COVID-19 Drives Surge of Excess Deaths in 2020

Steven H. Woolf, MD (PCORI)

Excess death correlated to the COVID-19 pandemic surged in 2020, according to a recent analysis of mortality in the United States.

The study, conducted at Virginia Commonwealth University, and led by Steven H. Woolf, MD, MPH, and Derek A. Chapman, PhD, showed the United States experienced 22.9% more deaths than expected, with a total mortality of 2,801,439, from March 2020 to January 2021.

This percentage greatly exceeds the average annual increase observed in recent years of ≤2.5%. More than 500,000 deaths (n = 522,368) were estimated to be excess.

The study used a Poisson regression model of US mortality data set from 2014 - 2019 to predict expected deaths in 2020, with sources including the National Center for Health Statistics and US Census Bureau. During the period of observation, data was taken from provisional, unweighted death counts for Washington, D.C. and 49 states, excluding North Carolina for insufficient data.

Mortality rates from non-COVID-19 causes were examined with data including all deaths where non-COVID-19 conditions were listed as the underlying cause of death.

Particular demographic groups were unequally impacted by the pandemic, reflecting racial disparities in COVID-19 mortality. The percentage of excess deaths among non-Hispanic black individuals was 16.9%, compared to their 12.5% share of the US population.

The data analysis also showed the non-Hispanic Black population experienced 208.4 deaths per 100,000. The non-Hispanic White population experienced 157.0 deaths per 100,000, and the Hispanic populations experienced 139.8 deaths per 100,000.

Geographic regions experienced surges in excess related to seasons throughout the year. The eastern US experienced a surge in April, whereas the southern and western states experienced extended summer and early winter surges. The regional surges were correlated with instances of COVID-19 outbreaks in the respective areas.

“Many of these states weakly embraced, or discouraged, pandemic control measures and lifted restrictions earlier than other states,” investigators wrote.

But by the end of 2020, deaths were exceeding against investigators’ model-based estimations in all regions of the country. States with the highest per capita excess death rate included New York and New Jersey in the northeast with a ratio of 1.38 and 1.37 observed versus expected deaths, respectively. Other areas including Arizona and New Mexico in the southwest had a 1.32 and 1.27 ratio of observed versus expected deaths.

Excess deaths could also result from immediate or delayed mortality from undocumented COVID-19 infection, as well as secondary non-COVID-19 deaths during surges. Prevalent drivers of death in the US, including heart disease and Alzheimer disease, increased during surges. Population aging could also contribute to an overestimation of excess deaths, which the study did not adjust for in their findings.

In an editorial accompanying the study, Alan M. Garber, MD, PhD, of Harvard University, championed the data found by Woolf and Chapman, comparing the pandemic to war and the failed response of the United States to combat its effects on mortality rates.

“Just as military leaders prepare their armies for fighting the last war, society will always be better prepared to fight the pandemics of the past than the unknown pandemics yet to come,” Garber said.

Garber believes despite the progress in creating vaccines and treating those with the disease, the increase in the risk of death and misclassifications and inconsistencies in reporting have caused death rates to go up, both directly and indirectly.

“The US and other countries are most likely to learn from the pandemic if they understand the consequences of failure,” Garber said. “The work of Woolf and colleagues illustrates what is at stake: despite the scientific, medical, and public health progress of recent decades, the loss of life attributable to the COVID-19 pandemic exceeds the mortality of major wars.”

The research letter, “Excess Deaths From COVID-19 and Other Causes in the US, March 1, 2020, to January 2, 2021,” was published online in JAMA.