656), with only the latter wave aligning with historic seasonal patterns.

Table.  Number of Deaths for Leading Causes of Death, US, 2015-2020a
Number of Deaths for Leading Causes of Death, US, 2015-2020a

Trends in Leading Causes of Death

The Table also presents leading causes of death in the US for the years 2015 to 2020.4 According to provisional data, in 2020, there were notable changes in the number and ranking of deaths compared with 2019.5 COVID-19 was the third leading cause of death in 2020, with an estimated 345 323 deaths, and was largely responsible for the substantial increase in total deaths from 2019 to 2020. Substantial increases from 2019 to 2020 also occurred for several other leading causes. Heart disease deaths increased by 4.8%, the largest increase in heart disease deaths since 2012. Increases in deaths also occurred for unintentional injury (11.1%), Alzheimer disease (9.8%), and diabetes (15.4%). Influenza and pneumonia deaths in 2020 increased by 7.5%, although the number of deaths was lower in 2020 than in 2017 and 2018. From 2019 to 2020, deaths due to chronic lower respiratory disease declined by 3.4% and suicide deaths declined by 5.6%.

Understanding Mortality in the Context of a Pandemic

Trends in mortality for leading causes of death are important indicators of shifting patterns in mortality. During the COVID-19 pandemic, changes in leading causes provide insight into the direct and indirect effects of the pandemic on mortality burden. Most of the increase in deaths from 2019 to 2020 was directly attributed to COVID-19. However, increases were also noted for several other leading causes of death. These increases may indicate, to some extent, underreporting of COVID-19, ie, limited testing in the beginning of the pandemic may have resulted in underestimation of COVID-19 mortality.6 Increases in other leading causes, especially heart disease, Alzheimer disease, and diabetes, may also reflect disruptions in health care that hampered early detection and disease management. Increases in unintentional injury deaths in 2020 were largely driven by drug overdose deaths. Final mortality data will help determine the effect of the pandemic on concurrent trends in drug overdose deaths.

Provisional, national mortality data show that the COVID-19 pandemic substantially affected mortality in 2020. Early estimates of life expectancy at birth, based on provisional data for January to June 2020, show historic declines not seen since World War II (1942-1943).7 The effects of the pandemic are likely to continue through 2021 as well because COVID-19 has already caused more than 100 000 deaths this year. However, the effects of COVID-19 on mortality trends may be mitigated in 2021 given better detection and treatment options as well as increasing natural and vaccine-related immunity.

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Article Information

Corresponding Author: Farida Ahmad, MPH, Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Rd, Hyattsville, MD 20782 (FBAhmad@cdc.gov).

Published Online: March 31, 2021. doi:10.1001/jama.2021.5469

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Additional Contributions: We are grateful for the efforts of vital statistics jurisdictions in their continued collaboration with the National Center for Health Statistics and provision of data during the COVID-19 pandemic. We thank the staff of the Division of Vital Statistics for coding and reviewing data, providing continuous database maintenance, and producing timely analysis.

References
1.
Ahmad  FB, Cisewski  JA, Miniño  A, Anderson  RN. Provisional Mortality Data—United States, 2020. MMWR Morb Mortal Wkly Rep. Published March 31, 2021. https://www.cdc.gov/mmwr/volumes/70/wr/mm7014e1.htm?s_cid=mm7014e1_w
2.
World Health Organization.  International Statistical Classification of Diseases, Tenth Revision (ICD-10). World Health Organization; 1992.
3.
National Center for Health Statistics, Centers for Disease Control and Prevention. National Vital Statistics System: instructions for classification of underlying and multiple causes of death—2021. Accessed March 26, 2021. https://www.cdc.gov/nchs/nvss/manuals/2a-2021.htm
4.
Heron  M.  Deaths: leading causes for 2017.   Natl Vital Stat Rep. 2019;68(6):1-77.PubMedGoogle Scholar
5.
Kochanek  KD, Xu  JQ, Arias  E. Mortality in the United States, 2019: NCHS data brief, no. 395. National Center for Health Statistics. Accessed March 22, 2021. https://www.cdc.gov/nchs/products/databriefs/db395.htm
6.
Gerberding  JL.  Measuring pandemic impact: vital signs from vital statistics.   Ann Intern Med. 2020;173(12):1022-1023. doi:10.7326/M20-6348 PubMedGoogle ScholarCrossref
7.
Arias  E, Tejada-Vera  B, Ahmad  F.  Vital Statistics Rapid Release: Provisional Life Expectancy Estimates for January Through June, 2020: Report No. 10. National Center for Health Statistics; 2021.
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    5 Comments for this article
    EXPAND ALL
    "Two Statisticians' View" of Leading Causes of Death
    Elisabet Englund, Professor | Lund University Hospital, Lund, Sweden
    Albeit of great interest, it is important to know that the given numbers come from death certificates.

    All of us who work with / read the reports from autopsy pathologists know that the reality is different when actually examining the deceased.

    A clinically unknown tumor is found in a large proportion of our cases, and so are unknown, potentially treatable infections. Clinically known/registered covid-19 patients die from various immediate causes. On top of that, a number of unknown covid-19 cases succumb - and this is shown only at autopsy with subsequent microscopical investigation.

    Perhaps paving way for
    an exchange of knowledge,

    Elisabet Englund, MD
    Lund, Sweden
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Death Certificates May Not Tell All - Suicide
    Gary Ordog, MD, DABEM, DABMT | County of Los Angeles, Department of Health Services, (retired)
    Thank you for your interesting article. Death certificates may not tell the entire story. I was surprised by the suicide rate reported to have a major decrease in 2020. It seems from most other reports that the suicide rate has increased since the pandemic began. This may be explained by the fact that the category of "Unintentional Injury" had a major increase at the same time, and the fact that this category includes drug overdoses. As there is often inadequate history in a fatal drug overdose case, many of these may be purposeful and so suicidal. This would explain the perceived increase in suicide rate since the current pandemic began. Perhaps further analysis of the data would elucidate this incongruity. Thank you again for your presentation. Gary Joseph Ordog, MD.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    The Biggest Pandemic
    Dean Ornish, M.D. | Founder & President, Preventive Medicine Research Institute; Clinical Professor of Medicine, UCSF
    Twice as many people died in 2020 of heart disease (690,8820 as from COVID-19 (345,323). This doesn't even include another 159,150 who died from stroke and another 106,106 from diabetes (mostly type 2), which have the same risk factors as heart disease.

    While Covid-19 is an airborne disease, and cardiovascular disease and type 2 diabetes are predominantly lifestyle and food-borne diseases, it would be wise for the CDC and HHS to put at least as much effort into preventing these chronic conditions as Covid-19.
    CONFLICT OF INTEREST: Book royalties; lecture honoraria; licensing fees from Sharecare.
    Death from Diabetes
    Frank Singer, MD | Straub Clinic & Hospital, Honolulu, HI
    How do you die from diabetes? Either diabetic ketoacidosis or hyperosmolar coma. The statistics for death from diabetes seem exaggerated.
    CONFLICT OF INTEREST: None Reported
    Risks of Death Certification-Based Epidemiology
    Peter Pressman, MD, MS, FACN | Saba University School of Medicine
    Ahmad and Anderson's Viewpoint and the associated comments from distinguished readers revives an important discussion of a substantial body of research over the past 4 decades that has repeatedly established conventional death certification as imprecise and often erroneous, replete with multi-level threats to validity that every clinician can readily acknowledge.

    Diagnostic accuracy in medicine continues to improve but the majority of those who die are not in a framework of intensive current investigation; historical data and agonal clinical examination is often all the information available to the certifier. Errors are therefore likely and raw data may
    not be reliable or representative. It is tempting to speculate about why there is apparent inertia in professional medical, administrative, and research cultures and in our gigantic research establishments about the limited attention to what we already know about the inaccuracies of cause of death reporting.

    Apart from interpreting cause of death data with a more critical eye, it may be both timely and valuable to consider the situation that preserves comfortably familiar but potentially misdirected funding priorities that stem from voids in end of life diagnostic accuracy and documentation.
    CONFLICT OF INTEREST: None Reported
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