Abstract
Deaths are frequently under-estimated during emergencies, times when accurate mortality estimates are crucial for emergency response. This study estimates excess all-cause, pneumonia and influenza mortality during the coronavirus disease 2019 (COVID-19) pandemic using the 11 September 2020 release of weekly mortality data from the United States (U.S.) Mortality Surveillance System (MSS) from 27 September 2015 to 9 May 2020, using semiparametric and conventional time-series models in 13 states with high reported COVID-19 deaths and apparently complete mortality data: California, Colorado, Connecticut, Florida, Illinois, Indiana, Louisiana, Massachusetts, Michigan, New Jersey, New York, Pennsylvania and Washington. We estimated greater excess mortality than official COVID-19 mortality in the U.S. (excess mortality 95% confidence interval (CI) 100 013-127 501 vs. 78 834 COVID-19 deaths) and 9 states: California (excess mortality 95% CI 3338-6344) vs. 2849 COVID-19 deaths); Connecticut (excess mortality 95% CI 3095-3952) vs. 2932 COVID-19 deaths); Illinois (95% CI 4646-6111) vs. 3525 COVID-19 deaths); Louisiana (excess mortality 95% CI 2341-3183 vs. 2267 COVID-19 deaths); Massachusetts (95% CI 5562-7201 vs. 5050 COVID-19 deaths); New Jersey (95% CI 13 170-16 058 vs. 10 465 COVID-19 deaths); New York (95% CI 32 538-39 960 vs. 26 584 COVID-19 deaths); and Pennsylvania (95% CI 5125-6560 vs. 3793 COVID-19 deaths). Conventional model results were consistent with semiparametric results but less precise. Significant excess pneumonia deaths were also found for all locations and we estimated hundreds of excess influenza deaths in New York. We find that official COVID-19 mortality substantially understates actual mortality, excess deaths cannot be explained entirely by official COVID-19 death counts. Mortality reporting lags appeared to worsen during the pandemic, when timeliness in surveillance systems was most crucial for improving pandemic response.
Highlights
The number of Coronavirus Disease 2019 (COVID-19) deaths may be under-reported, and COVID-19 may be indirectly responsible for additional deaths
To assess whether the COVID-19 pandemic was associated with reduced emergency department (ED) utilisation not for COVID-19, we identified 3 of the United States top 5 causes of death that present with acute symptoms that require immediate treatment, for which the choice not to seek healthcare may result in death: heart disease, chronic lower respiratory diseases and cerebrovascular disease
Using the quasi-Poisson model with the outcome daily emergency department visits for asthma syndrome in New York City (NYC), we found that during this period, asthma visits were 64% lower than expected, a substantial drop (IRR = 0.36, 95% CI 0.34–0.37)
Summary
The number of Coronavirus Disease 2019 (COVID-19) deaths may be under-reported, and COVID-19 may be indirectly responsible for additional deaths. The Centers for Disease Control and Prevention issues guidelines to determine cause of deaths, but underestimating the death toll of natural disasters, heatwaves, influenza and other emergencies is common. The underestimates can be extreme: chikungunya was officially associated with only 31 deaths during a 2014–2015 epidemic in Puerto Rico, but time-series analysis estimated excess mortality of 1310 deaths [1]. Deaths indirectly due to an emergency are common, due to an overloaded health system [5] or lack of healthcare access for routine care: during the 2014 West Africa Ebola epidemic, lack of routine care for malaria, HIV/AIDS and tuberculosis led to an estimated 10 600 additional deaths in the area [6]. Health emergencies may lead to indirect deaths from economic, social and emotional stress [7] and crowded emergency departments [8]
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