Leading Causes of Death Among Adults Aged 25 to 44 Years by Race and Ethnicity in Texas During the COVID-19 Pandemic, March to December 2020

In the United States, adults aged 25 to 44 years had the largest relative increase in all-cause mortality during the COVID-19 pandemic in 2020, with disproportionate increases among Black, Hispanic, and Latino adults.^1,2 In the first 6 months of the pandemic, the number of COVID-19–attributed deaths among people aged 25 to 44 years in regions with major outbreaks was similar to or exceeded the number to deaths from drug overdoses, which has been the usual leading cause of death in this age group in prior years.³ To better understand excess mortality among adults aged 25 to 44 years during the early months of the COVID-19 pandemic, we examined mortality data from Texas, a racially and ethnically diverse state.

Using records from the Texas Department of State Health Services, we obtained monthly mortality data (stratified by race and ethnicity [Hispanic, non-Hispanic Black, and non-Hispanic White]) among adults aged 25 to 44 years residing in Texas for the 6 leading causes of death (2015-2020) and COVID-19 (March-December 2020).⁴ The 6 leading causes of death were accidents (excluding unintentional overdoses), malignant neoplasms, diseases of the heart, intentional self-harm, assault (homicide), and unintentional overdoses (see eAppendix in the Supplement for diagnosis codes). To estimate 2020 population data, we used Centers for Disease Control and Prevention data for 2015 through 2019 and autoregressive integrated moving averaging as previously reported.³ We calculated incident mortality rates and corresponding 95% CIs for cause-specific mortality. For each racial and ethnic group, the cause of death with the greatest incident rate was considered the leading cause, as well as any other cause whose 95% CI overlapped with the 95% CI of the leading cause. Statistical analyses were performed in R, version 4.0.2 (R Foundation for Statistical Computing). The Texas Department of State Health Services’ Center for Health Statistics, per institutional policy, exempted the study from institutional review board approval.

Among Black, Hispanic, and White persons aged 25 to 44 years residing in Texas during March through December 2020, COVID-19 was the leading cause of death during the third quarter of 2020 and the second leading cause during the fourth quarter (Figure, A and Table). During July, November, and December, COVID-19 was the numeric leading cause of death in this combined group (Table). The leading cause of death for March through December 2020 was accidents (Figure, A).

Among Black individuals aged 25 to 44 years, COVID-19 was the sixth leading cause of death from March through December 2020 (Figure, B), though in July COVID-19 was numerically the leading cause of death (Table). The leading causes of death were assault, diseases of the heart, and accidents (Figure, B and Table).

Among Hispanic individuals aged 25 to 44 years, COVID-19 was the leading cause of death from March through December 2020 (Figure, C and Table) and during the third and fourth quarters of 2020. During the third quarter, more COVID-19–attributed deaths were recorded among Hispanic individuals aged 25 to 44 years than for the next 2 most-common causes combined (accidents and unintentional overdoses).

Among White individuals aged 25 to 44 years, COVID-19 was the sixth leading cause from March through December 2020 (Figure, D). The leading causes of death were unintentional overdoses and accidents (Figure, D and Table).

Results of this cohort study demonstrated that during March through December 2020, the first 10 months of the COVID-19 pandemic in the US, COVID-19 was the second leading cause of death among Black, Hispanic, and White residents of Texas aged 25 to 44 years, and the most common cause during the third quarter of 2020, with a markedly disproportionate increase in mortality among Hispanic residents. One possible explanation may be that Hispanic persons were more likely to be essential workers and, therefore, were less able to avoid exposure to SARS-CoV-2, which has previously been linked to socioeconomic factors.^5,6 Another possible explanation is that Hispanic residents were less likely to have access to primary care and, therefore, more likely to experience unmanaged medical comorbidities associated with worse COVID-19 outcomes. Limitations of this study include the accuracy of data from death certificates and the preliminary nature of 2020 data. Nevertheless, these findings highlight the markedly disparate effects of the COVID-19 pandemic in different populations of young adults, particularly among Hispanic residents of Texas.

Accepted for Publication: September 30, 2021.

Published Online: November 22, 2021. doi:10.1001/jamainternmed.2021.6734

Corresponding Author: Jeremy Samuel Faust, MD, MS, Department of Emergency Medicine, Brigham and Women’s Hospital, 10 Vining St, Boston, MA 02115 (jsfaust@gmail.com).

Author Contributions: Dr Faust had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Faust, Nguemeni Tiako, Barnett.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Faust, Nguemeni Tiako.

Critical revision of the manuscript for important intellectual content: Faust, Chen, Du, Li, Krumholz, Barnett.

Statistical analysis: Faust, Nguemeni Tiako, Li, Barnett.

Administrative, technical, or material support: Chen.

Supervision: Li, Barnett.

Conflict of Interest Disclosures: Dr Krumholz reports expenses and/or personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, Siegfried & Jensen law firm, Arnold & Porter law firm, Martin/Baughman law firm, F-Prime Capital, and the National Center for Cardiovascular Diseases in Beijing, China; owns Refactor Health and Hugo Health; and has grants and/or contracts from the Centers for Medicare & Medicaid Services, Medtronic, the US Food and Drug Administration, Johnson & Johnson, Foundation for a Smoke-Free World, the Connecticut Department of Public Health, and the Shenzhen Center for Health Information. Dr Barnett reports being retained as an expert witness by government plaintiffs in lawsuits against opioid manufacturers. No other disclosures were reported.

Additional Contributions: We thank the Center for Health Statistics’ Vital Events Data Management program of the Texas Department of State Health Services for helpfully providing data. There was no compensation for the contribution.