Estimation of Excess Deaths Associated With the COVID-19 Pandemic in the United States, March to May 2020 | Infectious Diseases | JAMA Internal Medicine | JAMA Network
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    5 Comments for this article
    New insights on excess deaths and COVID-19
    Harry Wetzler, MD, MSPH | Ofstead & Associates
    Weinberger and colleagues estimated that 27,065 of the 122,300 excess deaths between March 1 and May 30, 2020 did not have a COVID-19 cause of death. The Centers for Disease Control and Prevention (CDC) post weekly data on mortality for 13 causes of death from the most prevalent comorbid conditions reported on death certificates where COVID-19 was listed as a cause of death at CDC states “Estimated numbers of deaths due to these other causes of death could represent misclassified COVID-19 deaths, or potentially could be indirectly related to COVID-19 (e.g., deaths from other causes occurring in the context of health care shortages or overburdened health care systems).” We used these data to provide insight on those 27,065 excess deaths with a cause of death other than COVID-19.

    The 2015-2019 data for weeks 10 through 22 were used to estimate the baseline number of deaths from the 13 causes in the absence of COVID-19 during 2020. This baseline number was subtracted from the observed number of deaths for each cause during the period March 1 to May 30, 2020. The table shows the results using data submitted to CDC through June 13, 2020.

    Table 2020 2020
    Underlying Cause of Death Baseline Actual Difference
    Alzheimer disease and dementia 69,013 77,621 8,608
    Cerebrovascular diseases 38,429 39,350 921
    Chronic lower respiratory disease 41,693 40,582 -1,111
    Diabetes 22,536 25,480 2,944
    Heart failure 23,152 21,959 -1,193
    Hypertensive diseases 27,454 29,630 2,176
    Influenza and pneumonia 14,352 17,080 2,728
    Ischemic heart disease 91,568 96,309 4,741
    Malignant neoplasms 148,120 147,895 -225
    Other diseases of the circulatory system 44,521 43,018 -1,503
    Other diseases of the respiratory system 17,428 17,479 51
    Renal failure 12,543 12,901 358
    Sepsis 10,052 10,046 -6

    Totals 560,861 579,350 18,489

    The total difference, 18,489 deaths, accounts for over two-thirds of the 27,065 excess deaths not due to COVID-19. Compromised care processes (e.g., lack of intensive care capacity) combined with incomplete COVID-19 testing could decrease the attribution of COVID-19 as the cause of death. Moreover, the unknown manifestations of COVID-19 including being asymptomatic are additional factors for missed COVID-19 as the cause of death. Based on the excess death data and known issues in the process of care and identification, we submit that most of these deaths were due to COVID-19. For instance, the difference for Alzheimer disease and dementia is likely due in large part to long term care deaths that were actually COVID-19 related. The difference for IHD may be due to deaths where care was not sought due to fear of COVID-19 or from suboptimal care due to COVID-19 overload. Diabetes and hypertensive diseases seem to increase COVID-19 mortality risk; those deaths may have been caused by COVID-19.

    Combining the 95,235 reported COVID-19 deaths with the 18,489 listed above means that almost 93% of the excess deaths were likely due to COVID-19 and strongly suggests that COVID-19 deaths were undercounted. Ongoing assessment of excess deaths and causes of death is needed to help us understand the pandemic’s dynamics.
    Often Overlooked
    Stu Pidas, MSc MPH | Retired!
    I find it quite interesting that when excess deaths and their causes are investigated during an epidemic/pandemic one thing that is consistently overlooked in the calculations is the number of "usual" deaths that occur LESS frequently, due to a combination of government mandated restrictions and self imposed limits to normal routines. When looking at the data from "lightly" hit areas oftentimes the number of usual deaths actually decreases overall, as people generally are much less mobile and active. There is a major reduction in traffic fatalities, workplace and recreational accidents, death from violent trauma, etc. In the hard hit areas, as illnesses and deaths from the virus rise and the local area goes into a major shutdown/lockdown, these regular non-disease (of both the pathogen and all other diseases) related deaths decrease exponentially. I'd be interested if anyone is aware of any observational studies that take these things into consideration. I would suggest that when looked at in full context the number of excess deaths over the norm would be even higher than we suspect.
    Period Limited Approach to Excess Deaths might Mislead Interpretation
    Maurizio Rainisio, Dr Math | AbaNovus srl - Italy
    Using the period of maximum outbreak of COVID-19 might be misleading.
    Analyzing similar data in Italy across the whole winter season (July 1st - June 30) we found that especially among the elderly overall mortality has been lower than usual in January-February 2020 and again slightly after the peak of the outbreak. This might suggest that fragile persons have been 'spared' by a mild flu season only to be 'hit' during the COVID-19 outbreak, similarly, though reverse, after the peak.

    Comparing the 2019-20 excess mortality to the similar data of 2016-17, when an unusually severe flu season happened, we
    could evaluate that in the elderly population (older than 65) in the country as a whole the excess mortality presumably due to COVID-19 was approximately double that linked to the severe flu season. Moreover, the effect of COVID-19 was concentrated on the Northern part of the country, being the Centre-South apparently spared. This unlike the flu that in 2017 hit the whole country in a homogeneous way.

    Younger people data are displayed for completeness with the caveat that, to make the data readable, the scale is greatly enlarged.
    Excess Deaths over Expected Deaths
    Charles Brill, MD, Philadelphia, PA | Thomas Jefferson University, Retired
    According to a graphic in the 10/5/20 New York Times, the excess death curve for the US hit the expected death curve. Will there be a 2nd or 3rd wave?

    Missing an important word
    Judy Malmgren, PhD | University of Washington Epidemiology Department
    Official tallies of deaths due to COVID-19 may underestimate... The true extent of underestimation is not known as the cause of death is not known definitively so a qualifier is warranted no matter how strong the circumstantial evidence. The rest is correctly worded.
    Original Investigation
    July 1, 2020

    Estimation of Excess Deaths Associated With the COVID-19 Pandemic in the United States, March to May 2020

    Author Affiliations
    • 1Department of Epidemiology of Microbial Diseases and the Public Health Modeling Unit, Yale School of Public Health, New Haven, Connecticut
    • 2Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
    • 3Department of Biostatistics and the Public Health Modeling Unit, Yale School of Public Health, New Haven, Connecticut
    • 4Departments of Ecology and Evolutionary Biology, Statistics and Data Science, Yale School of Management, New Haven, Connecticut
    • 5Aledade Inc, Bethesda, Maryland
    • 6Department of Health and Mental Hygiene, New York, New York
    • 7Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst
    • 8Department of Science and Environment, Roskilde University, Fredeiksberg, Denmark
    JAMA Intern Med. 2020;180(10):1336-1344. doi:10.1001/jamainternmed.2020.3391
    Key Points

    Question  Did more all-cause deaths occur during the first months of the coronavirus disease 2019 (COVID-19) pandemic in the United States compared with the same months during previous years?

    Findings  In this cohort study, the number of deaths due to any cause increased by approximately 122 000 from March 1 to May 30, 2020, which is 28% higher than the reported number of COVID-19 deaths.

    Meaning  Official tallies of deaths due to COVID-19 underestimate the full increase in deaths associated with the pandemic in many states.


    Importance  Efforts to track the severity and public health impact of coronavirus disease 2019 (COVID-19) in the United States have been hampered by state-level differences in diagnostic test availability, differing strategies for prioritization of individuals for testing, and delays between testing and reporting. Evaluating unexplained increases in deaths due to all causes or attributed to nonspecific outcomes, such as pneumonia and influenza, can provide a more complete picture of the burden of COVID-19.

    Objective  To estimate the burden of all deaths related to COVID-19 in the United States from March to May 2020.

    Design, Setting, and Population  This observational study evaluated the numbers of US deaths from any cause and deaths from pneumonia, influenza, and/or COVID-19 from March 1 through May 30, 2020, using public data of the entire US population from the National Center for Health Statistics (NCHS). These numbers were compared with those from the same period of previous years. All data analyzed were accessed on June 12, 2020.

    Main Outcomes and Measures  Increases in weekly deaths due to any cause or deaths due to pneumonia/influenza/COVID-19 above a baseline, which was adjusted for time of year, influenza activity, and reporting delays. These estimates were compared with reported deaths attributed to COVID-19 and with testing data.

    Results  There were approximately 781 000 total deaths in the United States from March 1 to May 30, 2020, representing 122 300 (95% prediction interval, 116 800-127 000) more deaths than would typically be expected at that time of year. There were 95 235 reported deaths officially attributed to COVID-19 from March 1 to May 30, 2020. The number of excess all-cause deaths was 28% higher than the official tally of COVID-19–reported deaths during that period. In several states, these deaths occurred before increases in the availability of COVID-19 diagnostic tests and were not counted in official COVID-19 death records. There was substantial variability between states in the difference between official COVID-19 deaths and the estimated burden of excess deaths.

    Conclusions and Relevance  Excess deaths provide an estimate of the full COVID-19 burden and indicate that official tallies likely undercount deaths due to the virus. The mortality burden and the completeness of the tallies vary markedly between states.