Tuesday, October 13, 2020

JAMA: Excess Deaths From COVID-19 and Other Causes, March-July 2020



With the caveat that we'll probably be debating the death toll (direct and indirect) from COVID-19  for years (or even decades) to come, we've a new study - published yesterday in JAMA - that attempts to quantify the excess number of deaths in the United States during the opening months of the pandemic.  

While deaths are far from being the only burden from this emerging virus (see PAHO Epi Alert: Complications & Sequelae Of COVID-19), for many people the CFR (Case Fatality Rate) defines the severity of the pandemic. 

Unfortunately, as we've discussed dozens of times in the past (see here, here & here), counting individual deaths due to a specific cause is rarely straightforward.  The CDC's recently published Burden Of The 2019-2020 Flu Season  estimated the number of flu related deaths as 22,000, but that was averaged from a range of 17,970 - 29,053. 

The official count of pediatric flu deaths, which are legally reportable (unlike adult flu deaths), last year was 189.  But the CDC estimates that the true number was probably closer to 600.

Whether you are talking about COVID-19, influenza, or any other infectious disease - it is safe to assume that surveillance and reporting always under-represents the true burden of a disease (see 2018's Why Flu Fatality Numbers Are So Hard To Determine).

In early April, the New York Fire Department reported a 400% increase in sudden cardiac arrest death calls beginning in late March (see NBC affiliate Massive Spike in NYC ‘Cardiac Arrest’ Deaths Seen as Sign of COVID-19 Undercounting).

While most of these cases were never tested for COVID-19, this trend became so pronounced that the city ordered new Standards Of Care During A Pandemic: CPR & Cardiac Arrest, limiting the use of CPR in the field. 

We now know that COVID-19 can cause blot clots and severe cardiovascular damage (see Nature Med. Review: Extrapulmonary manifestations of COVID-19), meaning that some percentage of those cardiac arrests were likely due to the virus.  Most, however, were never tested for the virus. 

While it is impossible to count every COVID-19 related death, we do have an excellent idea of how many people are expected to die over a specific period of time in this country, and following the arrival of COVID-19, those numbers quickly skyrocketed in areas being hard hit by the virus. 

All of which brings us to a new study, published yesterday in JAMA, that compares the expected number of deaths in the United States during the opening months of the pandemic to the actual number of deaths, and finds far more than have been attributed to the virus. 

There is a lot here to absorb, and so we have a link to the study and some excerpts, links to two brief multi-media presentations, two accompanying editorials, and a press release. 

The upshot is that 50% more excess deaths have been reported in the United States since the pandemic began than have been directly attributed to the virus, which suggests the real death toll is substantially higher than has been reported. 


Previous studies of excess deaths (the gap between observed and expected deaths) during the coronavirus disease 2019 (COVID-19) pandemic found that publicly reported COVID-19 deaths underestimated the full death toll, which includes documented and undocumented deaths from the virus and non–COVID-19 deaths caused by disruptions from the pandemic.1,2
A previous analysis found that COVID-19 was cited in only 65% of excess deaths in the first weeks of the pandemic (March-April 2020); deaths from non–COVID-19 causes (eg, Alzheimer disease, diabetes, heart disease) increased sharply in 5 states with the most COVID-19 deaths.1 This study updates through August 1, 2020, the estimate of excess deaths and explores temporal relationships with state reopenings (lifting of coronavirus restrictions).
Between March 1 and August 1, 2020, 1 336 561 deaths occurred in the US, a 20% increase over expected deaths (1 111 031 [95% CI, 1 110 364 to 1 111 697]). The 10 states with the highest per capita rate of excess deaths were New York, New Jersey, Massachusetts, Louisiana, Arizona, Mississippi, Maryland, Delaware, Rhode Island, and Michigan. The states with the highest per capita rate of excess deaths changed from week to week (Video).
The increase in absolute deaths in these states relative to expected values ranged from 22% in Rhode Island and Michigan to 65% in New York (Table). Three states with the highest death rates (New Jersey, New York, and Massachusetts) accounted for 30% of US excess deaths but had the shortest epidemics (ED90 < 10 weeks). States that experienced acute surges in April (and reopened later) had shorter epidemics that returned to baseline in May, whereas states that reopened earlier experienced more protracted increases in excess deaths that extended into the summer (Figure).

Of the 225 530 excess deaths, 150 541 (67%) were attributed to COVID-19. Joinpoint analyses revealed an increase in deaths attributed to causes other than COVID-19, with 2 reaching statistical significance. US mortality rates for heart disease increased between weeks ending March 21 and April 11 (APC, 5.1 [95% CI, 0.2-10.2]), driven by the spring surge in COVID-19 cases. Mortality rates for Alzheimer disease/dementia increased twice, between weeks ending March 21 and April 11 (APC, 7.3 [95% CI, 2.9-11.8]) and between weeks ending June 6 and July 25 (APC, 1.5 [95% CI, 0.8-2.3]), the latter coinciding with the summer surge in sunbelt states.

         (Continue . . . )

You'll the find two accompanying editorials below, followed by a link and excepts from a press release from the Virginia Commonwealth University.

October 12, 2020

Excess Deaths and the Great Pandemic of 2020
Howard Bauchner, MD1; Phil B. Fontanarosa, MD, MBA1
Author Affiliations Article Information

JAMA. Published online October 12, 2020. doi:10.1001/jama.2020.20016

October 12, 2020

The Toll of COVID-19
Harvey V. Fineberg, MD, PhD1
Author Affiliations Article Information
JAMA. Published online October 12, 2020. doi:10.1001/jama.2020.20019

States that reopened sooner, such as Texas, Arizona and Florida, experienced summer surges, report says.

A map of the U.S. shows the states that have had the highest rates of excess deaths during the week of July 25, 2020. The latest study from a team of researchers at Virginia Commonwealth University found that some states saw a protracted summer surge in the rate of excess deaths, both from COVID-19 and from the effects of the pandemic itself. (Courtesy of JAMA Network)

By Jackie Kruszewski
C. Kenneth and Dianne Wright Center for Clinical and Translational Research
(804) 828-6671
Monday, Oct. 12, 2020
For every two deaths attributed to COVID-19 in the U.S., a third American dies as a result of the pandemic, according to new data published in the Journal of the American Medical Association.

The study, led by researchers at Virginia Commonwealth University, shows that deaths between March 1 and Aug. 1 increased 20% compared to previous years — maybe not surprising in a pandemic. But deaths attributed to COVID-19 only accounted for 67% of those deaths.

“Contrary to skeptics who claim that COVID-19 deaths are fake or that the numbers are much smaller than we hear on the news, our research and many other studies on the same subject show quite the opposite,” said lead author Steven Woolf, M.D., director emeritus of VCU’s Center on Society and Health.

The study also contains suggestive evidence that state policies on reopening early in April and May may have fueled the surges experienced in June and July.

“The high death counts in Sun Belt states show us the grave consequences of how some states responded to the pandemic and sound the alarm not to repeat this mistake going forward,” said Woolf, a professor in the Department of Family Medicine and Population Health at the VCU School of Medicine.
Total death counts in the U.S. are remarkably consistent from year to year, as the study notes. The study authors pulled data from the Centers for Disease Control and Prevention for 2014 to 2020, using regression models to predict expected deaths for 2020.
The gap between reported COVID-19 deaths and all unexpected deaths can be partially explained by delays in reporting COVID-19 deaths, miscoding or other data limitations, Woolf said. But the pandemic’s other ripple effects could explain more.
“Some people who never had the virus may have died because of disruptions caused by the pandemic,” said Woolf, VCU’s C. Kenneth and Dianne Wright Distinguished Chair in Population Health and Health Equity. “These include people with acute emergencies, chronic diseases like diabetes that were not properly care for, or emotional crises that led to overdoses or suicides.”
For example, the study specifically showed that the entire nation experienced significant increases in deaths from dementia and heart disease. Woolf said deaths from Alzheimer’s disease and dementia increased not only in March and April, when the pandemic began, but again in June and July when the COVID-19 surge in the Sun Belt occurred.

While COVID-19 qualifies in my mind as being a relatively low mortality - high morbidity pandemic (at least compared to what we've might have seen from MERS-CoV or avian flu), it has likely claimed 10 times more lives in the past 7 months than the moderate 2019-2020 flu season did in 12 months (est. 22,000).  

And since COVID-19 arrived in the spring, we have yet to go through a winter with this pandemic virus.  Full comparisons will have to wait until March or April. 

And the evidence right now suggests we are in for a long, and difficult winter.