Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020
Open accessAbstract
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.
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Several other studies have shown potential misclassified COVID-19 deaths in non-COVID-19 respiratory conditions, which might be amplified in locations with scarce or inadequate SARS-CoV-2 diagnostic capabilities.
“Several other studies have also shown potential misclassified COVID-19 deaths in non-COVID-19 respiratory conditions,82, 83 which might be amplified in locations with scarce or inadequate SARS-CoV-2 diagnostic capabilities.84”
These outcomes may reflect attributions of some COVID-19 deaths to lower respiratory tract infections generally, or may indicate the contribution of secondary respiratory infections such as mucormycosis to fatal outcomes among individuals with confirmed or unconfirmed SARS-CoV-2 infection, especially in healthcare settings.
“These outcomes may reflect attributions of some COVID-19 deaths to lower respiratory tract infections generally, as reported in other settings46, or may indicate the contribution of secondary respiratory infections such as mucormycosis to fatal outcomes among individuals with confirmed or unconfirmed SARS-CoV-2 infection, especially in healthcare settings.”
From Attributed causes of excess mortality during the COVID-19 pandemic in a south Indian city (2023) · cites this paper as [46]
Excess mortality approaches have been used for over a century to capture the full scope of large-scale infectious disease events, heatwaves, and earthquakes, by measuring the rise in mortality over a historical baseline.
“Excess mortality approaches have been used for over a century to capture the full scope of large-scale infectious disease events, heatwaves, and earthquakes, by measuring the rise in mortality over a historical baseline”
From Direct and indirect mortality impacts of the COVID-19 pandemic in the United States, March 1, 2020 to January 1, 2022 (2023) · cites this paper as Weinberger et al., 2020
In the early phase of the pandemic, excess mortality approaches highlighted substantial underestimation in official statistics of COVID-19 deaths due to limited viral testing.
“In the early phase of the pandemic, these approaches highlighted substantial underestimation in official statistics of COVID-19 deaths due to limited viral testing”
From Direct and indirect mortality impacts of the COVID-19 pandemic in the United States, March 1, 2020 to January 1, 2022 (2023) · cites this paper as Weinberger et al., 2020
Analyses of COVID-19-related deaths as well as excess mortality provide an alternative and potentially less biased picture of epidemic intensity.
“Analyses of COVID-19–related deaths as well as excess mortality provide an alternative and potentially less biased picture of epidemic intensity (7, 8).”
From Socioeconomic status determines COVID-19 incidence and related mortality in Santiago, Chile (2021) · cites this paper as [7]
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- Authors
- Weinberger, D. M., Chen, J., Cohen, T., Crawford, F. W., Mostashari, F., Olson, D., Pitzer, V. E., Reich, N. G., Russi, M., Simonsen, L., Watkins, A., & Viboud, C.
- Affiliations
- Yale University (US)
- National Institutes of Health (US)
- Aledade Inc, Bethesda, Maryland
- Department of Health and Mental Hygiene, New York, New York
- University of Massachusetts Amherst (US)
- Roskilde University (DK)
- Corresponding author
- Weinberger, Daniel M.
- ORCID
- Venue
- JAMA Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2020-10-01
- Volume
- 180
- Issue
- 10
- Pages
- 1336
- ISSN
- 2168-6106 (ISSN-L)
- PMC
- PMC7330834
- OpenAlex
- W3038501713
- Cited by
- 485
- References
- 14
- Citations by year
- 2026: 13 · 2025: 28 · 2024: 44 · 2023: 69 · 2022: 79 · 2021: 169 · 2020: 83
- FWCI
- 15.89
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Internal Medicine (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- RUCforsk (Roskilde University) (submittedVersion)
- Funders
- Pfizer
- New York City Department of Health and Mental Hygiene
- National Institutes of Health (UL1TR001863)
- Centers for Disease Control and Prevention (U01IP001122, 1U01IP001122)
- National Institute of General Medical Sciences (1U01IP001122, R35GM119582)
- National Institute of Allergy and Infectious Diseases (R01AI146555, R01AI123208, R01AI112970, R01AI137093)
- National Institute of Child Health and Human Development
- National Center for Advancing Translational Sciences
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (DP2HD091799)
- Topics
- Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Oncology › COVID-19 and healthcare impacts
- Keywords
- COVID-19 pandemic, excess mortality, all-cause mortality, underreporting of deaths, pneumonia mortality, influenza mortality, diagnostic test availability, state-level variation, United States, influenza surveillance, delayed reporting, SARS-CoV-2
- MeSH terms
- Betacoronavirus, COVID-19, SARS-CoV-2, COVID-19 Testing, Adult, Cause of Death, Female, Humans, Influenza, Human, Male, Mortality, Pneumonia, Pneumonia, Viral, Cost of Illness, Coronavirus Infections, Clinical Laboratory Techniques, Pandemics
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