Extended surges in the South and West in the summer and early winter of 2020 resulted in regional increases in excess death rates, both from COVID-19 and from other causes, a 50-state analysis of excess death trends has found. Virginia Commonwealth University researchers’ latest study notes that Black Americans had the highest excess death rates per capita of any racial or ethnic group in 2020.
The research, publishing Friday in the Journal of the American Medical Association, offers new data from the last 10 months of 2020 on how many Americans died during 2020 as a result of the effects of the pandemic – beyond the number of COVID-19 deaths alone – and which states and racial groups were hit hardest.
The rate of excess deaths – or deaths above the number that would be expected based on averages from the previous five years—is usually consistent, fluctuating 1% to 2% from year to year, said Steven Woolf, M.D., the study’s lead author and director emeritus of VCU’s Center on Society and Health. From March 1, 2020, to Jan. 2, 2021, excess deaths rose a staggering 22.9% nationally, fueled by COVID-19 and deaths from other causes, with regions experiencing surges at different times.
“COVID-19 accounted for roughly 72% of the excess deaths we’re calculating, and that’s similar to what our earlier studies showed. There is a sizable gap between the number of publicly reported COVID-19 deaths and the sum total of excess deaths the country has actually experienced,” Woolf said.
For the other 28% of the nation’s 522,368 excess deaths during that period, some may actually have been from COVID-19, even if the virus was not listed on the death certificates due to reporting issues.
But Woolf said disruptions caused by the pandemic were another cause of the 28% of excess deaths not attributed to COVID-19. Examples might include deaths resulting from not seeking or finding adequate care in an emergency such as a heart attack, experiencing fatal complications from a chronic disease such as diabetes, or facing a behavioral health crisis that led to suicide or drug overdose.
“All three of those categories could have contributed to an increase in deaths among people who did not have COVID-19 but whose lives were essentially taken by the pandemic,” said Woolf, a professor in the Department of Family Medicine and Population Health at the VCU School of Medicine.
The percentage of excess deaths among non-Hispanic Black individuals (16.9%) exceeded their share of the U.S. population (12.5%), reflecting racial disparities in mortality due to COVID-19 and other causes of death in the pandemic, Woolf and his co-authors write in the paper. The excess death rate among Black Americans was higher than rates of excess deaths among non-Hispanic white or Hispanic populations.
Woolf said his team was motivated to break down this information by race and ethnicity due to mounting evidence that people of color have experienced an increased risk of death from COVID-19.
“We found a disproportionate number of excess deaths among the Black population in the United States,” said Woolf, VCU’s C. Kenneth and Dianne Wright Distinguished Chair in Population Health and Health Equity.
“This, of course, is consistent with the evidence about COVID-19 but also indicates that excess deaths from some conditions other than COVID-19 are also occurring at higher rates in the African American population.”
Surges in excess deaths varied across regions of the United States. Northeastern states, such as New York and New Jersey, were among the first hit by the pandemic. Their pandemic curves looked like a capital “A,” Woolf said, peaking in April and returning rapidly to baseline within eight weeks because strict restrictions were put in place.
But the increase in excess deaths lasted much longer in other states that lifted restrictions early and were hit hard later in the year. Woolf cited economic or political reasons for decisions by some governors to weakly embrace, or discourage, pandemic control measures such as wearing masks.
“They said they were opening early to rescue the economy. The tragedy is that policy not only cost more lives, but actually hurt their economy by extending the length of the pandemic,” Woolf said. “One of the big lessons our nation must learn from COVID-19 is that our health and our economy are tied together. You can’t really rescue one without the other.”
According to the study’s data, the 10 states with the highest per capita rate of excess deaths were Mississippi, New Jersey, New York, Arizona, Alabama, Louisiana, South Dakota, New Mexico, North Dakota and Ohio.
Nationally, Woolf expects the U.S. will see consequences of the pandemic long after this year. For example, cancer mortality rates may increase in the coming years if the pandemic forced people to delay screening or chemotherapy.
Woolf said future illness and deaths from the downstream consequences of the devastated economy could be addressed now by “bringing help to families, expanding access to health care, improving behavioral health services and trying to bring economic stability to a large part of the population that was already living on the edge before the pandemic.”
Among other research, his team’s 2019 JAMA study of working-age mortality underscores the importance of prioritizing public health measures like these, he said.
“American workers are sicker and dying earlier than workers in businesses in other countries that are competing against America,” Woolf said. “So investments to help with health are important for the U.S. economy in that context just as they are with COVID-19.”
Derek Chapman, Ph.D., Roy Sabo, Ph.D., and Emily Zimmerman, Ph.D., of VCU’s Center on Society and Health and the School of Medicine joined Woolf as co-authors on the paper published Friday, “Excess Deaths From COVID-19 and Other Causes in the United States, March 1, 2020, to January 2, 2021.”
Their study also confirms a trend Woolf’s team noted in an earlier 2020 study: Death rates from several non-COVID-19 conditions, such as heart disease, Alzheimer’s disease and diabetes, increased during surges.
“This country has experienced profound loss of life due to the pandemic and its consequences, especially in communities of color,” said Peter Buckley, M.D., dean of the VCU School of Medicine. “While we must remain vigilant with social distancing and mask-wearing behaviors for the duration of this pandemic, we must also make efforts to ensure the equitable distribution of care if we are to reduce the likelihood of further loss of life.”
Based on current trends, Woolf said the surges the U.S. has seen might not be over, even with vaccinations underway.
“We’re not out of the woods yet because we’re in a race with the COVID-19 variants. If we let up too soon and don’t maintain public health restrictions, the vaccine may not win out over the variants,” Woolf said. “Unfortunately, what we’re seeing is that many states have not learned the lesson of 2020. Once again, they are lifting restrictions, opening businesses back up, and now seeing the COVID-19 variants spread through their population.
“To prevent more excess deaths, we need to hold our horses and maintain the public health restrictions that we have in place so the vaccine can do its work and get the case numbers under control.”
iven the lack of vaccines or specific causal therapies, many governments and scientists consider behavioral measures such as wearing face masks, maintaining distance from other people, avoiding large social gatherings and practicing increased hygiene to be the key tools in the fight against the Covid-19 pandemic [1]. Such “nonpharmaceutical interventions (NPIs)” are designed to slow the spread of Covid-19 by reducing physical contact within the population and by reducing uptake of the virus via droplet infection and inhalation [1, 2].
Early experiences from China pointed to the effectiveness of massive NPIs in shortening the serial interval of SARS-CoV-2 infections over time and in reducing the transmission of the virus [3–5]. Beginning in March 2020, national lockdowns were declared by many governments outside of China [6]. The exact extent and timing of measures to reduce the spread of Covid-19 varied between and even within countries [2, 7].
Since May 2020, some countries have started to ease or lift some of the government implemented anti-pandemic measures. Other measures such as keeping people at a distance and wearing face masks on public transport, in stores or even in all public places, have been maintained or reintroduced in view of the renewed rise in infection rates. However, more or less mandatory NPIs represent restrictions on freedom and, in their strong form, have massive economic impacts [8–10].
It is therefore not surprising that they are often controversial, and are not universally adopted by all governments and citizens [2, 10–12]. For example, many Western governments and health authorities, as well as the World Health Organization, initially made contradictory or ambivalent statements about the wearing of face masks, which led to misunderstandings and even stigmatization [2].
Indeed, the justification of invasive NPIs depends on their promise of sufficient benefit, and this is precisely what critics have repeatedly questioned. While NPIs can be useful in theory and their probable effect can be modelled mathematically, strong empirical evidence is scarce [1, 13, 14].
Randomized controlled trials (RCTs) would provide particularly meaningful evidence, but in the current explosive pandemic RCTs are encountering practical and ethical challenges that could be responsible for their absence to date [1]. Quasi-experimental designs (“natural experiments”) are therefore of great importance. One such study has recently shown a stronger decline in daily Covid-19 growth rates in 15 U.S. states following the introduction of face masks in public places compared to states that did not require this [11].
In addition, a strong negative correlation between the number of Covid-19 cases and lockdown measures was observed across 49 countries [7]. Model simulations specifically of wearing face masks [13] show that the community-wide benefit is likely to be greatest when face masks are used in conjunction with other NPIs, when adoption is nearly universal (nation-wide), and when adherence is high. The most important benefit of any health measure taken, however, would be a significant reduction in the mortality rate, as caused by Covid-19.
In the present study, we therefore examined, across eight countries whether higher adherence to behavioral NPIs predicted a smaller increase in Covid-19 mortality over a period of three months in a prospective longitudinal study with quasi-experimental design.
Building on and extending earlier work on the link between macrosocial factors and mental health [15, 16], we selected the United States, Russia, Poland, Sweden, Germany, France, Spain and the United Kingdom for our study. These countries not only represent different types of societies and health care systems, but also differ in their emphasis on personal freedom, government effectiveness and attitudes to NPIs [15–18].
In most countries, the first cases of Covid-19 were reported in January 2020 (except Poland, which reported first cases in March 2020) and governments and health authorities subsequently advocated behavioral measures to contain the pandemic. With the exception of Sweden, all countries declared total or partial lockdowns in March 2020, which were eased from April or May 2020 (see Table 1). Table 1 shows the times of lockdowns in spring 2020 and the governmental NPIs in the eight investigated countries that were effective in the end of May 2020 and in the beginning of June 2020.
reference link: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249392
More information: Journal of the American Medical Association (2021). DOI: 10.1001/jama.2021.5199 , jamanetwork.com/journals/jama/ … .1001/jama.2021.5199
