Alyssa\u00a0Bilinski,\u00a0Kathryn\u00a0Thompson,\u00a0Ezekiel\u00a0Emanuel<\/h3>\n\n\n\nJAMA.\u00a0<\/em>2023;329(1):92-94. doi:10.1001\/jama.2022.21795<\/h3>\n\n\n\nThe US experienced high COVID-19 death rates and higher excess all-cause mortality compared with peer countries during 2020.1<\/a><\/sup> However, an important question is how cross-national differences in mortality shifted during 2021 and 2022 with both widespread availability of vaccination and new variants. We compared COVID-19 and excess all-cause mortality in the US, the 10 most- and least-vaccinated states, and 20 peer Organization for Economic Co-operation and Development (OECD) countries during the Delta and winter Omicron waves.<\/a><\/p>\n\n\n\nMethods<\/p>\n\n\n\n
Using previous methodology, we compared the US overall, the 10 most- and least-vaccinated states, and the 20 OECD countries with 2021 population exceeding 5 million and greater than $25\u202f000 per capita gross domestic product (Supplement 1<\/a>).1<\/a><\/sup> US COVID-19 mortality, all-cause mortality, and vaccination data were obtained from the US Centers for Disease Control and Prevention.2<\/a><\/sup> For other countries, COVID-19 mortality data were obtained from the World Health Organization, all-cause mortality data from OECD databases, and vaccination data from Our World in Data (Supplement 1<\/a>).3<\/a><\/sup>-5<\/a><\/sup> Some mortality data from 2021 and 2022 were provisional.<\/a><\/p>\n\n\n\nEach location\u2019s COVID-19 mortality rate per capita was calculated over 2 periods: (1) Delta from June 27, 2021 (week 26), to December 25, 2021 (week 51), and (2) Omicron from December 26, 2021 (week 52), to March 26, 2022 (week 12). We estimated excess all-cause mortality by comparing mortality in each period with mortality in 2015-2019, fitting underlying trends using prepandemic, out-of-sample validation (Supplement 1<\/a>).6<\/a><\/sup><\/a><\/p>\n\n\n\nFor each period, we calculated the difference in US deaths if mortality rates of other locations were realized. We used regression models to statistically compare rates across locations (Supplement 1<\/a>), with significance set at P<\/em>\u2009<\u2009.005 for 2-sided tests to account for multiple testing. Analyses were conducted in R version 4.0.2 (R Foundation for Statistical Computing). The study was deemed not human subjects research by the Brown University institutional review board.<\/a><\/p>\n\n\n\nResults<\/p>\n\n\n\n
The US reported 370\u202f298 COVID-19 deaths (112 per 100\u202f000) during the Delta and Omicron waves (61\/100\u202f000 and 51\/100\u202f000, respectively). COVID-19 deaths per capita in the US overall and in both state subgroups significantly exceeded those of all peer countries during the study period (Table 1<\/a>). However, there were significantly fewer COVID-19 deaths in the top 10 states by vaccination uptake (73% coverage) at 75 deaths\/100\u202f000 compared with the bottom 10 (52% coverage) at 146 per 100\u202f000 (P<\/em>\u2009<\u2009.001).<\/p>\n\n\n\nUS excess all-cause mortality exceeded COVID-19 mortality at 145\/100\u202f000 and exceeded peer countries in all periods, as did excess all-cause mortality in the least-vaccinated states (Table 2<\/a>). However, the 10 most-vaccinated states had excess all-cause mortality comparable with or less than that of several peer countries over Delta and Omicron combined (eg, Denmark, Germany, the Netherlands, Austria, Italy, Finland). While excess all-cause mortality in the top 10 states significantly exceeded that of many comparators during Omicron, excess all-cause mortality was significantly less than COVID-19 mortality for the top 10 states during this wave (29 vs 47 per 100\u202f000, P<\/em>\u2009<\u2009.001).<\/a><\/p>\n\n\n\nFrom June 27, 2021, to March 26, 2022, the US would have averted 122\u202f304 deaths if COVID-19 mortality matched that of the 10 most-vaccinated states and 266\u202f700 deaths if US excess all-cause mortality rate matched that of the 10 most-vaccinated states. If the US matched the rates of other peer countries, averted deaths would have been substantially higher in most cases (range, 154\u202f622-357\u202f899 for COVID-19 mortality; 209\u202f924-465\u202f747 for all-cause mortality).<\/p>\n\n\n\n![\"\"\/](\"https:\/\/cdn.jamanetwork.com\/ama\/content_public\/journal\/jama\/939060\/jld220087t1_1671563416.70121.png?Expires=1675845203&Signature=J4am-J84nRrq-bcG4MD8IrI8fcnc0fzzqDrmjpLdSyliKfia63LatvHjK-VGYeNfPJMYBZUCq4MaBaLIYKlR9Qhhx6F0a6piwDkUWezu5Pgsf5Kfx4E17KaXoAYNyU4EOAdCxu~aid3o4ANUv1-fA2e1N~zubxCTfRPhrCkjxx-1Sb9e8~csmBoZMuqdb747-hsv8Fyq5dgfLX0F7mOQtqgBwXBv-upQcw9FFHHIsGu2vVxKZykoQbusxiEMawEThlQA8tTOsu8aHHG45rbvUh1K8s~aEN3amH7ROI-~MP4NFWZn-RN2u7XHyWohd7afq3qKhiRuB9E73kxieGA3BA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA\")
<\/figure>\n\n\n\n![\"\"\/](\"https:\/\/cdn.jamanetwork.com\/ama\/content_public\/journal\/jama\/939060\/jld220087t2_1671563416.71619.png?Expires=1675845203&Signature=Yy6TQG9qN6bwQVbqF1XenXj55mYe1kIbFPGCgjnsC6AgVZ9ic5V7Ed7hudTRJZ6nmoEkyixL-E0bMS~RwBDBOT80hNJmF99kIgOKb4WkU~3XzuIlJUB5cpcyBIrGRLJbHIPcVZjViC3MLVJva5XPQ27DUabA2Z0hc3IBDnUiQ3Y5gYaeKp4T1gPx8fmDkKDp8OTUT45-9yCw227OLpBeCNuMOj41cER40CMh6khqTwM03HJS4jH8EeVy8p3jVbXyNrqTUWbD-rsd18wfb4RzXXz1f9XjVnEQocoOHktrzUq150FDC0sPY76FKB3Xbuk9pXFXeM~MNDrgx30XOYSlWw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA\")
<\/figure>\n\n\n\nDiscussion<\/p>\n\n\n\n
The US continued to experience significantly higher COVID-19 and excess all-cause mortality compared with peer countries during 2021 and early 2022, a difference accounting for 150\u202f000 to 470\u202f000 deaths. This difference was muted in the 10 states with highest vaccination coverage; remaining gaps may be explained by greater vaccination uptake in peer countries, better vaccination targeting to older age groups, and differences in health and social infrastructure.<\/a><\/p>\n\n\n\nThis study also highlights the value of excess mortality in understanding effects of COVID-19. Excess all-cause mortality began to fall below COVID-19 mortality in several countries and highly vaccinated states during Omicron, perhaps owing to reductions in non\u2013COVID-19 deaths. However, cross-location differences may also reflect differences in COVID-19 death coding.<\/a><\/p>\n\n\n\nLimitations include use of some provisional mortality estimates and lack of adjustment by age and comorbidities. Nevertheless, unadjusted estimates remain important, because a country\u2019s response to COVID-19 should reflect risks in its population rather than a hypothetical standardized population.<\/a><\/p>\n\n\n\nThese findings highlight that the US continued to lag peer countries in COVID-19 and excess all-cause mortality, albeit with lower mortality in highly vaccinated states.<\/p>\n","protected":false},"excerpt":{"rendered":"
Research Letter November 18, 2022 COVID-19 and Ex […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[32,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/23348"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=23348"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/23348\/revisions"}],"predecessor-version":[{"id":23349,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/23348\/revisions\/23349"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=23348"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=23348"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=23348"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
The US experienced high COVID-19 death rates and higher excess all-cause mortality compared with peer countries during 2020.1<\/a><\/sup> However, an important question is how cross-national differences in mortality shifted during 2021 and 2022 with both widespread availability of vaccination and new variants. We compared COVID-19 and excess all-cause mortality in the US, the 10 most- and least-vaccinated states, and 20 peer Organization for Economic Co-operation and Development (OECD) countries during the Delta and winter Omicron waves.<\/a><\/p>\n\n\n\n Methods<\/p>\n\n\n\n Using previous methodology, we compared the US overall, the 10 most- and least-vaccinated states, and the 20 OECD countries with 2021 population exceeding 5 million and greater than $25\u202f000 per capita gross domestic product (Supplement 1<\/a>).1<\/a><\/sup> US COVID-19 mortality, all-cause mortality, and vaccination data were obtained from the US Centers for Disease Control and Prevention.2<\/a><\/sup> For other countries, COVID-19 mortality data were obtained from the World Health Organization, all-cause mortality data from OECD databases, and vaccination data from Our World in Data (Supplement 1<\/a>).3<\/a><\/sup>-5<\/a><\/sup> Some mortality data from 2021 and 2022 were provisional.<\/a><\/p>\n\n\n\n Each location\u2019s COVID-19 mortality rate per capita was calculated over 2 periods: (1) Delta from June 27, 2021 (week 26), to December 25, 2021 (week 51), and (2) Omicron from December 26, 2021 (week 52), to March 26, 2022 (week 12). We estimated excess all-cause mortality by comparing mortality in each period with mortality in 2015-2019, fitting underlying trends using prepandemic, out-of-sample validation (Supplement 1<\/a>).6<\/a><\/sup><\/a><\/p>\n\n\n\n For each period, we calculated the difference in US deaths if mortality rates of other locations were realized. We used regression models to statistically compare rates across locations (Supplement 1<\/a>), with significance set at P<\/em>\u2009<\u2009.005 for 2-sided tests to account for multiple testing. Analyses were conducted in R version 4.0.2 (R Foundation for Statistical Computing). The study was deemed not human subjects research by the Brown University institutional review board.<\/a><\/p>\n\n\n\n Results<\/p>\n\n\n\n The US reported 370\u202f298 COVID-19 deaths (112 per 100\u202f000) during the Delta and Omicron waves (61\/100\u202f000 and 51\/100\u202f000, respectively). COVID-19 deaths per capita in the US overall and in both state subgroups significantly exceeded those of all peer countries during the study period (Table 1<\/a>). However, there were significantly fewer COVID-19 deaths in the top 10 states by vaccination uptake (73% coverage) at 75 deaths\/100\u202f000 compared with the bottom 10 (52% coverage) at 146 per 100\u202f000 (P<\/em>\u2009<\u2009.001).<\/p>\n\n\n\n US excess all-cause mortality exceeded COVID-19 mortality at 145\/100\u202f000 and exceeded peer countries in all periods, as did excess all-cause mortality in the least-vaccinated states (Table 2<\/a>). However, the 10 most-vaccinated states had excess all-cause mortality comparable with or less than that of several peer countries over Delta and Omicron combined (eg, Denmark, Germany, the Netherlands, Austria, Italy, Finland). While excess all-cause mortality in the top 10 states significantly exceeded that of many comparators during Omicron, excess all-cause mortality was significantly less than COVID-19 mortality for the top 10 states during this wave (29 vs 47 per 100\u202f000, P<\/em>\u2009<\u2009.001).<\/a><\/p>\n\n\n\n From June 27, 2021, to March 26, 2022, the US would have averted 122\u202f304 deaths if COVID-19 mortality matched that of the 10 most-vaccinated states and 266\u202f700 deaths if US excess all-cause mortality rate matched that of the 10 most-vaccinated states. If the US matched the rates of other peer countries, averted deaths would have been substantially higher in most cases (range, 154\u202f622-357\u202f899 for COVID-19 mortality; 209\u202f924-465\u202f747 for all-cause mortality).<\/p>\n\n\n\n Discussion<\/p>\n\n\n\n The US continued to experience significantly higher COVID-19 and excess all-cause mortality compared with peer countries during 2021 and early 2022, a difference accounting for 150\u202f000 to 470\u202f000 deaths. This difference was muted in the 10 states with highest vaccination coverage; remaining gaps may be explained by greater vaccination uptake in peer countries, better vaccination targeting to older age groups, and differences in health and social infrastructure.<\/a><\/p>\n\n\n\n This study also highlights the value of excess mortality in understanding effects of COVID-19. Excess all-cause mortality began to fall below COVID-19 mortality in several countries and highly vaccinated states during Omicron, perhaps owing to reductions in non\u2013COVID-19 deaths. However, cross-location differences may also reflect differences in COVID-19 death coding.<\/a><\/p>\n\n\n\n Limitations include use of some provisional mortality estimates and lack of adjustment by age and comorbidities. Nevertheless, unadjusted estimates remain important, because a country\u2019s response to COVID-19 should reflect risks in its population rather than a hypothetical standardized population.<\/a><\/p>\n\n\n\n These findings highlight that the US continued to lag peer countries in COVID-19 and excess all-cause mortality, albeit with lower mortality in highly vaccinated states.<\/p>\n","protected":false},"excerpt":{"rendered":" Research Letter November 18, 2022 COVID-19 and Ex […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[32,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/23348"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=23348"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/23348\/revisions"}],"predecessor-version":[{"id":23349,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/23348\/revisions\/23349"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=23348"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=23348"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=23348"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}<\/figure>\n\n\n\n<\/figure>\n\n\n\n