Excess Deaths Associated With COVID-19, by Age and Race and Ethnicity

United States, January 26-October 3, 2020

Lauren M. Rossen, PhD; Amy M. Branum, PhD; Farida B. Ahmad, MPH; Paul Sutton, PhD; Robert N. Anderson, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(42):1522-1527. 

In This Article

Abstract and Introduction

Introduction

As of October 15, 216,025 deaths from coronavirus disease 2019 (COVID-19) have been reported in the United States*; however, this number might underestimate the total impact of the pandemic on mortality. Measures of excess deaths have been used to estimate the impact of public health pandemics or disasters, particularly when there are questions about underascertainment of deaths directly attributable to a given event or cause.[1–6] Excess deaths are defined as the number of persons who have died from all causes, in excess of the expected number of deaths for a given place and time. This report describes trends and demographic patterns in excess deaths during January 26–October 3, 2020. Expected numbers of deaths were estimated using overdispersed Poisson regression models with spline terms to account for seasonal patterns, using provisional mortality data from CDC's National Vital Statistics System (NVSS).[7] Weekly numbers of deaths by age group and race/ethnicity were assessed to examine the difference between the weekly number of deaths occurring in 2020 and the average number occurring in the same week during 2015–2019 and the percentage change in 2020. Overall, an estimated 299,028 excess deaths have occurred in the United States from late January through October 3, 2020, with two thirds of these attributed to COVID-19. The largest percentage increases were seen among adults aged 25–44 years and among Hispanic or Latino (Hispanic) persons. These results provide information about the degree to which COVID-19 deaths might be underascertained and inform efforts to prevent mortality directly or indirectly associated with the COVID-19 pandemic, such as efforts to minimize disruptions to health care.

Estimates of excess deaths can provide a comprehensive account of mortality related to the COVID-19 pandemic, including deaths that are directly or indirectly attributable to COVID-19. Estimates of the numbers of deaths directly attributable to COVID-19 might be limited by factors such as the availability and use of diagnostic testing (including postmortem testing) and the accurate and complete reporting of cause of death information on the death certificate. Excess death analyses are not subject to these limitations because they examine historical trends in all-cause mortality to determine the degree to which observed numbers of deaths differ from historical norms. In April 2020, CDC's National Center for Health Statistics (NCHS) began publishing data on excess deaths associated with the COVID-19 pandemic.[7,8] This report describes trends and demographic patterns in the number of excess deaths occurring in the United States from January 26, 2020, through October 3, 2020, and differences by age and race/ethnicity using provisional mortality data from the NVSS.§

Excess deaths are typically defined as the number of persons who have died from all causes, in excess of the expected number of deaths for a given place and time. A detailed description of the methodology for estimating excess deaths has been described previously.[7] Briefly, expected numbers of deaths are estimated using overdispersed Poisson regression models with spline terms to account for seasonal patterns. The average expected number, as well as the upper bound of the 95% prediction interval (the range of values likely to contain the value of a single new observation), are used as thresholds to determine the number of excess deaths (i.e., observed numbers above each threshold) and percentage excess (excess deaths divided by average expected number of deaths). Estimates described here refer to the number or percentage above the average; estimates above the upper bound threshold have been published elsewhere.[7] Observed numbers of deaths are weighted to account for incomplete reporting by jurisdictions (50 states and the District of Columbia [DC]) in the most recent weeks, where the weights were estimated based on completeness of provisional data in the past year.[7]

Weekly NVSS data on excess deaths occurring from January 26 (the week ending February 1), 2020, through October 3, 2020, were used to quantify the number of excess deaths and the percentage excess for deaths from all causes and deaths from all causes excluding COVID-19. Deaths attributed to COVID-19 have the International Classification of Diseases, Tenth Revision code U07.1 as an underlying or contributing cause of death.

Weekly numbers of deaths by age group (0–24, 25–44, 45–64, 65–74, 75–84, and ≥85 years) and race/ethnicity (Hispanic or Latino [Hispanic], non-Hispanic White [White], non-Hispanic Black or African American [Black], non-Hispanic Asian [Asian], non-Hispanic American Indian or Alaska Native [AI/AN], and other/unknown race/ethnicity, which included non-Hispanic Native Hawaiian or other Pacific Islander, non-Hispanic multiracial, and unknown) were used to examine the difference between the weekly number of deaths occurring in 2020 and the average number occurring in the same week during 2015–2019. These values were used to calculate an average percentage change in 2020 (i.e., above or below average compared with past years), over the period of analysis, by age group and race and Hispanic ethnicity. NVSS data in this report include all deaths occurring in the 50 states and DC and are not limited to U.S. residents. Approximately 0.2% of decedents overall are foreign residents. R statistical software (version 3.5.0; The R Foundation) was used to conduct all analyses.

From January 26, 2020, through October 3, 2020, an estimated 299,028 more persons than expected have died in the United States.** Excess deaths reached their highest points to date during the weeks ending April 11 (40.4% excess) and August 8, 2020 (23.5% excess) (Figure 1). Two thirds of excess deaths during the analysis period (66.2%; 198,081) were attributed to COVID-19 and the remaining third to other causes†† (Figure 1).

Figure 1.

Weekly numbers of deaths from all causes and from all causes excluding COVID-19 relative to the average expected number and the upper bound of the 95% prediction interval (A), and the weekly and total numbers of deaths from all causes and from all causes excluding COVID-19 above the average expected number and the upper bound of the 95% prediction interval (B) — National Vital Statistics System, United States, January–September 2020
Abbreviation: COVID-19 = coronavirus disease 2019.

The total number of excess deaths (deaths above average levels) from January 26 through October 3 ranged from a low of approximately 841 in the youngest age group (<25 years) to a high of 94,646 among adults aged 75–84 years.§§ However, the average percentage change in deaths over this period compared with previous years was largest for adults aged 25–44 years (26.5%) (Figure 2). Overall, numbers of deaths among persons aged <25 years were 2.0% below average,¶¶ and among adults aged 45–64, 65–74 years, 75–84, and ≥85 years were 14.4%, 24.1%, 21.5%, and 14.7% above average, respectively.

Figure 2.

Percentage change in the weekly number of deaths in 2020 relative to average numbers in the same weeks during 2015–2019, by age group — United States, 2015–2019 and 2020

When examined by race and ethnicity, the total numbers of excess deaths during the analysis period ranged from a low of approximately 3,412 among AI/AN persons to a high of 171,491 among White persons. For White persons, deaths were 11.9% higher when compared to average numbers during 2015–2019. However, some racial and ethnic subgroups experienced disproportionately higher percentage increases in deaths (Figure 3). Specifically, the average percentage increase over this period was largest for Hispanic persons (53.6%). Deaths were 28.9% above average for AI/AN persons, 32.9% above average for Black persons, 34.6% above average for those of other or unknown race or ethnicity, and 36.6% above average for Asian persons.

Figure 3.

Percentage change in the weekly number of deaths in 2020 relative to average numbers in the same weeks during 2015–2019, by race and Hispanic ethnicity — United States, 2015–2019 and 2020

*CDC official counts of cases and deaths are released daily at https://covid.cdc.gov/covid-data-tracker/.
https://www.medrxiv.org/content/10.1101/2020.06.06.20120857v1.full.pdf.
§ https://www.cdc.gov/nchs/nvss/deaths.htm.
Deaths from all causes excluding COVID-19 are calculated by subtracting the number of confirmed or presumed COVID-19 deaths from the total number of deaths. Deaths with confirmed or presumed COVID-19 are assigned the International Classification of Diseases, Tenth Revision code U07.1 as a contributing or underlying cause of death on the death certificate.
**Excess deaths over this period ranged from 224,173 to 299,028. The lower end of this range corresponds to the total number above the upper bound of the 95% prediction intervals, and the upper end of the range corresponds to the total number above the average expected counts. Deaths above the upper bound threshold are significantly higher than expected. https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm.
††Excess deaths attributed to COVID-19 were calculated by subtracting the number of excess deaths from all causes excluding COVID-19 from the total number of excess deaths from all causes. These excess death estimates were based on the numbers of deaths above the average expected number. Using the upper bound of the 95% prediction interval for the expected numbers (the upper bound threshold), an estimated 224,173 excess deaths occurred during this period, 85.5% of which were attributed to COVID-19.
§§Weeks when the observed numbers of deaths were below the average numbers from 2015 to 2019 were excluded from the total numbers of excess deaths above average levels (i.e., negative values were treated as 0 excess deaths).
¶¶The total average percentage change in the number of deaths occurring from the week ending February 1, 2020, through October 3, 2020, included weeks where the percentage difference was negative (i.e., deaths were fewer than expected). This mainly affected the youngest age group, among whom, overall, deaths during this period were 2.0% below average. Excluding weeks with negative numbers of excess deaths results in overall percentage increases of 4.2% for decedents aged <25 years. Increases for other age groups were similar when excluding weeks with negative numbers of excess deaths, with the exception of those aged ≥85 years, among whom the percentage increase was larger (18.1%) when weeks with negative values were excluded.

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