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USA: Excess death data compared to confirmed COVID-19 fatalities
Total deaths in seven states that have been hard hit by the coronavirus pandemic are nearly 50 percent higher than normal for the five weeks from March 8 through April 11, according to new death statistics from the Centers for Disease Control and Prevention. That is 9,000 more deaths than were reported as of April 11 in official counts of deaths from the coronavirus.
Estimates of excess deaths can provide information about the burden of mortality potentially related to COVID-19, beyond the number of deaths that are directly attributed to COVID-19. Excess deaths are typically defined as the difference between observed numbers of deaths and expected numbers. This visualization provides weekly data on excess deaths by jurisdiction of occurrence. Counts of deaths in more recent weeks are compared with historical trends to determine whether the number of deaths is significantly higher than expected.
Estimates of excess deaths can be calculated in a variety of ways, and will vary depending on the methodology and assumptions about how many deaths are expected to occur. Estimates of excess deaths presented in this webpage were calculated using Farrington surveillance algorithms (1). For each jurisdiction, a model is used to generate a set of expected counts, and the upper bound of the 95% Confidence Intervals (95% CI) of these expected counts is used as a threshold to estimate excess deaths. Observed counts are compared to these upper bound estimates to determine whether a significant increase in deaths has occurred. Provisional counts are weighted to account for potential underreporting in the most recent weeks. However, data for the most recent week(s) are still likely to be incomplete. Only about 60% of deaths are reported within 10 days of the date of death, and there is considerable variation by jurisdiction. More detail about the methods, weighting, data, and limitations can be found in the Technical Notes.
This visualization includes several different estimates:
Number of excess deaths: The number of excess deaths was calculated as the difference between the observed count and the threshold, by week and jurisdiction. Negative values, where the observed count fell below the threshold, were set to zero.
Percent excess: The percent excess was defined as the number of excess deaths divided by the threshold.
Total number of excess deaths: The total number of excess deaths in each jurisdiction was calculated by summing the excess deaths in each week, from January 1, 2020 to present. Similarly, the total number of excess deaths for the US overall was computed as a sum of jurisdiction-specific numbers of excess deaths (with negative values set to zero), and not directly estimated using the Farrington surveillance algorithms.
Weekly counts of deaths from all causes were examined, including deaths due to COVID-19. As many deaths due to COVID-19 may be assigned to other causes of deaths (for example, if COVID-19 was not mentioned on the death certificate as a suspected cause of death), tracking all-cause mortality can provide information about whether an excess number of deaths is observed, even when COVID-19 mortality may be undercounted. Additionally, deaths from all causes excluding COVID-19 were also estimated. Comparing these two sets of estimates — excess deaths with and without COVID-19 — can provide insight about how many excess deaths are identified as due to COVID-19, and how many excess deaths are reported as due to other causes of death. These deaths could represent misclassified COVID-19 deaths, or potentially could be indirectly related to COVID-19 (e.g., deaths from other causes occurring in the context of health care shortages or overburdened health care systems).
Estimates presented here will be updated periodically, and additional information by cause of death will be added in future releases.
Select a dashboard from the drop-down menu, then click on “Update Dashboard” to navigate through different graphics.
The first dashboard shows the weekly predicted counts of deaths from all causes, and the threshold for the expected number of deaths. Select a jurisdiction from the drop-down menu to show data for that jurisdiction.
The second dashboard shows the weekly predicted counts of deaths from all causes and the weekly count of deaths from all causes excluding COVID-19. Select a jurisdiction from the drop-down menu to show data for that jurisdiction.
The third dashboard shows the weekly counts of deaths from all causes. Predicted counts (weighted) are shown, along with reported (unweighted) counts, to illustrate the impact of underreporting. Select a jurisdiction from the drop-down menu to show data for that jurisdiction.
The fourth dashboard shows the total number of excess deaths in 2020. Jurisdictions with one or more excess deaths are shown. Use the radio button to select all-cause mortality, or all-cause excluding COVID-19. Use the drop-down menu to select certain jurisdictions.
The fifth dashboard shows the percent by which the observed counts exceed the threshold (i.e. percent excess) by week and jurisdiction. Use the radio button to select all-cause mortality, or all-cause excluding COVID-19. Use the drop-down menu to select certain jurisdictions.
Download datasets in CSV format by clicking on the link for the desired dataset under “CSV Format” link. Additional file formats are available for download for each dataset at Data.CDC.Gov.
... https://www.cdc.gov/nchs/nvss/vsrr/c...ess_deaths.htm
Twitter: @RonanKelly13
The views expressed are mine alone and do not represent the views of my employer or any other person or organization.
Note: Provisional death counts are based on death certificate data received and coded by the National Center for Health Statistics as of May 15, 2020. Death counts are delayed and may differ from other published sources (see Technical Notes). Counts will be updated periodically. Additional information will be added to this site as available.
The provisional counts for coronavirus disease (COVID-19) deaths are based on a current flow of mortality data in the National Vital Statistics System. National provisional counts include deaths occurring within the 50 states and the District of Columbia that have been received and coded as of the date specified. It is important to note that it can take several weeks for death records to be submitted to National Center for Health Statistics (NCHS), processed, coded, and tabulated. Therefore, the data shown on this page may be incomplete, and will likely not include all deaths that occurred during a given time period, especially for the more recent time periods. Death counts for earlier weeks are continually revised and may increase or decrease as new and updated death certificate data are received from the states by NCHS. COVID-19 death counts shown here may differ from other published sources, as data currently are lagged by an average of 1–2 weeks.
The provisional data presented on this page include the weekly provisional count of deaths in the United States due to COVID-19, deaths from all causes and percent of expected deaths (i.e., number of deaths received over number of deaths expected based on data from previous years), pneumonia deaths (excluding pneumonia deaths involving influenza), pneumonia deaths involving COVID-19, influenza deaths, and deaths involving pneumonia, influenza, or COVID-19; (a) by week ending date and (b) by specific jurisdictions.
Table 1 has counts of death involving COVID-19 and select causes of death by the week ending date in which the death occurred. For COVID-19 deaths by week ending date at the state level, Click here to download.Table 1. Deaths involving coronavirus disease 2019 (COVID-19), pneumonia, and influenza reported to NCHS by week ending date, United States. Week ending 2/1/2020 to 5/9/2020.*
Updated May 15, 2020
Total Deaths
60,299
857,948
101
81,318
26,516
6,158
120,370
2/1/2020
0
57,535
97
3,705
0
472
4,177
2/8/2020
1
58,140
97
3,703
0
506
4,210
2/15/2020
0
57,480
98
3,734
0
535
4,269
2/22/2020
2
57,510
99
3,602
0
553
4,157
2/29/2020
7
57,784
100
3,714
5
625
4,341
3/7/2020
32
57,373
99
3,796
16
608
4,419
3/14/2020
51
55,856
98
3,781
26
598
4,403
3/21/2020
517
55,965
99
4,291
237
518
5,083
3/28/2020
2,897
59,074
106
5,804
1,314
420
7,758
4/4/2020
8,893
66,978
120
9,208
4,260
445
14,066
4/11/2020
14,287
72,459
131
10,983
6,372
450
19,018
4/18/2020
14,077
68,029
126
9,893
6,082
246
17,954
4/25/2020
10,760
60,216
112
7,851
4,607
128
14,045
5/2/2020
6,464
47,070
87
5,057
2,660
43
8,889
5/9/2020
2,311
26,479
50
2,196
937
11
3,581
NOTE: Number of deaths reported in this table are the total number of deaths received and coded as of the date of analysis and do not represent all deaths that occurred in that period. The United States population, based on 2018 postcensal estimates from the U.S. Census Bureau, is 327,167,434.
*Data during this period are incomplete because of the lag in time between when the death occurred and when the death certificate is completed, submitted to NCHS and processed for reporting purposes. This delay can range from 1 week to 8 weeks or more, depending on the jurisdiction, age, and cause of death.
1Deaths with confirmed or presumed COVID-19, coded to ICD–10 code U07.1
2Percent of expected deaths is the number of deaths for all causes for this week in 2020 compared to the average number across the same week in 2017–2019. Previous analyses of 2015–2016 provisional data completeness have found that completeness is lower in the first few weeks following the date of death (<25%), and then increases over time such that data are generally at least 75% complete within 8 weeks of when the death occurred (8).
3Pneumonia death counts exclude pneumonia deaths involving influenza.
4Influenza death counts include deaths with pneumonia or COVID-19 also listed as a cause of death. 5Deaths with confirmed or presumed COVID-19, pneumonia, or influenza, coded to ICD–10 codes U07.1 or J09–J18.9.Table 2. Deaths involving coronavirus disease 2019 (COVID-19), pneumonia, and influenza reported to NCHS by jurisdiction of occurrence, United States. Week ending 2/1/2020 to 5/9/2020.*
Updated May 15, 2020
United States6
60,299
857,948
101
81,318
26,516
6,158
120,370
Alabama
342
14,849
95
955
94
87
1,289
Alaska
-
1,034
83
49
-
-
58
Arizona
401
18,648
103
1,350
191
108
1,668
Arkansas
57
9,075
96
629
17
71
740
California
1,904
80,587
99
7,113
1,113
557
8,461
Colorado
878
12,853
109
1,219
486
92
1,698
Connecticut
525
3,503
37
315
118
47
768
Delaware
162
2,549
93
193
62
15
308
District of Columbia
161
1,823
101
286
161
-
293
Florida
1,477
63,846
102
4,824
777
295
5,814
Georgia
935
23,893
95
1,744
432
100
2,347
Hawaii
15
3,318
96
221
-
19
250
Idaho
66
4,170
99
224
21
24
293
Illinois
2,245
34,358
109
3,466
1,200
173
4,681
Indiana
1,088
20,130
102
1,983
509
125
2,685
Iowa
188
8,666
96
618
39
82
849
Kansas
132
7,715
97
540
59
86
699
Kentucky
207
12,684
88
1,155
109
91
1,344
Louisiana
1,497
13,862
103
1,272
670
68
2,162
Maine
61
4,397
101
353
15
31
430
Maryland
1,320
16,383
110
1,594
493
118
2,524
Massachusetts
4,108
22,373
125
3,033
1,492
155
5,797
Michigan
3,361
32,764
113
3,674
1,682
231
5,580
Minnesota
469
13,466
103
1,009
136
116
1,457
Mississippi
334
9,518
102
886
152
51
1,119
Missouri
380
17,936
93
1,167
130
170
1,587
Montana
15
2,707
88
157
-
33
203
Nebraska
42
4,520
89
350
10
27
409
Nevada
237
7,573
98
684
182
38
777
New Hampshire
117
3,753
102
271
32
30
385
New Jersey
7,237
31,292
141
5,545
3,592
112
9,292
New Mexico
148
5,161
93
388
68
27
495
New York7
7,267
38,394
129
6,528
3,675
199
10,303
New York City
15,440
37,759
236
8,079
5,871
928
17,779
North Carolina
145
15,431
54
971
57
177
1,236
North Dakota
17
1,743
83
160
-
19
190
Ohio
797
33,082
90
2,104
348
241
2,794
Oklahoma
193
10,149
85
930
76
99
1,143
Oregon
119
10,093
93
541
47
61
674
Pennsylvania
2,819
35,445
87
2,984
1,065
182
4,917
Rhode Island
205
2,784
88
215
72
24
372
South Carolina
220
14,778
102
911
79
94
1,146
South Dakota
21
2,203
90
172
-
21
205
Tennessee
204
21,581
98
1,612
93
122
1,845
Texas
745
57,248
96
4,295
319
321
5,040
Utah
57
5,628
101
321
21
40
397
Vermont
47
1,753
102
116
11
14
166
Virginia
744
21,243
104
1,292
259
109
1,884
Washington
747
16,242
95
1,403
398
102
1,850
West Virginia
36
5,513
81
407
-
57
493
Wisconsin
355
16,160
103
908
47
147
1,361
Wyoming
-
1,313
98
102
-
-
113
Puerto Rico
98
6,298
74
897
50
36
981
NOTE: Number of deaths reported in this table are the total number of deaths received and coded as of the date of analysis and do not represent all deaths that occurred in that period.
*Data during this period are incomplete because of the lag in time between when the death occurred and when the death certificate is completed, submitted to NCHS and processed for reporting purposes. This delay can range from 1 week to 8 weeks or more, depending on the jurisdiction, age, and cause of death.
1Deaths with confirmed or presumed COVID-19, coded to ICD–10 code U07.1.
2Percent of expected deaths is the number of deaths for all causes for this week in 2020 compared to the average number across the same week in 2017–2019.
3Pneumonia death counts exclude pneumonia deaths involving influenza.
4Influenza death counts include deaths with pneumonia or COVID-19 also listed as a cause of death.
5Deaths with confirmed or presumed COVID-19, pneumonia, or influenza, coded to ICD–10 codes U07.1 or J09-18.9.
6United States death count includes the 50 states, plus the District of Columbia and New York City. 7Excludes New York City. Understanding the Numbers: Provisional Death Counts and COVID-19
Provisional death counts deliver our most complete and accurate picture of lives lost to COVID-19. They are based on death certificates, which are the most reliable source of data and contain information not available anywhere else, including comorbid conditions, race and ethnicity, and place of death. How it works
The National Center for Health Statistics (NCHS) uses incoming data from death certificates to produce provisional COVID-19 death counts. These include deaths occurring within the 50 states and the District of Columbia.
NCHS also provides summaries that examine deaths in specific categories and in greater geographic detail, such as deaths by county, by race and Hispanic origin.
COVID-19 deaths are identified using a new ICD–10 code. When COVID-19 is reported as a cause of death – or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation. Why these numbers are different
Provisional death counts may not match counts from other sources, such as media reports or numbers from county health departments. Our counts often track 1–2 weeks behind other data.
Death certificates take time to be completed. There are many steps to filling out and submitting a death certificate. Waiting for test results can create additional delays.
States report at different rates. Currently, 63% of all U.S. deaths are reported within 10 days of the date of death, but there is significant variation between states.
It takes extra time to code COVID-19 deaths. While 80% of deaths are electronically processed and coded by NCHS within minutes, most deaths from COVID-19 must be coded by a person, which takes an average of 7 days.
Other reporting systems use different definitions or methods for counting deaths.
Things to know about the data
Provisional counts are not final and are subject to change. Counts from previous weeks are continually revised as more records are received and processed.
Provisional data are not yet complete. Counts will not include all deaths that occurred during a given time period, especially for more recent periods. However, we can estimate how complete our numbers are by looking at the average number of deaths reported in previous years.
Death counts should not be compared across states. Some states report deaths on a daily basis, while other states report deaths weekly or monthly. State vital record reporting may also be affected or delayed by COVID-19 related response activities.
Note: Provisional death counts are based on death certificate data received and coded by the National Center for Health Statistics as of May 22, 2020. Death counts are delayed and may differ from other published sources (see Technical Notes). Counts will be updated periodically. Additional information will be added to this site as available.
The provisional counts for coronavirus disease (COVID-19) deaths are based on a current flow of mortality data in the National Vital Statistics System. National provisional counts include deaths occurring within the 50 states and the District of Columbia that have been received and coded as of the date specified. It is important to note that it can take several weeks for death records to be submitted to National Center for Health Statistics (NCHS), processed, coded, and tabulated. Therefore, the data shown on this page may be incomplete, and will likely not include all deaths that occurred during a given time period, especially for the more recent time periods. Death counts for earlier weeks are continually revised and may increase or decrease as new and updated death certificate data are received from the states by NCHS. COVID-19 death counts shown here may differ from other published sources, as data currently are lagged by an average of 1–2 weeks.
The provisional data presented on this page include the weekly provisional count of deaths in the United States due to COVID-19, deaths from all causes and percent of expected deaths (i.e., number of deaths received over number of deaths expected based on data from previous years), pneumonia deaths (excluding pneumonia deaths involving influenza), pneumonia deaths involving COVID-19, influenza deaths, and deaths involving pneumonia, influenza, or COVID-19; (a) by week ending date and (b) by specific jurisdictions.
Table 1 has counts of death involving COVID-19 and select causes of death by the week ending date in which the death occurred. For COVID-19 deaths by week ending date at the state level, Click here to download.Table 1. Deaths involving coronavirus disease 2019 (COVID-19), pneumonia, and influenza reported to NCHS by week ending date, United States. Week ending 2/1/2020 to 5/16/2020.*
Updated May 22, 2020
Total Deaths
73,639
922,510
103
89,555
32,320
6,253
136,219
2/1/2020
0
57,584
97
3,713
0
475
4,188
2/8/2020
1
58,245
97
3,715
0
507
4,223
2/15/2020
0
57,585
98
3,747
0
541
4,288
2/22/2020
2
57,640
99
3,610
0
553
4,165
2/29/2020
5
57,956
101
3,727
3
629
4,358
3/7/2020
32
57,716
100
3,816
16
610
4,441
3/14/2020
51
56,421
98
3,818
26
600
4,442
3/21/2020
532
56,801
99
4,351
242
528
5,163
3/28/2020
2,964
60,375
106
5,902
1,343
429
7,903
4/4/2020
9,215
68,401
120
9,352
4,431
451
14,365
4/11/2020
15,031
73,869
133
11,235
6,749
456
19,640
4/18/2020
15,311
70,194
130
10,335
6,584
252
19,132
4/25/2020
12,457
64,426
122
8,760
5,400
136
15,863
5/2/2020
9,359
56,606
108
6,839
3,986
50
12,244
5/9/2020
6,764
46,487
94
4,924
2,795
30
8,917
5/16/2020
1,915
22,204
53
1,711
745
6
2,887
NOTE: Number of deaths reported in this table are the total number of deaths received and coded as of the date of analysis and do not represent all deaths that occurred in that period. The United States population, based on 2018 postcensal estimates from the U.S. Census Bureau, is 327,167,434.
*Data during this period are incomplete because of the lag in time between when the death occurred and when the death certificate is completed, submitted to NCHS and processed for reporting purposes. This delay can range from 1 week to 8 weeks or more, depending on the jurisdiction, age, and cause of death.
1Deaths with confirmed or presumed COVID-19, coded to ICD–10 code U07.1
2Percent of expected deaths is the number of deaths for all causes for this week in 2020 compared to the average number across the same week in 2017–2019. Previous analyses of 2015–2016 provisional data completeness have found that completeness is lower in the first few weeks following the date of death (<25%), and then increases over time such that data are generally at least 75% complete within 8 weeks of when the death occurred (8).
3Pneumonia death counts exclude pneumonia deaths involving influenza.
4Influenza death counts include deaths with pneumonia or COVID-19 also listed as a cause of death. 5Deaths with confirmed or presumed COVID-19, pneumonia, or influenza, coded to ICD–10 codes U07.1 or J09–J18.9.Table 2. Deaths involving coronavirus disease 2019 (COVID-19), pneumonia, and influenza reported to NCHS by jurisdiction of occurrence, United States. Week ending 2/1/2020 to 5/16/2020.*
Updated May 22, 2020
United States6
73,639
922,510
103
89,555
32,320
6,253
136,219
Alabama
423
15,836
95
1,023
120
88
1,413
Alaska
-
1,125
85
54
-
-
64
Arizona
518
19,997
105
1,483
254
109
1,856
Arkansas
82
9,842
98
673
22
74
807
California
2,485
86,030
100
7,718
1,414
562
9,350
Colorado
1,088
13,815
111
1,361
588
93
1,949
Connecticut
918
4,875
48
438
195
56
1,216
Delaware
217
2,758
96
220
85
15
367
District of Columbia
216
1,962
103
344
216
-
351
Florida
1,698
67,473
102
5,135
889
300
6,237
Georgia
1,139
25,493
97
1,895
530
102
2,606
Hawaii
15
3,538
97
236
-
19
265
Idaho
70
4,362
98
227
23
24
298
Illinois
3,016
37,267
112
3,986
1,601
174
5,572
Indiana
1,396
21,367
102
2,149
629
126
3,039
Iowa
264
9,244
97
662
62
83
947
Kansas
163
8,126
97
574
73
87
751
Kentucky
274
13,570
90
1,243
141
93
1,468
Louisiana
1,754
14,889
105
1,411
778
70
2,452
Maine
70
4,643
101
364
16
31
449
Maryland
1,752
17,873
113
1,810
648
121
3,020
Massachusetts
5,066
24,287
128
3,431
1,836
159
6,812
Michigan
3,904
33,752
111
3,936
1,973
231
6,094
Minnesota
618
14,431
104
1,097
182
117
1,649
Mississippi
391
9,902
101
939
176
51
1,205
Missouri
496
19,301
95
1,262
173
171
1,756
Montana
16
2,965
90
166
-
34
213
Nebraska
88
5,093
95
396
28
28
484
Nevada
292
8,081
100
744
220
38
854
New Hampshire
156
4,010
103
301
49
30
437
New Jersey
9,253
35,069
149
6,487
4,582
115
11,261
New Mexico
190
5,446
93
414
84
27
547
New York7
8,256
40,874
130
7,035
4,135
200
11,339
New York City
17,002
40,229
236
8,742
6,560
937
19,316
North Carolina
222
18,651
63
1,208
87
196
1,539
North Dakota
24
1,839
83
167
10
19
200
Ohio
1,101
35,529
90
2,327
469
246
3,204
Oklahoma
214
10,642
85
983
87
99
1,206
Oregon
137
10,748
95
578
52
61
724
Pennsylvania
4,439
39,622
92
3,735
1,699
183
6,655
Rhode Island
304
3,045
93
261
110
24
479
South Carolina
339
16,102
106
1,023
131
95
1,325
South Dakota
34
2,354
93
182
13
21
224
Tennessee
246
22,827
100
1,704
105
124
1,969
Texas
962
61,339
99
4,620
405
325
5,500
Utah
70
5,990
102
334
26
40
418
Vermont
51
1,866
104
123
12
14
176
Virginia
962
22,339
105
1,394
329
110
2,135
Washington
766
17,726
100
1,460
409
103
1,916
West Virginia
50
5,864
84
438
12
58
534
Wisconsin
419
17,109
105
958
67
148
1,456
Wyoming
-
1,393
103
104
-
-
115
Puerto Rico
110
7,274
86
1,026
58
47
1,124
NOTE: Number of deaths reported in this table are the total number of deaths received and coded as of the date of analysis and do not represent all deaths that occurred in that period.
*Data during this period are incomplete because of the lag in time between when the death occurred and when the death certificate is completed, submitted to NCHS and processed for reporting purposes. This delay can range from 1 week to 8 weeks or more, depending on the jurisdiction, age, and cause of death.
1Deaths with confirmed or presumed COVID-19, coded to ICD–10 code U07.1.
2Percent of expected deaths is the number of deaths for all causes for this week in 2020 compared to the average number across the same week in 2017–2019.
3Pneumonia death counts exclude pneumonia deaths involving influenza.
4Influenza death counts include deaths with pneumonia or COVID-19 also listed as a cause of death.
5Deaths with confirmed or presumed COVID-19, pneumonia, or influenza, coded to ICD–10 codes U07.1 or J09-18.9.
6United States death count includes the 50 states, plus the District of Columbia and New York City. 7Excludes New York City. Understanding the Numbers: Provisional Death Counts and COVID-19
Provisional death counts deliver our most complete and accurate picture of lives lost to COVID-19. They are based on death certificates, which are the most reliable source of data and contain information not available anywhere else, including comorbid conditions, race and ethnicity, and place of death. How it works
The National Center for Health Statistics (NCHS) uses incoming data from death certificates to produce provisional COVID-19 death counts. These include deaths occurring within the 50 states and the District of Columbia.
NCHS also provides summaries that examine deaths in specific categories and in greater geographic detail, such as deaths by county, by race and Hispanic origin.
COVID-19 deaths are identified using a new ICD–10 code. When COVID-19 is reported as a cause of death – or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation. Why these numbers are different
Provisional death counts may not match counts from other sources, such as media reports or numbers from county health departments. Our counts often track 1–2 weeks behind other data.
Death certificates take time to be completed. There are many steps to filling out and submitting a death certificate. Waiting for test results can create additional delays.
States report at different rates. Currently, 63% of all U.S. deaths are reported within 10 days of the date of death, but there is significant variation between states.
It takes extra time to code COVID-19 deaths. While 80% of deaths are electronically processed and coded by NCHS within minutes, most deaths from COVID-19 must be coded by a person, which takes an average of 7 days.
Other reporting systems use different definitions or methods for counting deaths.
Things to know about the data
Provisional counts are not final and are subject to change. Counts from previous weeks are continually revised as more records are received and processed.
Provisional data are not yet complete. Counts will not include all deaths that occurred during a given time period, especially for more recent periods. However, we can estimate how complete our numbers are by looking at the average number of deaths reported in previous years.
Death counts should not be compared across states. Some states report deaths on a daily basis, while other states report deaths weekly or monthly. State vital record reporting may also be affected or delayed by COVID-19 related response activities.
Question Did more all-cause deaths occur during the first months of the coronavirus disease 2019 (COVID-19) pandemic in the United States compared with the same months during previous years?
Findings In this cohort study, the number of deaths due to any cause increased by approximately 122 000 from March 1 to May 30, 2020, which is 28% higher than the reported number of COVID-19 deaths.
Meaning Official tallies of deaths due to COVID-19 underestimate the full increase in deaths associated with the pandemic in many states.
Abstract
Importance Efforts to track the severity and public health impact of coronavirus disease 2019 (COVID-19) in the United States have been hampered by state-level differences in diagnostic test availability, differing strategies for prioritization of individuals for testing, and delays between testing and reporting. Evaluating unexplained increases in deaths due to all causes or attributed to nonspecific outcomes, such as pneumonia and influenza, can provide a more complete picture of the burden of COVID-19.
Objective To estimate the burden of all deaths related to COVID-19 in the United States from March to May 2020.
Design, Setting, and Population This observational study evaluated the numbers of US deaths from any cause and deaths from pneumonia, influenza, and/or COVID-19 from March 1 through May 30, 2020, using public data of the entire US population from the National Center for Health Statistics (NCHS). These numbers were compared with those from the same period of previous years. All data analyzed were accessed on June 12, 2020.
Main Outcomes and Measures Increases in weekly deaths due to any cause or deaths due to pneumonia/influenza/COVID-19 above a baseline, which was adjusted for time of year, influenza activity, and reporting delays. These estimates were compared with reported deaths attributed to COVID-19 and with testing data.
Results There were approximately 781 000 total deaths in the United States from March 1 to May 30, 2020, representing 122 300 (95% prediction interval, 116 800-127 000) more deaths than would typically be expected at that time of year. There were 95 235 reported deaths officially attributed to COVID-19 from March 1 to May 30, 2020. The number of excess all-cause deaths was 28% higher than the official tally of COVID-19–reported deaths during that period. In several states, these deaths occurred before increases in the availability of COVID-19 diagnostic tests and were not counted in official COVID-19 death records. There was substantial variability between states in the difference between official COVID-19 deaths and the estimated burden of excess deaths.
Conclusions and Relevance Excess deaths provide an estimate of the full COVID-19 burden and indicate that official tallies likely undercount deaths due to the virus. The mortality burden and the completeness of the tallies vary markedly between states.
Introduction
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged in December 2019 in Wuhan, China, and rapidly grew into a global pandemic.1 Without adequate capacity to test for SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), during the early part of the pandemic, laboratory-confirmed cases captured only an estimated 10% to 15% of all infections.2 As a result, estimating the number of deaths caused by COVID-19 is a challenge.
Questions have been raised about the reported tallies of deaths related to COVID-19 in the United States. Some officials have raised concerns that deaths not caused by the virus were improperly attributed to COVID-19, inflating the reported tolls. However, given the limited availability of viral testing and the imperfect sensitivity of the tests,3,4 there have likely been a number of deaths caused by the virus that were not counted. Furthermore, if patients with chronic conditions turn away from the health care system because of concerns about potential COVID-19 infection, there could be increases in certain categories of deaths unrelated to COVID-19. In the midst of a large outbreak, there is also an unavoidable delay in the compilation of death certificates and ascertainment of causes of death. Overall, the degree of testing, criteria for attributing deaths to COVID-19, and the length of reporting delays are expected to vary between states, further complicating efforts to obtain an accurate count of deaths related to the pandemic.
To estimate the mortality burden of a new infectious agent when there is a lack of comprehensive testing, it is common to assess increases in rates of death beyond what would be expected if the pathogen had not circulated.5-7 The “excess death” approach can be applied to specific causes of death directly related to the pathogen (eg, pneumonia or other respiratory conditions), or this approach can be applied to other categories of deaths that may be directly or indirectly influenced by viral circulation or pandemic interventions (eg, cardiac conditions, traffic injuries, or all causes). The excess deaths methodology has been used to quantify official undercounting of deaths for many pathogens, including pandemic influenza viruses and HIV.7-9
In this study, we estimate the excess deaths due to any cause in each week of the COVID-19 pandemic across the United States. We compare these estimates of excess deaths with the reported numbers of deaths due to COVID-19 in different states and evaluate the timing of these increases in relation to testing and pandemic intensity. These analyses provide insights into the burden of COVID-19 in the early months of the outbreak in the United States and serve as a surveillance platform that can be updated as new data accrue.
Methods
Data
Data on deaths due to pneumonia, influenza, and COVID-19 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes U07.1 or J09-J18) and on deaths due to all causes were obtained from the National Center for Health Statistics (NCHS) mortality surveillance system.10 Data were stratified by state and week.
The NCHS reports deaths as they are received from the states and processed; counts of deaths from recent weeks are highly incomplete, reflecting delays in reporting. These “provisional” counts are updated regularly for past weeks, and the counts are not finalized until more than a year after the deaths occur.
Historical data on the proportion of deaths due to pneumonia and influenza in previous years were obtained from Centers for Disease Control and Prevention (CDC) weekly influenza death reports (https://gis.cdc.gov/grasp/fluview/mortality.html) via the cdcfluview package in R (R Foundation), and these were used to determine the number of pneumonia and influenza deaths in the baseline period. All data were accessed June 12, 2020.
Connecticut and North Carolina were missing mortality data for recent months and were therefore excluded from the analyses and from the baseline numbers.
We also compiled data on COVID-19–related morbidity to gauge the timing and intensity of the pandemic in different locations. We used CDC data on influenza-like illness,11 a long-standing indicator of morbidity due to acute respiratory infections, which has been used to monitor COVID-19. We also obtained information on influenza virus circulation to adjust baseline estimates.12 See the eAppendix in the Supplement for details.
To compare our excess mortality estimates with official COVID-19 tallies, we compiled weekly numbers of reported deaths due to COVID-19 in each state from the NCHS,13 and these data were supplemented with data from the COVID Tracking Project.14 State-specific testing information was obtained from the COVID Tracking Project14
These analyses use publicly available aggregate data and were deemed exempt from human subjects review by the Yale institutional review board (protocol 1411014890).
Excess Mortality and Morbidity Analysis
To calculate the number of excess deaths, we first needed to estimate the baseline number of deaths in the absence of COVID-19. We then subtracted the expected number of deaths in each week from the observed number of deaths for the period March 1, 2020, to May 30, 2020.
Each of the 48 states (excluding North Carolina and Connecticut) and the District of Columbia were analyzed individually. We fit Poisson regression models to the weekly state-level death counts from January 5, 2015, to January 25, 2020 (see the eAppendix in the Supplement for details). The baseline was then projected forward until May 30, 2020, to generate baseline deaths; excess mortality was defined as the observed mortality minus the baseline for the pandemic period March 1, 2020, to May 30, 2020. The baseline model was adjusted for seasonality, year-to-year baseline variation, influenza epidemics, and reporting delays. The model for pneumonia/influenza/COVID-19 mortality used all-cause deaths as a denominator and did not have a separate adjustment for reporting delays. Poisson 95% prediction intervals were estimated by sampling from the uncertainty distributions for the estimated model parameters.15 Pennsylvania was not highlighted in the data despite having a large number of excess deaths because the data were incomplete during March 2020. Deaths for New York City are reported separately by the NCHS, and we report estimates for New York City and the rest of New York State separately. To obtain national-level estimates, the observed count and predicted counts (median estimate from the model) for each state were summed for each week and compared. Estimates for excess all-cause deaths were rounded to the nearest 100 and for excess pneumonia/influenza/COVID-19 deaths to the nearest 10. Medians and 95% prediction intervals are presented.
Adjusting for Reporting Delays
Reporting delays make it challenging to estimate excess deaths for recent weeks. To adjust for incomplete data in recent weeks, we adjusted the baseline based on an estimate for data completeness in that week. The estimate of completeness is based on the number of weeks that passed between the week in which the data set was obtained and the week in which the death occurred. We used a modified version of the NobBS package in R to estimate the proportion of deaths that were reported for each date and incorporated that as an adjustment in the main analysis16 (eAppendix in the Supplement). For instance, if we estimated that the data were 75% complete for a particular week, we multiplied the baseline by 0.75. These reporting delays were estimated using provisional data for deaths that occurred since March 29, 2020, and thus reflect changes in reporting that might have occurred during the pandemic. The completeness of the data varied markedly between states (eFigure 1 in the Supplement).
A study by Woolf et al17 of excess deaths in the US used the same database and a related harmonic regression method. The main differences in methodology are that Woolf et al did not adjust for reporting delays, the study period ended on April 25, 2020, and that study controlled for time trends using an adjustment for calendar year rather than epidemiological year.
Across the United States, there were 95 235 reported deaths officially attributed to COVID-19 from March 1 to May 30, 2020. In comparison, there were an estimated 122 300 (95% prediction interval, 116 800-127 000) excess deaths during the same period (Table). The deaths officially attributed to COVID-19 accounted for 78% of the excess all-cause deaths, leaving 22% unattributed to COVID-19. The proportion of excess deaths that were attributed to COVID-19 varied between states and increased over time (Table and Figure 1).
The changes in mortality that occurred during the pandemic varied by state and region. In New York City, all-cause mortality rose 7-fold above baseline at the peak of the pandemic, for a total of 25 100 (95%prediction interval, 24 800-25 400) excess deaths, of which 26% were unattributed to COVID-19 (Table and Figure 2). In contrast, in the rest of New York State, the increase was more moderate, rising 2-fold above baseline and resulting in 12 300 (95% prediction interval, 11 900-12 700) excess deaths. There were notable per capita increases in rates of death due to any cause in many other states, including New Jersey, Massachusetts, Louisiana, Illinois, and Michigan, where the number of deaths greatly exceeded the expected levels (Table, Figure 2, and Figure 3; eFigure 2 in the Supplement for additional states). Other states, particularly smaller states in the central United States and northern New England, had some COVID-19 deaths reported in official tallies but small or no detectable increases in all-cause deaths above expected levels (Table).
The gap between the reported COVID-19 deaths and the estimated all-cause excess deaths varied among states (Table; eFigure 3 in the Supplement). For instance, California had 4046 reported deaths due to COVID-19 and 6800 (95% prediction interval, 6100-7500) excess all-cause deaths, leaving 41% of the excess deaths unattributed to COVID-19 (Table). Texas and Arizona had even wider gaps, with approximately 55% and 53% of the excess deaths unattributed to COVID-19, respectively. In contrast, there was better agreement between the reported COVID-19 deaths and the excess all-cause deaths in Minnesota, with 12% unattributed to COVID-19 (Table).
Some of the discrepancy between reported COVID-19 deaths and excess deaths could be related to the intensity and timing of increases in testing. In some states (eg, Texas, California), excess all-cause mortality preceded the widespread adoption of testing for SARS-CoV-2 by several weeks (Figure 4; eFigure 4 in the Supplement for additional states). In other states (eg, Massachusetts, Minnesota), testing intensity increased prior to or with the increase in excess deaths, and the gap between COVID-19 deaths and excess deaths was smaller (Figure 4).
The increase in excess deaths in many states trailed an increase in outpatient visits due to influenza-like illness by several weeks (eFigure 5 in the Supplement).
We performed several sensitivity analyses. We refit the seasonal baseline without adjusting for influenza activity (eTable in the Supplement). Excluding influenza pulled the baseline upward and led to smaller excess estimates in some states. Furthermore, we created an empirical baseline by averaging the number of deaths in corresponding weeks of the previous years. This yielded weekly estimates of excess death that aligned closely with estimates from our model in April 2020. The estimates of excess deaths based on the empirical baseline were slightly higher than those calculated with the modeled baseline in March 2020 and much lower estimates for May (eFigure 6 in the Supplement). The difference in the estimates for May is driven by reporting delays, which are adjusted for in the modeling approach but not in the empirical baseline. This suggests that our modeling approach provides robust estimates of excess mortality while allowing for formal quantification of uncertainty and more timely estimates than other empirical approaches. Finally, we explored the accuracy of our adjustment for reporting lags (eFigure 8 in the Supplement). The reporting delay correction underestimates deaths by 5% to 8% 2 weeks after the deaths at the national level but then stabilizes after 3 weeks or more. Therefore, our excess mortality estimates for the most recent week are modestly conservative.
Monitoring excess deaths has been used as a method for tracking influenza mortality for more than a century. Herein, we used a similar strategy to capture COVID-19 deaths that had not been attributed specifically to the pandemic coronavirus. Monitoring trends in broad mortality outcomes, like changes in all-cause and pneumonia/influenza/COVID-19 mortality, provides a window into the magnitude of the mortality burden missed in official tallies of COVID-19 deaths. Given the variability in testing intensity between states and over time, this type of monitoring provides key information on the severity of the pandemic and the degree to which viral testing might be missing deaths caused by COVID-19. These findings demonstrate that estimates of the death toll of COVID-19 based on excess all-cause mortality may be more reliable than those relying only on reported deaths, particularly in places that lack widespread testing.
Syndromic end points, such as deaths due to pneumonia/influenza/COVID-19, outpatient visits for influenza-like illness, and emergency department visits for fever, can provide a crude but informative measure of the progression of the outbreak.18 These measures themselves can be biased by changes in health-seeking behavior and how conditions are recorded. However, in the absence of widespread and systematic testing for COVID-19, they provide a useful measure of pandemic progression and the impact of interventions.
The gap between reported COVID-19 deaths and excess deaths can be influenced by several factors, including the intensity of testing; guidelines on the recording of deaths that are suspected to be related to COVID-19 but do not have a laboratory confirmation; and the location of death (eg, hospital, nursing home, or unattended death at home). For instance, deaths that occur in nursing homes might be more likely to be recognized as part of an epidemic and correctly recorded as due to COVID-19. As the pandemic has progressed, official statistics have become better aligned with excess mortality estimates, perhaps due to enhanced testing and increased recognition of the clinical features of COVID-19. In New York City, official COVID-19 death counts were revised after careful inspection of death certificates, adding an extra 5048 probable deaths to the 13 831 laboratory-confirmed deaths.19 As a result, the all-cause excess mortality burden from March 11 to May 2, 2020, is only 27% higher than official COVID-19 statistics.19 This aligns well with our estimate of 26% for a similar period in New York City, using a slightly different modeling approach.
Many European countries have experienced sharp increases in all-cause deaths associated with the pandemic. Real-time all-cause mortality data from the EuroMomo project (https://www.euromomo.eu/) demonstrate gaps between the official COVID-19 death toll and excess deaths that echo findings in our study. These gaps are more pronounced in countries that were affected more and earlier by the pandemic and had weak testing. Very limited excess mortality information is available from Asia, Africa, the Middle East, and South America thus far; these data will be important to fully capture the heterogeneity of death rates related to the COVID-19 pandemic across the world. Prior work on the 1918 and 2009 pandemics has shown substantial heterogeneity in mortality burden between countries, in part related to health care.8,20
Limitations
These analyses are all based on provisional data, which are incomplete for recent weeks in some states because of reporting delays. We have attempted to correct for these reporting delays in the analysis. Sensitivity analyses suggest that these corrections might result in estimates that are conservative (smaller estimates of excess) in the most recent week (eFigure 8 in the Supplement) at the national level, but the correction might overestimate excess deaths in the most recent week in some states. Since several months of data have accrued, and pandemic activity is currently low nationally, any inaccuracies in correcting for reporting delays in recent weeks would likely have a minor impact on the overall estimates of excess deaths.
An alternative approach to the one presented here would be to simply apply the observed number of deaths to the average number of deaths in the corresponding weeks from previous years (eFigure 6 in the Supplement). While this would yield similar answers during certain periods (particularly in April 2020), using an empirical baseline would ignore secular trends in death rates, the potential impact of influenza epidemics in the early part of the COVID-19 pandemic, and reporting delays in more recent weeks. While it would be ideal to wait until the pandemic is over and analyze complete data, there is a need for timely data and analysis during public health emergencies, so the trade-off between data completeness is warranted.
The number of excess deaths reported herein could reflect increases in rates of death directly caused by the virus, increases indirectly related to the pandemic response (eg, due to avoidance of health care), as well as declines in certain causes (eg, deaths due to motor vehicle collisions or triggered by air pollution). Further work is needed to determine the relative importance of these different forces on the overall estimates of excess deaths.
The national estimates do not include data from Connecticut and North Carolina. Together, these account for only 4.5% of the US population and are unlikely to have a large influence on the national-level estimates.
We used a Poisson regression model for analysis. While there was modest overdispersion in some of the larger states, the 95% prediction intervals provide adequate coverage during the prepandemic period (eFigure 7 in the Supplement).
We present a comparison of excess deaths with influenza-like illness. Influenza activity declined to historically low levels starting in March 2020. At the same time, health care–seeking behavior changed drastically. Therefore, analyses of influenza and influenza-like illness need to be interpreted with caution. Regardless, this analysis demonstrates the expected time lag between outpatient visits for influenza-like illness and excess deaths (eFigure 8 in the Supplement).
Conclusions
Monitoring syndromic causes of death can provide crucial additional information on the severity and progression of the COVID-19 pandemic. Estimates of excess deaths will be less biased by variations in viral testing, but reporting lags need to be properly accounted for. Even in situations of ample testing, deaths due to viral pathogens, including SARS-CoV-2, can occur indirectly via secondary bacterial infections or exacerbation of comorbidities. There can also be secondary effects on mortality due to changes in population behavior brought about by strict lockdown measures and an aversion of the health care system. Together with information on official tallies of COVID-19 deaths, monitoring excess mortality provides a key tool in evaluating the effects of an ongoing pandemic.
Author Contributions: Dr Weinberger had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Acquisition, analysis, or interpretation of data: Weinberger, Crawford, Mostashari, Olson, Reich, Russi, Watkins, Viboud.
Drafting of the manuscript: Weinberger, Russi, Watkins, Viboud.
Critical revision of the manuscript for important intellectual content: Weinberger, Chen, Cohen, Crawford, Mostashari, Olson, Pitzer, Reich, Simonsen, Watkins, Viboud.
Administrative, technical, or material support: Chen, Olson, Russi, Viboud.
Conflict of Interest Disclosures: Dr Weinberger reported receipt of consulting fees from Pfizer, Merck, GlaxoSmithKline, and Affinivax for topics unrelated to this work and being principal investigator on a research grant from Pfizer on an unrelated topic. Dr Pitzer reported having received reimbursement from Merck and Pfizer for travel expenses to scientific input engagements unrelated to the topic of this work and being a member of the World Health Organization Immunization and Vaccine-related Implementation Research Advisory Committee (IVIR-AC). No other disclosures were reported.
Funding/Support: This study was supported by grants R01AI123208 (Dr Weinberger), R01AI137093 (Drs Weinberger and Pitzer), R01AI112970 (Dr Pitzer), and R01AI146555 (Dr Cohen) from the National Institute of Allergy and Infectious Diseases/National Institutes of Health; by grant 1DP2HD091799-01 (Dr Crawford) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development; by grant R35GM119582 (Dr Reich) from the National Institute of General Medical Sciences/National Institutes of Health; by grant 1U01IP001122 (Dr Reich) from the CDC; and by grant CF20-0046 (Dr Simonsen) from the Carlsberg Foundation.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Disclaimer: This study does not necessarily represent the views of the National Institutes of Health or the US government. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the New York City Department of Health and Mental Hygiene, or the CDC.
Additional Contributions: We thank Andrew Ba Tran, BA, The Washington Post, for feedback on the analysis code. No compensation was received.
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Twitter: @RonanKelly13
The views expressed are mine alone and do not represent the views of my employer or any other person or organization.
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