Drug Overdose Mortality Rates by Educational Attainment and Sex for Adults Aged 25 to 64 in the United States Before and During the COVID-19 Pandemic, 2015 to 2021 (preprint)

Introduction: Dramatic increases in U.S. drug overdose deaths involving synthetic opioids, most prominently fentanyl, beginning around 2014 have driven a marked progression in national rates of overall drug overdose deaths, which sharply rose to unprecedented levels amid the COVID-19 pandemic. Disparities in U.S. drug overdose mortality burden by educational attainment have not been widely scrutinized during the fentanyl era of the drug overdose epidemic and its intersection with the COVID-19 pandemic. Methods: Utilizing restricted-use mortality data from the National Vital Statistics System and population estimates from the American Community Survey, we estimated annual national age-adjusted drug overdose mortality rates jointly stratified by educational attainment and sex for adults aged 25-64 from 2015 to 2021. State-level age-adjusted mortality rates were estimated in 2015 and 2021 to examine geographic trends in the cumulative evolution of disparities in drug overdose deaths by educational attainment over the course of the analysis period. Results: Over 452,700 drug overdose deaths among U.S. adults aged 25-64 occurred from 2015 to 2021. For both men and women in this age range, age-adjusted mortality rates rose fastest among persons with at most a high school-level education, whereas little to no change in age-adjusted mortality rates was observed for Bachelors degree holders, widening pre-existing disparities in drug overdose mortality burden by educational attainment. During the analysis period, the difference in age-adjusted mortality rates between persons with at most a high school-level education and Bachelors degree holders, for both men and women, increased from less than 8-fold to approximately 13-fold. These disparities widened in nearly every state, and the widening accelerated after the onset of the COVID-19 pandemic. Among non-Bachelors degree holders, age-adjusted mortality rates increased markedly faster among men. Conclusions: The widening disparities in drug overdose deaths by educational attainment are a likely indicator of a rapidly-increasing socioeconomic divide in drug overdose mortality more broadly. Policy strategies should address the upstream socioeconomic drivers of drug use and overdose, especially among men, and tailor interventions accordingly.

Variation in National COVID-19 Mortality Rates Across Asian Subgroups in the United States, 2020 (preprint)

Provisional U.S. national COVID-19 mortality data for the year 2020 analyzed by the CDC in March 2021 indicated that non-Hispanic Asians fared markedly better overall than other racial/ethnic minority groups-and marginally better than non-Hispanic Whites-in terms of age-adjusted mortality rates. However, Asians in the United States are composed of diverse array of origin subgroups with highly varying social, economic, and environmental experiences, which influence health outcomes. As such, lumping all Asians together into a single category can mask meaningful health disparities among more vulnerable Asian subgroups. To date, there has not been a national-level analysis of COVID-19 mortality outcomes between Asian subgroups. Utilizing final multiple cause of death data for 2020 and population projections from the U.S. Census Bureau's Current Population Survey Annual Social and Economic Supplement for 2020, crude and age-adjusted national COVID-19 mortality rates, both overall and stratified by sex, were calculated for the six major single-race Asian origin subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) and a catch-all seventh category that comprises the remaining Asian subgroups (Other Asians), contrasting them to the corresponding mortality rates of other racial/ethnic groups. A substantially more nuanced picture emerges when disaggregating Asians into its diverse origin subgroups and stratifying by sex, with Filipino males and Asian males outside of the six major Asian subgroups in particular experiencing markedly higher age-adjusted mortality rates than their White male counterparts, whether comparisons were restricted to their non-Hispanic subsets or not. During the COVID-19 pandemic and in the post-pandemic recovery, it is imperative not to overlook the health needs of vulnerable Asian populations. Public health strategies to mitigate the effects of COVID-19 must avoid viewing Asians as a monolithic entity and recognize the heterogeneous risk profiles within the U.S. Asian population.

National Population-Level Disparities in COVID-19 Mortality Across the Intersection of Race/Ethnicity and Sex in the United States (preprint)

Males and certain racial/ethnic minority groups have borne a disproportionate burden of COVID-19 mortality in the United States, and substantial scientific research has sought to quantify and characterize population-level disparities in COVID-19 mortality outcomes by sex and across categories of race/ethnicity. However, there has not yet been a national population-level study to quantify disparities in COVID-19 mortality outcomes across the intersection of these demographic dimensions. Here, we analyze a publicly available dataset from the National Center for Health Statistics comprising COVID-19 death counts stratified by race/ethnicity, sex, and age for the year 2020, calculating mortality rates for each race/ethnicity-sex-age stratum and age-adjusted mortality rates for each race/ethnicity-sex stratum, quantifying disparities in terms of mortality rate ratios and rate differences. Our results reveal persistently higher COVID-19 age-adjusted mortality rates for males compared to females within every racial/ethnic group, with notable variation in the magnitudes of the sex disparity by race/ethnicity. However, non-Hispanic Black, Hispanic, and non-Hispanic American Indian or Alaska Native females have higher age-adjusted mortality rates than non-Hispanic White and non-Hispanic Asian/Pacific Islander males. Moreover, persistent racial/ethnic disparities are observed among both males and females, with higher COVID-19 age-adjusted mortality rates observed for non-Hispanic Blacks, Hispanics, and non-Hispanic American Indian or Alaska Natives relative to non-Hispanic Whites.

Male-Female Disparities in Years of Potential Life Lost Attributable to COVID-19 in the United States: A State-by-State Analysis (preprint)

Males are at higher risk relative to females of severe outcomes following COVID-19 infection. Focusing on COVID-19-attributable mortality in the United States (U.S.), we quantify and contrast years of potential life lost (YPLL) attributable to COVID-19 by sex based on data from the U.S. National Center for Health Statistics as of 31 March 2021, specifically by contrasting male and female percentages of total YPLL with their respective percent population shares and calculating age-adjusted male-to-female YPLL rate ratios both nationally and for each of the 50 states and the District of Columbia. Using YPLL before age 75 to anchor comparisons between males and females and a novel Monte Carlo simulation procedure to perform estimation and uncertainty quantification, our results reveal a near-universal pattern across states of higher COVID-19-attributable YPLL among males compared to females. Furthermore, the disproportionately high COVID-19 mortality burden among males is generally more pronounced when measuring mortality in terms of YPLL compared to age-irrespective death counts, reflecting dual phenomena of males dying from COVID-19 at higher rates and at systematically younger ages relative to females. The U.S. COVID-19 epidemic also offers lessons underscoring the importance of a public health environment that recognizes sex-specific needs as well as different patterns in risk factors, health behaviors, and responses to interventions between men and women. Public health strategies incorporating focused efforts to increase COVID-19 vaccinations among men are particularly urged.

Racial and Ethnic Disparities in Years of Potential Life Lost Attributable to COVID-19 in the United States: An Analysis of 45 States and the District of Columbia (preprint)

The coronavirus disease 2019 (COVID-19) epidemic in the United States has disproportionately impacted communities of color across the country. Focusing on COVID-19-attributable mortality, we expand upon a national comparative analysis of years of potential life lost (YPLL) attributable to COVID-19 by race/ethnicity (Bassett et al., 2020), estimating percentages of total YPLL for non-Hispanic Whites, non-Hispanic Blacks, Hispanics, non-Hispanic Asians, and non-Hispanic American Indian or Alaska Natives, contrasting them with their respective percent population shares, as well as age-adjusted YPLL rate ratios - anchoring comparisons to non-Hispanic Whites - in each of 45 states and the District of Columbia using data from the National Center for Health Statistics as of December 30, 2020. Using a novel Monte Carlo simulation procedure to quantify estimation uncertainty, our results reveal substantial racial/ethnic disparities in COVID-19-attributable YPLL across states, with a prevailing pattern of non-Hispanic Blacks and Hispanics experiencing disproportionately high and non-Hispanic Whites experiencing disproportionately low COVID-19-attributable YPLL. Furthermore, observed disparities are generally more pronounced when measuring mortality in terms of YPLL compared to death counts, reflecting the greater intensity of the disparities at younger ages. We also find substantial state-to-state variability in the magnitudes of the estimated racial/ethnic disparities, suggesting that they are driven in large part by social determinants of health whose degree of association with race/ethnicity varies by state.