Geographic and Temporal Patterns in Covid-19 Mortality by Race and Ethnicity in the United States from March 2020 to February 2022

Prior research has established that American Indian, Alaska Native, Black, Hispanic, and Pacific Islander populations in the United States have experienced substantially higher mortality rates from Covid-19 compared to non-Hispanic white residents during the first year of the pandemic. What remains less clear is how mortality rates have changed for each of these racial/ethnic groups during 2021, given the increasing prevalence of vaccination. In particular, it is unknown how these changes in mortality have varied geographically. In this study, we used provisional data from the National Center for Health Statistics (NCHS) to produce age-standardized estimates of Covid-19 mortality by race/ethnicity in the United States from March 2020 to February 2022 in each metro-nonmetro category, Census region, and Census division. We calculated changes in mortality rates between the first and second years of the pandemic and examined mortality changes by month. We found that when Covid-19 first affected a geographic area, non-Hispanic Black and Hispanic populations experienced extremely high levels of Covid-19 mortality and racial/ethnic inequity that were not repeated at any other time during the pandemic. Between the first and second year of the pandemic, racial/ethnic inequities in Covid-19 mortality decreased--but were not eliminated--for Hispanic, non-Hispanic Black, and non-Hispanic AIAN residents. These inequities decreased due to reductions in mortality for these populations alongside increases in non-Hispanic white mortality. Though racial/ethnic inequities in Covid-19 mortality decreased, substantial inequities still existed in most geographic areas during the pandemics second year: Non-Hispanic Black, non-Hispanic AIAN, and Hispanic residents reported higher Covid-19 death rates in rural areas than in urban areas, indicating that these communities are facing serious public health challenges. At the same time, the non-Hispanic white mortality rate worsened in rural areas during the second year of the pandemic, suggesting there may be unique factors driving mortality in this population. Finally, vaccination rates were associated with reductions in Covid-19 mortality for Hispanic, non-Hispanic Black, and non-Hispanic white residents, and increased vaccination may have contributed to the decreases in racial/ethnic inequities in Covid-19 mortality observed during the second year of the pandemic. Despite reductions in mortality, Covid-19 mortality remained elevated in nonmetro areas and increased for some racial/ethnic groups, highlighting the need for increased vaccination delivery and equitable public health measures especially in rural communities. Taken together, these findings highlight the continued need to prioritize health equity in the pandemic response and to modify the structures and policies through which systemic racism operates and has generated racial health inequities.

Missing Americans: Early Death in the United States, 1933-2021

We assessed how many U.S. deaths would have been averted each year, 1933-2021, if U.S. age-specific mortality rates had equaled those of other wealthy nations. The annual number of excess deaths in the U.S. increased steadily beginning in the late 1970s, reaching 626,353 in 2019. Excess deaths surged during the COVID-19 pandemic. In 2021, there were 1,092,293 "Missing Americans" and 25 million years of life lost due to excess mortality relative to peer nations. In 2021, half of all deaths under 65 years and 91% of the increase in under-65 mortality since 2019 would have been avoided if the U.S. had the mortality rates of its peers. Black and Native Americans made up a disproportionate share of Missing Americans, although the majority were White. One sentence summaryIn 2021, 1.1 million U.S. deaths - including 1 in 2 deaths under age 65 years - would have been averted if the U.S. had the mortality rates of other wealthy nations.

Excess all-cause mortality across counties in the United States, March 2020 to December 2021

Excess mortality is the difference between expected and observed mortality in a given period and has emerged as a leading measure of the overall impact of the Covid-19 pandemic that is not biased by differences in testing or cause-of-death assignment. Spatially and temporally granular estimates of excess mortality are needed to understand which areas have been most impacted by the pandemic, evaluate exacerbating and mitigating factors, and inform response efforts, including allocating resources to affected communities. We estimated all-cause excess mortality for the United States from March 2020 through February 2022 by county and month using a Bayesian hierarchical model trained on data from 2015 to 2019. An estimated 1,159,580 excess deaths occurred during the first two years of the pandemic (first: 620,872; second: 538,708). Overall, excess mortality decreased in large metropolitan counties, but increased in nonmetro counties, between the first and second years of the pandemic. Despite the initial concentration of mortality in large metropolitan Northeast counties, beginning in February 2021, nonmetro South counties had the highest cumulative relative excess mortality. These results highlight the need for investments in rural health as the pandemics disproportionate impact on rural areas continues to grow.

COVID-19 mortality among working-age Americans in 46 states, by industry and occupation

IntroductionA small body of epidemiological research suggests that working in an essential sector is a risk factor for SARS-CoV-2 infection or subsequent disease or mortality. However, there is limited evidence to date on the US, or on how the risks associated with essential work differ across demographic subgroups defined by age, sex, and race/ethnicity. MethodsUsing publicly available data from the National Center for Health Statistics on deaths occurring in the US in 2020, we calculated per-capita COVID-19 mortality by industry and occupation. We additionally calculated per-capita COVID-19 mortality by essential industry--essential or not--by age group, sex, and race/ethnicity. ResultsAmong non-military individuals and individuals with a known industry or occupation, there were 48,030 reported COVID-19 deaths, representing 25.1 COVID-19 deaths per 100,000 working-age individuals after age standardization. Per-capita age-standardized COVID-19 mortality was 1.96 times higher among essential workers than among workers in non-essential industries, representing an absolute difference of 14.9 per 100,000. Across industry, per-capita age-standardized COVID-19 mortality was highest in the following industries: accommodation and food services (45.4 per 100,000); transportation and warehousing (43.4); agriculture, forestry, fishing and hunting (42.3); mining (39.6); and construction (38.7). DiscussionGiven that SARS-CoV-2 is an airborne virus, we call for collaborative efforts to ensure that workplace settings are properly ventilated and that workers have access to effective masks. We also urge for paid sick leave, which can help increase vaccine access and minimize disease transmission.

"Pandemic of the unvaccinated"? At midlife, white people are less vaccinated but still at less risk of Covid-19 mortality in Minnesota

IntroductionRecent research underscores the exceptionally young age distribution of Covid-19 deaths in the United States compared with international peers. This brief characterizes how high levels of Covid mortality at midlife ages (45-64) are deeply intertwined with continuing racial inequity in Covid-19 mortality. MethodsMortality data from Minnesota in 2020-2022 were analyzed in June 2022. Death certificate data and published vaccination rates in Minnesota allow vaccination and mortality rates to be observed with greater age and temporal precision than national data. ResultsBlack, Hispanic, and Asian adults under age 65 were all more highly vaccinated than white populations of the same ages during most of Minnesotas substantial and sustained Delta surge and all of the subsequent Omicron surge. However, white mortality rates were lower than those of all other groups. These disparities were extreme; at midlife ages (ages 45-64), during the Omicron period, more highly-vaccinated populations had COVID-19 mortality that was 164% (Asian-American), 115% (Hispanic), or 208% (Black) of white Covid-19 mortality at these ages. In Black, Indigenous, and People of Color (BIPOC) populations as a whole, Covid-19 mortality at ages 55-64 was greater than white mortality at 10 years older. ConclusionsThis discrepancy between vaccination and mortality patterning by race/ethnicity suggests that, if the current period is a "pandemic of the unvaccinated," it also remains a "pandemic of the disadvantaged" in ways that can decouple from vaccination rates. This result implies an urgent need to center health equity in the development of Covid-19 policy measures.

COVID-19 mortality and excess mortality among working-age Californians, by occupational sector: March 2020 through November 2021

BackgroundDuring the first year of the pandemic, essential workers faced higher rates of SARS-CoV-2 infection and COVID-19 mortality than non-essential workers. It is unknown whether disparities in pandemic-related mortality across occupational sectors have continued to occur, amidst SARS-CoV-2 variants and vaccine availability. MethodsWe obtained data on all deaths occurring in the state of California from 2016 through 2021. We restricted our analysis to California residents who were working age (18-65 years at time of death) and died of natural causes. Occupational sector was classified into 9 essential sectors; non-essential; or not in the labor market. We calculated the number of COVID-19 deaths in total and per capita that occurred in each occupational sector. Separately, using autoregressive integrated moving average models, we estimated total, per-capita, and relative excess natural-cause mortality by week between March 1, 2020, and November 30, 2021, stratifying by occupational sector. We additionally stratified analyses of occupational risk into regions with high versus low vaccine uptake, categorizing high-uptake regions as counties where at least 50% of the population completed a vaccination series by August 1, 2021. FindingsFrom March 2020 through November 2021, essential work was associated with higher COVID-19 and excess mortality compared with non-essential work, with the highest per-capita COVID-19 mortality in agriculture (131.8 per 100,000), transportation/logistics (107.1), manufacturing (103.3), and facilities (101.1). Essential workers continued to face higher COVID-19 and excess mortality during the period of widely available vaccines (March through November 2021). Between July and November 2021, emergency workers experienced higher per-capita COVID-19 mortality (113.7) than workers from any other sector. Essential workers faced the highest COVID-19 mortality in counties with low vaccination rates, a difference that was more pronounced during the period of the Delta surge in Summer 2021. InterpretationEssential workers have continued to bear the brunt of high COVID-19 and excess mortality throughout the pandemic, particularly in the agriculture, emergency, manufacturing, facilities, and transportation/logistics sectors. This high death toll has continued during periods of vaccine availability and the delta surge. In an ongoing pandemic without widespread vaccine coverage and anticipated threats of new variants, the US must actively adopt policies to more adequately protect essential workers.

Impact of Covid-19 Pandemic on Racial/Ethnic Differences in Mortality by Cause of Death

ObjectivesTo quantify changes in all-cause and cause-specific mortality by race and ethnicity between 2019 and 2020. MethodsUsing 2019 and 2020 provisional death counts from the National Center for Health Statistics and population estimates from the US Census Bureau, we estimate age-standardized death rates by race/ethnicity and attribute changes in mortality to various causes of death. We also examine how patterns of change across racial/ethnic groups vary by age and sex. ResultsCovid-19 death rates in 2020 were highest in the Hispanic community whereas Black individuals had the largest increase in all-cause mortality between 2019 and 2020. Increases in mortality from heart disease, diabetes, and external causes of death accounted for the adverse trend in all-cause mortality within the Black population. Percentage increases in all-cause mortality were similar for men and women and for ages 25-64 and 65+ for Black and White populations, but increases were greatest for working-aged men among the Hispanic population. ConclusionsExamining increases in non-Covid-19 causes of death is essential for fully capturing both the direct and indirect impact of the Covid-19 pandemic on racial/ethnic mortality disparities.

County-Level Estimates of Excess Mortality associated with COVID-19 in the United States

BackgroundThe COVID-19 pandemic in the U.S. has been largely monitored on the basis of death certificates containing reference to COVID-19. However, prior analyses reveal that a significant percentage of excess deaths associated with the pandemic were not directly assigned to COVID-19. MethodsIn the present study, we estimate a generalized linear model of expected mortality in 2020 based on historical trends in deaths by county of residence between 2011 and 2019. We use the results of the model to generate estimates of excess mortality and excess deaths not assigned to COVID-19 for 1,470 county-sets in the U.S. representing 3,138 counties. ResultsDuring 2020, more than one-fourth of U.S. residents (91.2 million) lived in counties where less than 75% of excess deaths were assigned to COVID-19. Across the country, we estimated that 439,698 excess deaths occurred in 2020, among which 86.7% were assigned to COVID-19. Some regions (Mideast, Great Lakes, New England, and Far West) reported the most excess deaths in large central metros, whereas other regions (Southwest, Southeast, Plains, and Rocky Mountains) reported the highest excess mortality in nonmetro areas. The proportion assigned to COVID-19 was lowest in large central metro areas (79.3%) compared to medium or small metros (87.4%), nonmetro areas (89.4%) and large fringe metros (95.2%). Regionally, the proportion of excess deaths assigned to COVID-19 was lowest in the Southeast (81.1%), Far West (81.2%), Southwest (82.6%), and Rocky Mountains (85.2%). Across the regions, the number of excess deaths exceeded the number of directly assigned COVID-19 deaths in the majority of counties. The exception to this was in New England, which reported more directly assigned COVID-19 deaths than excess deaths in large central metro areas, large fringe metros, and medium or small metros. ConclusionsAcross the U.S., many counties had substantial numbers of excess deaths that were not accounted for in direct COVID-19 death counts. Estimates of excess mortality at the local level can inform the allocation of resources to areas most impacted by the pandemic and contribute to positive protective behavior feedback loops (i.e. increases in mask-wearing and vaccine uptake).

Assessing the Impact of the Covid-19 Pandemic on US Mortality: A County-Level Analysis

BackgroundCovid-19 excess deaths refer to increases in mortality over what would normally have been expected in the absence of the Covid-19 pandemic. Several prior studies have calculated excess deaths in the United States but were limited to the national or state level, precluding an examination of area-level variation in excess mortality and excess deaths not assigned to Covid-19. In this study, we take advantage of county-level variation in Covid-19 mortality to estimate excess deaths associated with the pandemic and examine how the extent of excess mortality not assigned to Covid-19 varies across subsets of counties defined by sociodemographic and health characteristics. Methods and FindingsIn this ecological, cross-sectional study, we made use of provisional National Center for Health Statistics (NCHS) data on direct Covid-19 and all-cause mortality occurring in U.S. counties from January 1 to December 31, 2020 and reported before March 12, 2021. We used data with a ten week time lag between the final day that deaths occurred and the last day that deaths could be reported to improve the completeness of data. Our sample included 2,096 counties with 20 or more Covid-19 deaths. The total number of residents living in these counties was 319.1 million. On average, the counties were 18.7% Hispanic, 12.7% non-Hispanic Black and 59.6% non-Hispanic White. 15.9% of the population was older than 65 years. We first modeled the relationship between 2020 all-cause mortality and Covid-19 mortality across all counties and then produced fully stratified models to explore differences in this relationship among strata of sociodemographic and health factors. Overall, we found that for every 100 deaths assigned to Covid-19, 120 all-cause deaths occurred (95% CI, 116 to 124), implying that 17% (95% CI, 14% to 19%) of excess deaths were ascribed to causes of death other than Covid-19 itself. Our stratified models revealed that the percentage of excess deaths not assigned to Covid-19 was substantially higher among counties with lower median household incomes and less formal education, counties with poorer health and more diabetes, and counties in the South and West. Counties with more non-Hispanic Black residents, who were already at high risk of Covid-19 death based on direct counts, also reported higher percentages of excess deaths not assigned to Covid-19. Study limitations include the use of provisional data that may be incomplete and the lack of disaggregated data on county-level mortality by age, sex, race/ethnicity, and sociodemographic and health characteristics. ConclusionsIn this study, we found that direct Covid-19 death counts in the United States in 2020 substantially underestimated total excess mortality attributable to Covid-19. Racial and socioeconomic inequities in Covid-19 mortality also increased when excess deaths not assigned to Covid-19 were considered. Our results highlight the importance of considering health equity in the policy response to the pandemic. Authors SummaryO_ST_ABSWhy Was This Study Done?C_ST_ABSO_LIThe Covid-19 pandemic has resulted in excess mortality that would not have occurred in the absence of the pandemic. C_LIO_LIExcess deaths include deaths assigned to Covid-19 in official statistics as well as deaths that are not assigned to Covid-19 but are attributable directly or indirectly to Covid-19. C_LIO_LIWhile prior studies have identified significant racial and socioeconomic inequities in directly assigned Covid-19 deaths, few studies have documented how excess mortality in 2020 has differed across sociodemographic or health factors in the United States. C_LI What Did the Researchers Do and Find?O_LILeveraging data from 2,096 counties on Covid-19 and all-cause mortality, we assessed what percentage of excess deaths were not assigned to Covid-19 and examined variation in excess deaths by county characteristics. C_LIO_LIIn these counties, we found that for every 100 deaths directly assigned to Covid-19 in official statistics, an additional 20 deaths occurred that were not counted as direct Covid-19 deaths. C_LIO_LIThe proportion of excess deaths not counted as direct Covid-19 deaths was even higher in counties with lower average socioeconomic status, counties with more comorbidities, and counties in the South and West. Counties with more non-Hispanic Black residents who were already at high risk of Covid-19 death based on direct counts, also reported a higher proportion of excess deaths not assigned to Covid-19. C_LI What Do These Findings Mean?O_LIDirect Covid-19 death counts significantly underestimate excess mortality in 2020. C_LIO_LIMonitoring excess mortality will be critical to gain a full picture of socioeconomic and racial inequities in mortality attributable to the Covid-19 pandemic. C_LIO_LITo prevent inequities in mortality from growing even larger, health equity must be prioritized in the policy response to the Covid-19 pandemic. C_LI