Indirect impact of COVID-19 results in higher pandemic death toll

Contributed Photo/Courtesy U.S. Census Bureau

Racial inequality in pandemic mortality widens when age, indirect impact taken into account

By Victoria Udalova

WASHINGTON D.C. – Racial disparities in the mortality impact of the pandemic vary widely across U.S. states and are even more pronounced when accounting for age, according to independent research by the U.S. Census Bureau.

recent research paper also shows that the total reported death toll from COVID-19 actually undercounts mortality. That’s because it does not take into account factors indirectly associated with the pandemic, including people who died because they delayed health care.

Measuring true impact of COVID-19 on mortality

Understanding the total death toll of the current pandemic requires measuring what’s called “excess all-cause mortality,” which provides an estimate of the additional number of deaths from any cause — not just from COVID-19 infections — beyond what is normally expected during a given period.

This measure includes people who died from COVID-19 and people who died for other reasons related to the pandemic.

For example, some may have died of heart attacks or uncontrolled diabetes because they delayed seeking health care for fear of catching the virus. Others may have suffered anxiety and depression from related job loss and financial uncertainty, which may have led them to take their own lives.

This measure also captures any reduction in mortality that can be attributed to the pandemic, such as decreased seasonal influenza (more people staying home and wearing masks) or improved air quality (less pollution as fewer drive to work).

Measuring both direct and indirect impacts on mortality paints a more complete picture of the devastation caused by the ongoing COVID-19 pandemic. Excess all-cause mortality is calculated by taking the difference between expected (based on historical trends) and observed mortality during a given period.

Recent research indicates that excess all-cause mortality was 2.4 per 10,000 individuals in the United States in April 2020  –  the first full month of the pandemic – which represents about 30% more deaths than the number of COVID deaths reported in that month.

Greater mortality impacts on older individuals

Excess all-cause mortality in April 2020 increased with age. Mortality from the direct and indirect impact of the pandemic was highly concentrated in older age groups.

While individuals 85 years old and older accounted for only 3% of the U.S. population ages 25 years and older, they accounted for a disproportionate 34% of the overall excess mortality in the country during the first full month.

Racial disparities

Racial disparities in the direct impact of the pandemic on mortality (the number who died from the virus) have been widely reported. New research now focuses on mortality by race from any cause associated with COVID-19, which also shows significant racial disparities.

Research based on individual-level administrative data (that nearly covers the universe of the U.S. population) from January 2011 through April 2020, found a significant deviation in mortality from the historic trend for all race and ethnicity groups (Figure 3).

This research relied on death information from the U.S. Census Bureau’s version of the Social Security Administration’s Numerical Identification (Census Numident) database and additional individual-level demographic information, particularly self-reported race information from the 2010 Census.

Findings:

  • Excess all-cause mortality was the lowest for Hawaiian and Pacific Islander, non-Hispanic individuals at 1.3 excess deaths per 10,000 individuals, a 22% increase from the predicted rate in April 2020.
  • At the other end of the spectrum, Black, non-Hispanic individuals experienced the highest excess all-cause mortality of 6.1 excess deaths per 10,000 individuals, a 79% increase from their predicted rate.
  • The other five race and ethnicity groups experienced excess mortality between the two extremes. White, non-Hispanic individuals had 2.1 excess deaths (21% increase); Hispanics of any race had 2.7 excess deaths (64% increase); Asian, non-Hispanic individuals had 2.9 excess deaths (64% increase); American Indian and Alaska Native, non-Hispanic individuals had 1.9 excess deaths (22% increase); and those reporting other race or two or more races had 2.7 excess deaths (60% increase).

Age and race

Racial disparities were even larger after adjusting for differences in age distributions.

There are large differences in age distribution across race groups and it is important to account for age when comparing excess mortality across racial groups.

Age differences increase disparities in excess mortality for every racial group compared to White, non-Hispanic individuals.

Without adjusting for age differences, excess mortality overstates the impact of the pandemic on White, non-Hispanic individuals who are, on average, older relative to other racial groups, and it understates it for all other racial and ethnic groups.

Racial disparities in the mortality impact of the pandemic in April 2020 were more pronounced when controlling for other demographic characteristics and geographic location.

In addition to age, when sex and geographic differences are taken into account, White, non-Hispanic individuals had the lowest excess mortality of 1.5 deaths per 10,000. Black, non-Hispanic individuals had the highest excess mortality of 6.8 deaths per 10,000.

Pandemic’s racial disparities varied across states

Even when adjusting for sex and age differences across race and ethnicity, racial gaps in excess all-cause mortality during April 2020 were not uniform across all states.

Some states had similar rates of mortality among White, non-Hispanics but very different rates among Black, non-Hispanic and Hispanic individuals. Some states had no significant increase in mortality for White, non-Hispanics but significant excess mortality for the other groups.

This research shows the breadth of factors affecting the indirect impact of the virus.

More research is needed

These findings are limited to the impact of the pandemic in April 2020. Future research is needed to evaluate the trajectory of these impacts since then.

It is also important to study the causes and consequences of racial disparities in the pandemic’s impact on mortality. For example: Why are there significant geographic differences in racial disparities? What role do social and environmental factors, such as income, education, and occupation, play?

The Census Bureau’s existing data from surveys, decennial censuses, and administrative records, along with the ability to link data across all sources and over time, is invaluable in understanding health disparities during the ongoing pandemic and beyond.

Victoria Udalova is a senior economist and program manager of the Enhancing Health Data (EHealth) program at the U.S. Census Bureau.

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