Age-Specific All-Cause Mortality Disparities by Race and Ethnicity During the COVID-19 Pandemic (preprint)

BACKGROUND. The end of the public health emergency provides an opportunity to fully describe disparities during the Covid-19 pandemic. METHODS. In this retrospective cohort analysis of US deaths during the Covid-19 public health emergency (March 2020-April 2023), all-cause excess mortality and years of potential life lost (YPLL) were calculated by race or ethnicity overall and by age groups (ages <25 years, 25-64 years, [≥]65 years). Temporal correlations with Covid-19-specific mortality were measured. RESULTS. >1.38 million all-cause excess deaths and ~23 million corresponding YPLL occurred during the pandemic. Had the rate of excess mortality observed among the White population been observed among the total population, >252,300 (18%) fewer excess deaths, and >5,192,000 fewer (22%) YPLL would have occurred. The highest excess mortality rates were among the American Indian/Alaska Native (AI/AN, 822 per 100,000; ~405,700 YPLL) and the Black (549 per 100,000; ~4,289,200 YPLL) populations. The highest relative increase in mortality was observed in the AI/AN population (1.34; 95% CI 1.31-1.37), followed by Hispanic (1.31; 95% CI 1.27-1.34), Native Hawaiian or Other Pacific Islander (1.24; 95% CI 1.21-1.27), Asian (1.20; 95% CI 1.18-1.20), Black (1.20; 95% CI 1.18-1.22) and White (1.12; 95% CI 1.09-1.15) populations. Greater disparities occurred among children and adults <65 years. CONCLUSIONS. Excess mortality occurred in all groups during the Covid-19 pandemic, with disparities by race and ethnicity, especially in younger and middle-aged populations. >252,000 and 5.2 million fewer YPLL would have been observed had increases in mortality among the total population been similar to the White population.

Suicide deaths during the COVID-19 pandemic in the United States, by region, gender and age, March 1, 2020-June 30, 2022 (preprint)

The COVID-19 pandemic imposed substantial mental health stressors leading to concerns about an increased suicide risk. To investigate this issue, we investigated suicide mortality rates in the United States from March 1, 2020, through June 30, 2022, comparing them with data from the pre-pandemic period of January 2015 through February 2020. Suicide mortality in the United States was 3% below expected levels during the study period. However, there was an increased suicide incidence in adults ages 18–34 years. The concerns that the pandemic contributed to an overall marked increase in suicide risk is not supported by this analysis, but young adults did experience an increase.

An estimate of pediatric lives saved due to non-pharmacologic interventions during the early COVID-19 pandemic (preprint)

The net effect of the pandemic mitigation strategies on childhood mortality is not known. During the first year of the COVID-19 pandemic, mitigation policies and behaviors were widespread, and although vaccinations and effective treatments were not yet widely available, the risk of death from SARS-CoV-2 infection was low. In that first year, there was a 7% decrease in medical ("natural causes") mortality among children ages 0-9 during the first pandemic year (5% among infants <1 year and 15% among children ages 1-9) in the United States, resulting in an estimated 1,488 deaths due to medical causes averted among children ages 0-9, and 1,938 deaths averted over 24 months. The usual expected surge in winter medical deaths, particularly among children ages >1 year was absent. However, smaller increases in external ("non-natural causes") mortality were also observed during the study period, which decreased the overall number of pediatric deaths averted during both years and the pandemic period. In total, 1,468 fewer all-cause pediatric deaths than expected occurred in the United States during the first 24 months of the COVID-19 pandemic.

State-Level Excess Mortality in US Adults During the Delta and Omicron Waves of COVID-19 (preprint)

Introduction The US has continued to see excess mortality through the Delta and Omicron periods. We sought to quantify excess mortality on a state level and calculate potential deaths averted if all states matched the excess mortality rates of those with the 10 lowest excess mortality rates. Methods Observational cohort, US and state-level data. Expected monthly deaths were modeled using pre-pandemic US and state-level data (2015-2020). Mortality data was accessed from CDC public reporting. Results We find that during the Delta and Omicron waves, the US recorded over 596,000 excess deaths. 60% of the nation's total excess mortality during these periods could have been averted if all states had excess mortality rates equal to those with the 10 lowest excess mortality rates. Conclusion With large differences in excess mortality across US states in our 15-month study period, we note that a significant portion of deaths could have been averted with higher vaccination rates, policies and other behaviors.

Excess Mortality in the Vaccination Era in the United States, By State and 6-Month Period (preprint)

Introduction The US continued to record all-cause excess mortality after the rollout of vaccines. We sought to quantify excess mortality by state and compare these rates to primary series vaccination completion levels. Methods Observational cohort, US and state-level data. Expected monthly deaths were modeled using pre-pandemic US and state-level data (2015-2020). Mortality data was accessed from CDC public reporting. Results We find that in a two-year period since the rollout of vaccines, the US recorded >874,000 excess deaths. Vaccination rates and excess mortality were most strongly correlated in first two periods before the Omicron variant. Conclusion The association between vaccination and lower excess mortality rates was strongest in 2021 and early 2022, prior to high population rates of infection-acquired immunity. The findings underscore the benefits of the rapid vaccination rollout campaign and the continued need to boost at-risk populations.

Suicide deaths during the COVID-19 pandemic in the United States, by region, March 1, 2020-June 30, 2022 (preprint)

Introduction: There were concerns that suicide deaths might increase due to Covid-19 pandemic-related stressors. Previous research demonstrated that suicide deaths actually decreased in 2020 in the US. An update covering 2021-2022 with regional data is warranted. Methods: Observational cohort, US and regional data. Expected monthly deaths were modeled using pre-pandemic US and regional data (2015-2020). Mortality data was accessed from CDC public reporting. Results: We find that suicide deaths in the United States were below expected levels throughout the pandemic period (March 1, 2020-June 30,2022) with >4,100 fewer suicide deaths than would have been expected to occur during the study period. Stratifying suicide mortality by US Census Bureau region yielded statistically significant decreases from expected suicide deaths in all regions except the Midwest, (which recorded no significant change in suicide deaths during the overall pandemic period). Conclusion: Suicide mortality is down in the US since the pandemic began, through June 30, 2022. Possible explanations include an early 'coming together' effect; Later, increased access to mental health resources and a greater focus on mental health in the media may have reduced stigma and barriers in seeking necessary psychiatric care.

Two years of COVID-19: Excess mortality by age, region, gender, and race/ethnicity in the United States during the COVID-19 pandemic, March 1, 2020, through February 28, 2022 (preprint)

Introduction Excess mortality does not depend on labeling the cause of death and is an accurate representation of the pandemic population-level effects. A comprehensive evaluation of all-cause excess mortality in the United States during the first two years of the COVID-19 pandemic, stratified by age, sex, region, and race/ethnicity can provide insight into the extent and variation in harm. Methods With Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics (NCHS) data from 2014-2022, we use seasonal autoregressive integrated moving averages (sARIMA) to estimate excess mortality during the pandemic, defined as the difference between the number of observed and expected deaths. We continuously correct monthly expected deaths to reflect the decreased population owing to cumulative pandemic-associated excess deaths recorded. We calculate excess mortality for the total US population, and by age, sex, US census division, and race/ethnicity. Results From March 1, 2020, through February 28, 2022, there were 1.17 million excess deaths in the United States. Overall, mortality was 20% higher than expected during the study period. Of the excess deaths, 799,477 (68%) were among residents aged 65 and older. The largest relative increase in all-cause mortality was 27% among adults ages 18-49 years. Males comprised most of the excess mortality (57%), but this predominance declined with age. A higher relative mortality occurred among non-Hispanic American Indian/Alaskan Native, non-Hispanic Black, non-Hispanic Native Hawaiian and Other Pacific Islander, Hispanic people. Excess mortality differed by region; the highest rates were in the South, including in the population ages ≥65 years. Excess mortality rose and fell contemporaneously with COVID-19 waves. Conclusion In the first two years of the pandemic, the US experienced 1.17 million excess deaths, with greater relative increases in all-cause mortality among men, in American Indian/Alaskan Native, Black and Hispanic people, and the South.

The uncoupling of all-cause excess mortality from Covid-19 cases and associated hospitalizations in late winter and spring of 2022 in a highly vaccinated state. (preprint)

Introduction: Since March 2020, all-cause excess mortality (the number of all-cause deaths exceeding the baseline number of expected deaths) has been observed in waves coinciding with Covid-19 outbreaks in the United States. We recently described high levels of excess mortality in Massachusetts during the initial 8-week Omicron wave. However, whether excess mortality continued after that period (during which an outbreak of Omicron subvariants occurred) is unknown. Methods: We applied seasonal autoregressive integrated moving averages to five years of pre-pandemic data provided by the Massachusetts Registry of Vital Records and Statistics (MRVRS) to project the weekly populations and expected deaths for the pandemic period. Observed deaths during the pandemic were also provided by MRVRS and are >99% complete for all study weeks. Results: During the 18-week Omicron subvariant period (the week ending February 27, 2022, through June 26, 2022) the incidence of all-cause excess mortality was 0.1 per 100,000-person weeks, corresponding to 148 excess deaths (95%. CI -907 to 1153), representing a 97.1% decrease from the initial Omicron period (during which all-cause excess mortality was 4.0 per 100,000-person-weeks), and a 91.9% reduction from the Delta and Delta-Omicron transition period (during which all-cause excess mortality was 1.5 per 100,000-person-weeks), despite >226,000 reported new Covid-19 cases during the subvariant/spring period. However, Covid-19-associated hospitalizations were observed during the subvariant/spring 2022 period. Conclusion: In a highly vaccinated state with a recent wave of SARS-CoV-2, all-cause excess mortality was uncoupled from new case counts, indicating the possibility of temporary protection from the most severe outcomes related to Covid-19 among high-risk individuals. However, given the possibility of waning immunity and the emerging of new variants, continued monitoring is warranted.

Absence of Excess Mortality in a Highly Vaccinated Population During the Initial Covid-19 Delta Period. (preprint)

BackgroundAll-cause excess mortality (the number of deaths that exceed projections in any period) has been widely reported during the Covid-19 pandemic. Whether excess mortality has occurred during the Delta wave is less well understood. MethodsWe performed an observational study using data from the Massachusetts Department of Health. Five years of US Census population data and CDC mortality statistics were applied to a seasonal autoregressive integrated moving average (sARIMA) model to project the number of expected deaths for each week of the pandemic period, including the Delta period (starting in June 2021, extending through August 28th 2021, for which mortality data are >99% complete). Weekly Covid-19 cases, Covid-19-attributed deaths, and all-cause deaths are reported. County-level excess mortality during the vaccine campaign are also reported, with weekly rates of vaccination in each county that reported 100 or more all-cause deaths during any week included in the study period. ResultsAll-cause mortality was not observed after March 2021, by which time over 75% of persons over 65 years of age in Massachusetts had received a vaccination. Fewer deaths than expected (which we term deficit mortality) occurred both during the summer of 2020, the spring of 2021 and during the Delta wave (beginning June 13, 2021 when Delta isolates represented >10% of sequenced cases). After the initial wave in the spring of 2020, more Covid-19-attributed deaths were recorded that all-cause excess deaths, implying that Covid-19 was misattributed as the underlying cause, rather than a contributing cause of death in some cases. ConclusionIn a state with high vaccination rates, excess mortality has not been recorded during the Delta period. Deficit mortality has been recorded during this period.

Mortality from injury, overdose and suicide during the 2020 COVID-19 pandemic, March-July, 2020 (preprint)

Introduction: The COVID-19 pandemic has been associated with substantial rates of all-cause excess mortality. The contribution of external causes of death to excess mortality including drug overdose, homicide, suicide, and unintentional injuries during the initial outbreak in the United States is less well documented. Methods Using public data published by the National Center for Health Statistics on February 10, 2021, we measured monthly excess mortality (the gap between observed and expected deaths) from five external causes using national-level data published by National Center for Health Statistics; assault (homicide); intentional self-harm (suicide); accidents (unintentional injuries); and motor vehicle accidents. We used seasonal autoregressive integrated moving average (sARIMA) models developed with cause-specific monthly mortality counts and US population data from 2015-2019 and estimated the contribution of individual cause-specific mortality to all-cause excess mortality from March-July 2020. Results From March-July, 2020, 212,825 (95% CI 136,236-290,776) all-cause excess deaths occurred in the US). There were 8,540 excess drug overdoses (all intents) (95% CI 5,106 to 11,975), accounting for 4% of all excess mortality; 1,455 excess homicide deaths (95% CI 708 to 2202, accounting for 0.7% of excess mortality; 5,492 excess deaths due to unintentional accidents occurred (95% CI 85 to 10,899, accounting for 2.6% of excess mortality. Though a non-significantly 135 (95% CI -1361 to 1,630) more MVA deaths were recorded during the study period, a significant decrease in April (525; 95% CI -817 to -233) and significant increases in June-July (965; 95% CI 348 to 1,587) were observed. Suicide deaths were statistically lower than projected by 2,067 (95% CI 941-3,193 fewer deaths). Meaning Excess deaths from drug overdoses, homicide, and addicents occurred during the pandemic but represented a small fraction of all-cause excess mortality. The excess external causes of death, however, still represent thousands of lives lost. Notably, deaths from suicide were lower than expected and therefore did not contribute to excess mortality.

Correcting excess mortality for pandemic-associated population decreases (preprint)

Objectives We identify a correction for excess mortality that takes the sudden unexpected changes in the size of the United States population into account. Design This is a weekly cross-sectional analysis of all-cause mortality since week 5, 2020. We describe and apply a simple correction that takes population changes into account in order to provide corrected weekly estimates of expected deaths for 2020 and 2021. Setting The United States. Participants All United States residents. Interventions The covid-19 pandemic. Main outcome measures Expected and excess mortality for the United States during the covid-19 period. Results As of week 53, 2020 (ending January 2, 2021), approximately >10,200 more excess deaths have occurred in the United States than could be detected if expected deaths projections were not amended to reflect population decreases during 2020. The figure is projected to rise to >12,600 (>600 weekly) by week 5, 2021. Assuming recent excess mortality and pandemic-associated visa reductions continue until the earliest time herd immunity could be approached resulting from a combination of infections and vaccinations (week 17, 2021), if point estimates of expected deaths are not corrected, expected deaths will be overestimated (and therefore potential excess mortality underestimated) by ∼43,000 during 2021, or >53,300 since the outbreak of the pandemic measurement period (beginning week 5, 2020). By late December 2021, weekly expected death differences are projected to approach 1,000 per week. Conclusions Current models measuring excess mortality should be revised immediately so that public health officials do not lose the ability to detect ongoing excess mortality as the population changes continue to compound, lowering the number of weekly expected deaths. A similar approach should be used in the middle and late phases of all future pandemics.

Emergency Department Utilization for Emergency Conditions During COVID-19.

STUDY OBJECTIVE: We use a national emergency medicine clinical quality registry to describe recent trends in emergency department (ED) visitation overall and for select emergency conditions. METHODS: Data were drawn from the Clinical Emergency Department Registry, including 164 ED sites across 35 states participating in the registry with complete data from January 2019 through November 15, 2020. Overall ED visit counts, as well as specific emergency medical conditions identified by International Classification of Diseases, Tenth Revision, Clinical Modification code (myocardial infarction, cerebrovascular accident, cardiac arrest/ventricular fibrillation, and venous thromboembolisms), were tabulated. We plotted biweekly visit counts overall and across specific geographic regions. RESULTS: The largest declines in visit counts occurred early in the pandemic, with a nadir in April 46% lower than the 2019 monthly average. By November, overall ED visit counts had increased, but were 23% lower than prepandemic levels. The proportion of all ED visits that were for the select emergency conditions increased early in the pandemic; however, total visit counts for acute myocardial infarction and cerebrovascular disease have remained lower in 2020 compared with 2019. Despite considerable geographic and temporal variation in the trajectory of the coronavirus disease 2019 outbreak, the overall pattern of ED visits observed was similar across regions and time. CONCLUSION: The persistent decline in ED visits for these time-sensitive emergency conditions raises the concern that coronavirus disease 2019 may continue to impede patients from seeking essential care. Efforts thus far to encourage individuals with concerning signs and symptoms to seek emergency care may not have been sufficient.

SARS-CoV-2 Infection Hospitalization Rate and Infection Fatality Rate among the Non-Congregant Population in Connecticut (preprint)

ImportanceCOVID-19 case fatality and hospitalization rates, calculated using the number of confirmed cases of COVID-19, have been described widely in the literature. However, the number of infections confirmed by testing underestimates the total infections as it is biased based on the availability of testing and because asymptomatic individuals may remain untested. The infection fatality rate (IFR) and infection hospitalization rate (IHR), calculated using the estimated total infections based on a representative sample of a population, is a better metric to assess the actual toll of the disease. ObjectiveTo determine the IHR and IFR for COVID-19 using the statewide SARS-CoV-2 seroprevalence estimates for the non-congregate population in Connecticut. DesignCross-sectional. SettingAdults residing in a non-congregate setting in Connecticut between March 1 and June 1, 2020. ParticipantsIndividuals aged 18 years or above. ExposureEstimated number of adults with SARS-CoV-2 antibodies. Main Outcome and MeasuresCOVID-19-related hospitalizations and deaths among adults residing in a non-congregate setting in Connecticut between March 1 and June 1, 2020. ResultsOf the 2.8 million individuals residing in the non-congregate settings in Connecticut through June 2020, 113,515 (90% CI 56,758-170,273) individuals had SARS-CoV-2 antibodies. There were a total of 9425 COVID-19-related hospitalizations and 4071 COVID-19-related deaths in Connecticut between March 1 and June 1, 2020, of which 7792 hospitalizations and 1079 deaths occurred among the non-congregate population. The overall COVID-19 IHR and IFR was 6.86% (90% CI, 4.58%-13.72%) and 0.95% (90% CI, 0.63%-1.90%) among the non-congregate population. Older individuals, men, non-Hispanic Black individuals and those belonging to New Haven and Litchfield counties had a higher burden of hospitalization and deaths, compared with younger individuals, women, non-Hispanic White or Hispanic individuals, and those belonging to New London county, respectively. Conclusion and RelevanceUsing representative seroprevalence estimates, the overall COVID-19 IHR and IFR were estimated to be 6.86% and 0.95% among the non-congregate population in Connecticut. Accurate estimation of IHR and IFR among community residents is important to guide public health strategies during an infectious disease outbreak.

Suicide Deaths during the Stay-at-Home Advisory in Massachusetts. (preprint)

Many believe that shelter-in-place or stay-at-home policies might cause an increase in so-called deaths of despair. While increases in psychiatric stressors during the COVID-19 pandemic are anticipated, whether suicide rates changed during stay-at-home periods has not been described. This was an observational cohort study that assembled suicide death data for persons aged 10 years or older from the Massachusetts Department of Health Registry of Vital Records and Statistics from January 2015 through May 2020. Using autoregressive integrated moving average (ARIMA) and seasonal ARIMA to analyze suicide deaths in Massachusetts, we compared the observed number of suicide deaths in Massachusetts during the stay-at-home period (March through May, 2020) in Massachusetts to the projected number of expected deaths. To be conservative, we also accounted for the deaths still pending final cause determination The incident rate for suicide deaths in Massachusetts was 0.67 per 100,000 person-month (95% CI 0.56-0.79) versus 0.81 per 100,000 person-month (95% CI 0.69-0.94) during the 2019 corresponding period (incident rate ratio of 0.83; 95% CI 0.66-1.03). The addition of the 57 deaths pending cause determination occurring from March through May 2020 and the 33 cases still pending determination from the 2019 corresponding period did not change these findings. The observed number of suicide deaths during the stay-at-home period did not deviate from ARIMA projected expectations using either preliminary data or an alternate scenario in which deaths pending investigation (exceeding the average remaining number of deaths still pending investigation which occurred during the corresponding 2015-2019 period) were ascribed to suicide. Decedent age and sex demographics were unchanged during the pandemic period compared to 2015-2019. The stable rates of suicide deaths during the stay-at-home advisory in Massachusetts parallel findings following ecological disasters. As the pandemic persists, uncertainty about its scope and economic impact may increase. However, our data are reassuring that an increase in suicide deaths in Massachusetts during the stay-at-home advisory period did not occur.

Clinical efficacy of Lianhua Qingwen integrated with Western medicine on COVID-19 by Meta-analysis

Objective: To systematically evaluate the efficacy of Lianhua Qingwen (LQC) on COVID-19, and provide evidence for the formulation and optimization of clinical therapy on COVID-19. Methods: Six databases (PubMed, Cochrane Library, Wanfang, Weipu, CBM and CNKI) were searched up to May 27, 2020. The Cochrane collaborative bias risk tool was used for risk evaluation and quality assessment;Meta-analysis was carried out by Stata 15 software. Begg's test was used for publication bias. Results: Seven clinical trials were included with 665 COVID-19 patients. Compared with Western medicine alone, integrated Lianhua Qingwen significantly improved the effective rate of clinical symptoms [RR = 1.24, 95% CI (1.12, 1.38), P < 0.05] of COVID-19, increased CT improvement [RR = 1.14, 95% CI (1.02, 1.28), P < 0.05] and reduced the proportion of progressing into sever clinical level [RR = 0.48, 95% CI (0.31, 0.72), P < 0.05];In addition, integrated Lianhua Qingwen could effectively shorten the duration of fever [SMD = -0.87, 95% CI (-1.22,-0.52), P < 0.05], time of clinical symptoms disappearance [SMD = -1.19, 95% CI (-1.56, -0.82), P < 0.05] and hospital stay [SMD = -0.61, 95% CI (-0.91, -0.30), P < 0.05]. Conclusion: Lianhua Qingwen could be used as adaptive and complementary medicine to improve clinical symptoms and CT for COVID-19.

Seroprevalence of SARS-CoV-2-Specific IgG Antibodies Among Adults Living in Connecticut Between March 1 and June 1, 2020: Post-Infection Prevalence (PIP) Study (preprint)

BackgroundA seroprevalence study can estimate the percentage of people with SARS-CoV-2 antibodies in the general population, however, most existing reports have used a convenience sample, which may bias their estimates. MethodsWe sought a representative sample of Connecticut residents, aged [≥]18 years and residing in non-congregate settings, who completed a survey between June 4 and June 23, 2020 and underwent serology testing for SARS-CoV-2-specific IgG antibodies between June 10 and July 29, 2020. We also oversampled non-Hispanic Black and Hispanic subpopulations. We estimated the seroprevalence of SARS-CoV-2-specific IgG antibodies and the prevalence of symptomatic illness and self-reported adherence to risk mitigation behaviors among this population. ResultsOf the 567 respondents (mean age 50 [{+/-}17] years; 53% women; 75% non-Hispanic White individuals) included at the state-level, 23 respondents tested positive for SARS-CoV-2-specific antibodies, resulting in weighted seroprevalence of 4.0 (90% confidence interval [CI] 2.0-6.0). The weighted seroprevalence for the oversampled non-Hispanic Black and Hispanic populations was 6.4% (90% CI 0.9-11.9) and 19.9% (90% CI 13.2-26.6), respectively. The majority of respondents at the state-level reported following risk mitigation behaviors: 73% avoided public places, 75% avoided gatherings of families or friends, and 97% wore a facemask, at least part of the time. ConclusionsThese estimates indicate that the vast majority of people in Connecticut lack antibodies against SARS-CoV-2 and there is variation by race/ethnicity. There is a need for continued adherence to risk mitigation behaviors among Connecticut residents to prevent resurgence of COVID-19 in this region.