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Editor's Comment
COVID-19

Tallying the Toll of Excess Deaths from COVID-19

  • 1Editor, JAMA Health Forum
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor

Since the first person tested positive for COVID-19 in the United States on January 20, 2020, approximately 2.5 million individuals in the United States have subsequently been diagnosed with this novel coronavirus infection, and more than 125 000 US deaths from COVID-19 have been reported. An outbreak that was initially concentrated in metropolitan areas such as New York City, Detroit, and New Orleans has now spread throughout the country, particularly in states such as Arizona, Florida, and Texas that were largely spared during the early months of the pandemic but are now major hot spots of infection.

Two new JAMA Network studies published online today report excess US deaths during the early months of the COVID-19 pandemic.1,2 These studies analyzed provisional mortality data that were available just 3 weeks ago from the National Center for Health Statistics for 48 states. Each of the studies compared observed deaths in 2020 to model-based estimates of expected deaths derived from other recent years. The 2 studies add a national view to a recent report documenting excess deaths in New York City during the first 2 months of the pandemic.3

In a JAMA research letter, Woolf et al estimated 87 001 excess deaths between March 1 and April 25, 2020, representing 17% of all observed US deaths during these 8 weeks.1 The authors attributed 65% of these excess deaths to COVID-19. In the 5 states (New York, New Jersey, Pennsylvania, Michigan and Massachusetts) with the largest numbers of excess deaths during this time period, substantial proportions of the deaths were attributed to causes other than COVID-19, including heart disease, cerebrovascular disease, diabetes, and Alzheimer disease.

Using similar methods in a JAMA Internal Medicine study, Weinberger and colleagues reported 122 300 excess deaths between March 1 and May 30, 2020, representing 16% of all observed US deaths during this 3-month period.2 The authors noted that 78% of these excess deaths had been officially attributed to COVID-19. They also noted that the association between diagnostic testing and excess deaths attributed to COVID-19 varied widely among states, suggesting that testing availability could explain some of the differences among states in the proportion of excess deaths attributed to COVID-19.

The excess deaths reported in the 2 studies likely occurred in 3 groups of decedents. The first group included those who were diagnosed and treated for COVID-19, representing most of the excess deaths in these studies. The second group consisted of those who died at home or in nursing homes or skilled nursing facilities from COVID-19 and related acute cardiopulmonary complications4-7 without being tested for the virus.

The third group was composed of those without COVID-19 who delayed or avoided seeking medical care for other life-threatening conditions, such as myocardial infarction or stroke, due to concerns about being exposed to COVID-19 in hospital settings.8 During mid-March through late May of this year, visits to emergency departments for these 2 cardiovascular conditions declined by 20% or more nationally relative to the preceding 10 weeks.9 Among some individuals with more severe forms of these conditions, excess deaths might have been averted with timely medical care.

The United States and other countries have been focused on understanding the mortality and morbidity that can be directly measured among individuals who have tested positive for COVID-19. However, the 2 new studies published today in JAMA and JAMA Internal Medicine suggest that up to one-third of excess deaths during the pandemic may occur in those who have not tested positive for COVID-19. Thus, these studies underscore the importance of continuing to measure excess deaths in the months and years ahead to gain a more complete understanding of the pandemic’s overall death toll, especially by race and ethnicity,10 and to guide more effective strategies to limit this toll.

References
1.
Woolf  SH, Chapman  DA, Sabo  RT, Weinberger  DM, Hill  L.  Excess deaths from COVID-19 and other causes, March-April 2020.   JAMA. Published online July 1, 2020. doi:10.1001/jama.2020.11787Google Scholar
2.
Weinberger  DM, Chen  J, Cohen  T,  et al.  Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020.   JAMA Intern Med. Published online July 1, 2020. doi:10.1001/jamainternmed.2020.3391Google Scholar
3.
New York City Department of Health and Mental Hygiene (DOHMH) COVID-19 Response Team.  Preliminary estimate of excess mortality during the COVID-19 outbreak—New York City, March 11-May 2, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(19):603-605. doi:10.15585/mmwr.mm6919e5PubMedGoogle ScholarCrossref
4.
Shi  S, Qin  M, Shen  B,  et al.  Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China.   JAMA Cardiol. Published online March 25, 2020. doi:10.1001/jamacardio.2020.0950PubMedGoogle Scholar
5.
Guo  T, Fan  Y, Chen  M,  et al.  Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19).   JAMA Cardiol. Published online March 27, 2020. doi:10.1001/jamacardio.2020.1017PubMedGoogle Scholar
6.
Madjid  M, Safavi-Naeini  P, Solomon  SD, Vardeny  O.  Potential effects of coronaviruses on the cardiovascular system: a review.   JAMA Cardiol. Published online March 27, 2020. doi:10.1001/jamacardio.2020.1286PubMedGoogle Scholar
7.
Moores  LK, Tritschler  T, Brosnahan  S,  et al  Prevention, diagnosis and treatment of VTE in patients with COVID-19: CHEST guideline and expert panel report.   Chest. Published online June 2, 2020. doi:10.1016/j.chest.2020.05.559Google Scholar
8.
Kocher  KE, Macy  ML.  Emergency department patients in the early months of the Coronavirus Disease 2019 (COVID-19) pandemic—what have we learned?   JAMA Health Forum. 2020;1(6):e200705. doi:10.1001/jamahealthforum.2020.0705Google Scholar
9.
Lange  SJ, Ritchey  MD, Goodman  AB,  et al.  Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions — United States, January–May 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2PubMedGoogle ScholarCrossref
10.
Essien  UR, Venkataramani  A.  Data and policy solutions to address racial and ethnic disparities in the COVID-19 pandemic.   JAMA Health Forum. 2020;1(4):e200535. doi:10.1001/jamahealthforum.2020.0535Google Scholar
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    1 Comment for this article
    EXPAND ALL
    Downward Trend in Excess Deaths Since June 2020
    Sai Kiang Lim, PhD | Institute of Molecular and Cell Biology, A*STAR
    I refer to your editorial comments on Woolf et a (1) who estimated 87 001 excess deaths between March 1 and April 25, 2020, and Weinberger and colleagues (2) who reported 122 300 excess deaths between March 1 and May 30, 2020.

    Based on CDC provisional data on weekly percentage of deaths from all causes versus expected deaths (3)  there was a consistent weekly downward trend after a peak of 142% on 11 April 2020. From June 13, 2020, the weekly excess death percentage started to move into negative territory i.e. <100% (6/20/2020: 95%; 6/27/2020: 82%; 7/4/2020: 60%; 7/11/2020: 30%).


    Although the data are provisional and the number of weekly reported deaths may lag behind actual number of deaths, the trend is consistently downward since the week of 11 April.

    This downward trend is also evident in most European countries by late June 2020 after an apparent peak in late March and early April. Some of these countries are also moving towards a negative weekly percentage of excess deaths (4).

    While the robustness and sustainability of this downward trend in excess COVID-19 deaths towards negativity remains to be confirmed, there is a possibility that the final tally of all deaths in 2020 may not exceed the expected number of deaths in 2020. The current provisional overall percentage of 105% excess deaths to date for the year 2020 in US provides some optimism for this possibility (5).


    References

    1. Woolf, S.H., Chapman, D.A., Sabo, R.T., Weinberger, D.M., and Hill, L. (2020). Excess deaths from COVID-19 and other causes, March-April 2020. Jama.

    2. Weinberger, D.M., Chen, J., Cohen, T., Crawford, F.W., Mostashari, F., Olson, D., Pitzer, V.E., Reich, N.G., Russi, M., Simonsen, L., et al. (2020). Estimation of Excess Deaths Associated With the COVID-19 Pandemic in the United States, March to May 2020. JAMA Internal Medicine.

    3. (https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Week-Ending-D/r8kw-7aab; accessed on 16 July 2020),

    4. https://www.economist.com/graphic-detail/2020/07/15/tracking-covid-19-excess-deaths-across-countries, accessed 16 July 2020

    5. https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Week-Ending-D/r8kw-7aab; accessed 16 July 2020
    CONFLICT OF INTEREST: None Reported
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