Immigrant mortality advantage in the United States during the first year of the COVID-19 pandemic.

OBJECTIVES: To investigate the mortality impact of the COVID-19 pandemic on US-born and foreign-born populations by race and Hispanic origin in the United States in 2020. METHODS: Death records from the National Center for Health Statistics and population data from CDC WONDER were used to estimate (1) age-standardized all-cause and cause-specific mortality at ages 25+, 25-64, and 65+ in 2017-2019 and 2020 by nativity, race, Hispanic origin, and sex; (2) changes in mortality between these two periods; and (3) the cause-specific contributions to these changes. RESULTS: Mortality increased in 2020 relative to 2017-2019 for all racial and Hispanic-origin groups. Adjusting for age, mortality increases were larger at ages 25+ among foreign-born males (390 deaths for 100,000 residents) and females (189) than among US-born males (223) and females (144). The large mortality rise among foreign-born Hispanic men (593) contributed to the narrowing of their mortality advantage relative to White men, from 426 to 134. An increase in mortality among both foreign-born and US-born Black males and females increased the Black-White mortality disparities by 318 for males and by 180 for females. Although COVID-19 mortality was the main driver of the increase among foreign-born residents, circulatory diseases and malignant neoplasms also contributed. CONTRIBUTION: We show that the COVID-19 pandemic had a greater impact on foreign-born populations than on their US-born counterparts. These findings highlight the need to address the underlying inequalities and unique challenges faced by foreign-born populations.

Excess natural-cause mortality in US counties and its association with reported COVID-19 deaths.

In the United States, estimates of excess deaths attributable to the COVID-19 pandemic have consistently surpassed reported COVID-19 death counts. Excess deaths reported to non-COVID-19 natural causes may represent unrecognized COVID-19 deaths, deaths caused by pandemic health care interruptions, and/or deaths from the pandemic's socioeconomic impacts. The geographic and temporal distribution of these deaths may help to evaluate which explanation is most plausible. We developed a Bayesian hierarchical model to produce monthly estimates of excess natural-cause mortality for US counties over the first 30 mo of the pandemic. From March 2020 through August 2022, 1,194,610 excess natural-cause deaths occurred nationally [90% PI (Posterior Interval): 1,046,000 to 1,340,204]. A total of 162,886 of these excess natural-cause deaths (90% PI: 14,276 to 308,480) were not reported to COVID-19. Overall, 15.8 excess deaths were reported to non-COVID-19 natural causes for every 100 reported COVID-19 deaths. This number was greater in nonmetropolitan counties (36.0 deaths), the West (Rocky Mountain states: 31.6 deaths; Pacific states: 25.5 deaths), and the South (East South Central states: 26.0 deaths; South Atlantic states: 25.0 deaths; West South Central states: 24.2 deaths). In contrast, reported COVID-19 death counts surpassed estimates of excess natural-cause deaths in metropolitan counties in the New England and Middle Atlantic states. Increases in reported COVID-19 deaths correlated temporally with increases in excess deaths reported to non-COVID-19 natural causes in the same and/or prior month. This suggests that many excess deaths reported to non-COVID-19 natural causes during the first 30 mo of the pandemic in the United States were unrecognized COVID-19 deaths.

Does bribery increase maternal mortality? Evidence from 135 Sub-Saharan African regions.

About 295,000 women died globally during and following pregnancy and childbirth in 2017. Two-thirds of these deaths occurred in Sub-Saharan Africa. By linking individual and regional data from 135 regions in 17 Sub-Saharan African countries over the period 2002-2018 this study explores how bribery affects maternal mortality in Sub-Saharan Africa. Our results show that the percentage of people who had first-hand experience in bribery is significantly and positively associated with pregnancy related deaths. We find that a 10 p.p. increase in the prevalence of bribery is associated with up to 41 [95% CI: 10-73] additional deaths for every 1,000 pregnancy-related deaths. However, the healthcare system quality appears to be an important moderator. To reduce maternal mortality, policy makers should not only increase investments in healthcare, they need also to implement measures to combat corruption.

COVID-19 and All-Cause Mortality by Race, Ethnicity, and Age Across Five Periods of the Pandemic in the United States.

Racial/ethnic and age disparities in COVID-19 and all-cause mortality during 2020 are well documented, but less is known about their evolution over time. We examine changes in age-specific mortality across five pandemic periods in the United States from March 2020 to December 2022 among four racial/ethnic groups (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian) for ages 35+. We fit Gompertz models to all-cause and COVID-19 death rates by 5-year age groups and construct age-specific racial/ethnic mortality ratios across an Initial peak (Mar-Aug 2020), Winter peak (Nov 2020-Feb 2021), Delta peak (Aug-Oct 2021), Omicron peak (Nov 2021-Feb 2022), and Endemic period (Mar-Dec 2022). We then compare to all-cause patterns observed in 2019. The steep age gradients in COVID-19 mortality in the Initial and Winter peak shifted during the Delta peak, with substantial increases in mortality at working ages, before gradually returning to an older age pattern in the subsequent periods. We find a disproportionate COVID-19 mortality burden on racial and ethnic minority populations early in the pandemic, which led to an increase in all-cause mortality disparities and a temporary elimination of the Hispanic mortality advantage at certain age groups. Mortality disparities narrowed over time, with racial/ethnic all-cause inequalities during the Endemic period generally returning to pre-pandemic levels. Black and Hispanic populations, however, faced a younger age gradient in all-cause mortality in the Endemic period relative to 2019, with younger Hispanic and Black adults in a slightly disadvantageous position and older Black adults in a slightly advantageous position, relative to before the pandemic.

Monthly excess mortality across counties in the United States during the COVID-19 pandemic, March 2020 to February 2022.

Excess mortality is the difference between expected and observed mortality in a given period and has emerged as a leading measure of the COVID-19 pandemic's mortality impact. Spatially and temporally granular estimates of excess mortality are needed to understand which areas have been most impacted by the pandemic, evaluate exacerbating factors, and inform response efforts. 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 1,179,024 excess deaths occurred during the first 2 years of the pandemic (first: 634,830; second: 544,194). Overall, excess mortality decreased in large metropolitan counties but increased in nonmetropolitan counties. Despite the initial concentration of mortality in large metropolitan Northeastern counties, nonmetropolitan Southern counties had the highest cumulative relative excess mortality by July 2021. These results highlight the need for investments in rural health as the pandemic's rural impact grows.

COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022.

Importance: Prior research has established that Hispanic and non-Hispanic Black residents in the US experienced substantially higher COVID-19 mortality rates in 2020 than non-Hispanic White residents owing to structural racism. In 2021, these disparities decreased. Objective: To assess to what extent national decreases in racial and ethnic disparities in COVID-19 mortality between the initial pandemic wave and subsequent Omicron wave reflect reductions in mortality vs other factors, such as the pandemic's changing geography. Design, Setting, and Participants: This cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention for COVID-19 deaths from March 1, 2020, through February 28, 2022, among adults aged 25 years and older residing in the US. Deaths were examined by race and ethnicity across metropolitan and nonmetropolitan areas, and the national decrease in racial and ethnic disparities between initial and Omicron waves was decomposed. Data were analyzed from June 2021 through March 2023. Exposures: Metropolitan vs nonmetropolitan areas and race and ethnicity. Main Outcomes and Measures: Age-standardized death rates. Results: There were death certificates for 977 018 US adults aged 25 years and older (mean [SD] age, 73.6 [14.6] years; 435 943 female [44.6%]; 156 948 Hispanic [16.1%], 140 513 non-Hispanic Black [14.4%], and 629 578 non-Hispanic White [64.4%]) that included a mention of COVID-19. The proportion of COVID-19 deaths among adults residing in nonmetropolitan areas increased from 5944 of 110 526 deaths (5.4%) during the initial wave to a peak of 40 360 of 172 515 deaths (23.4%) during the Delta wave; the proportion was 45 183 of 210 554 deaths (21.5%) during the Omicron wave. The national disparity in age-standardized COVID-19 death rates per 100 000 person-years for non-Hispanic Black compared with non-Hispanic White adults decreased from 339 to 45 deaths from the initial to Omicron wave, or by 293 deaths. After standardizing for age and racial and ethnic differences by metropolitan vs nonmetropolitan residence, increases in death rates among non-Hispanic White adults explained 120 deaths/100 000 person-years of the decrease (40.7%); 58 deaths/100 000 person-years in the decrease (19.6%) were explained by shifts in mortality to nonmetropolitan areas, where a disproportionate share of non-Hispanic White adults reside. The remaining 116 deaths/100 000 person-years in the decrease (39.6%) were explained by decreases in death rates in non-Hispanic Black adults. Conclusions and Relevance: This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic. These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response.

Associations between mortality from COVID-19 and other causes: A state-level analysis.

BACKGROUND: During the COVID-19 pandemic, the high death toll from COVID-19 was accompanied by a rise in mortality from other causes of death. The objective of this study was to identify the relationship between mortality from COVID-19 and changes in mortality from specific causes of death by exploiting spatial variation in these relationships across US states. METHODS: We use cause-specific mortality data from CDC Wonder and population estimates from the US Census Bureau to examine relationships at the state level between mortality from COVID-19 and changes in mortality from other causes of death. We calculate age-standardized death rates (ASDR) for three age groups, nine underlying causes of death, and all 50 states and the District of Columbia between the first full year of the pandemic (March 2020-February 2021) and the year prior (March 2019-February 2020). We then estimate the relationship between changes in cause-specific ASDR and COVID-19 ASDR using linear regression analysis weighted by the size of the state's population. RESULTS: We estimate that causes of death other than COVID-19 represent 19.6% of the total mortality burden associated with COVID-19 during the first year of the COVID-19 pandemic. At ages 25+, circulatory disease accounted for 51.3% of this burden while dementia (16.4%), other respiratory diseases (12.4%), influenza/pneumonia (8.7%) and diabetes (8.6%) also contribute. In contrast, there was an inverse association across states between COVID-19 death rates and changes in death rates from cancer. We found no state-level association between COVID-19 mortality and rising mortality from external causes. CONCLUSIONS: States with unusually high death rates from COVID-19 experienced an even larger mortality burden than implied by those rates alone. Circulatory disease served as the most important route through which COVID-19 mortality affected death rates from other causes of death. Dementia and other respiratory diseases made the second and third largest contributions. In contrast, mortality from neoplasms tended to decline in states with the highest death rates from COVID-19. Such information may help to inform state-level responses aimed at easing the full mortality burden of the COVID-19 pandemic.

Differences Between Reported COVID-19 Deaths and Estimated Excess Deaths in Counties Across the United States, March 2020 to February 2022.

Accurate and timely tracking of COVID-19 deaths is essential to a well-functioning public health surveillance system. The extent to which official COVID-19 death tallies have captured the true toll of the pandemic in the United States is unknown. In the current study, we develop a Bayesian hierarchical model to estimate monthly excess mortality in each county over the first two years of the pandemic and compare these estimates to the number of deaths officially attributed to Covid-19 on death certificates. Overall, we estimated that 268,176 excess deaths were not reported as Covid-19 deaths during the first two years of the Covid-19 pandemic, which represented 23.7% of all excess deaths that occurred. Differences between excess deaths and reported COVID-19 deaths were substantial in both the first and second year of the pandemic. Excess deaths were less likely to be reported as COVID-19 deaths in the Mountain division, in the South, and in nonmetro counties. The number of excess deaths exceeded COVID-19 deaths in all Census divisions except for the New England and Middle Atlantic divisions where there were more COVID-19 deaths than excess deaths in large metro areas and medium or small metro areas. Increases in excess deaths not assigned to COVID-19 followed similar patterns over time to increases in reported COVID-19 deaths and typically preceded or occurred concurrently with increases in reported COVID-19 deaths. Estimates from this study can be used to inform targeting of resources to areas in which the true toll of the COVID-19 pandemic has been underestimated.

Monthly excess mortality across counties in the United States during the Covid-19 pandemic, March 2020 to February 2022.

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 pandemic's disproportionate impact on rural areas continues to grow.