COVID-19 may have killed 20% more than reported in US

Overhead view of people on plaza
Overhead view of people on plaza

Meinzahn / iStock

The COVID-19 pandemic may have exacted a 20% higher US death toll than previously estimated, particularly among racial minorities, underscoring the need to adapt policies to address deepening ethnic and sociodemographic disparities, according to a study led by Boston University researchers.

The study, published yesterday in PLOS Medicine, consisted of analyzing provisional county-level COVID-19 and all-cause death data from the National Center for Health Statistics from Jan 1 to Dec 31, 2020. The sample included 2,096 counties (out of more than 3,000 in the country) that reported at least 20 coronavirus deaths during that time, representing a total of 319.1 million people.

Direct, indirect causes

For every 100 deaths attributed to COVID-19, another 20 deaths were ascribed to other causes. The percentage of non–COVID-19 excess deaths was significantly higher in southern and western counties and those with larger proportions of Black residents, lower median household incomes, lower educational levels, poorer health, and higher rates of diabetes. Counties with high COVID-19 death rates also had high all-cause death rates before the pandemic.

"We estimated that 17% of excess deaths attributable to the COVID-19 pandemic were not assigned to COVID-19 on death certificates," the researchers said. Excess deaths refer to those that would not be expected in a non-pandemic year.

"Direct deaths from unfamiliar complications of COVID-19 such as coagulopathy, myocarditis, inflammatory processes, and arrhythmias may have caused confusion and led to attributions of death to other causes, especially early in the pandemic and among persons with comorbid conditions," the authors wrote.

They added that indirect effects of the pandemic may have also led to higher-than-normal death rates. "Indirect effects may include increases in mortality resulting from reductions in access to and use of healthcare services and psychosocial consequences of stay-at-home orders," the researchers said.

"Increases in stress, depression, and substance use related to the pandemic could also lead to suicides and overdose deaths," they noted. "Economic hardship, housing insecurity, and food insecurity may cause indirect deaths, especially among those living with chronic illnesses or who face acute heath emergencies and cannot afford medicines or medical supplies."

Sample counties were, on average, 18.7% Hispanic, 12.7% Black, 59.6% White, and 16.7% rural, with a median household income of $65,603. Residents older than age 65 made up 15.9% of the population, of whom 16.7% reported being in poor or fair health.

Racial, socioeconomic disparities

When noncoronavirus deaths were taken into account, racial and socioeconomic inequities in COVID-19 death rates also increased. "Our results highlight the importance of considering health equity in the policy response to the pandemic," the researchers concluded.

In a Boston University press release, lead study author Andrew Stokes, PhD, said that COVID-19 deaths were likely underreported on death certificates, owing to severe testing shortages, strained healthcare systems, and a lack of familiarity with the clinical signs and complications of a novel respiratory infection.

"Official COVID-19 death tallies also fail to capture the pandemic's profound social and economic consequences, including the downstream effects of interruptions in receiving health care, loss of employment, evictions, and social isolation and loneliness," Stokes said.

Reluctance to seek medical care for fear of infection also likely contributed to the underreporting, according to the authors. "A more complete accounting of COVID-19 deaths in local communities using excess deaths could lead to increased public awareness and vaccine uptake, particularly in areas where the official death counts suggested the pandemic had a limited impact," Stokes said.

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