key: cord-0825878-3v9f4msm authors: Chen, Y.-H.; Riley, A. R.; Duchowny, K. A.; Aschmann, H. E.; Chen, R.; Kiang, M. V.; Mooney, A.; Stokes, A. C.; Glymour, M. M.; Bibbins-Domingo, K. title: COVID-19 mortality and excess mortality among working-age Californians, by occupational sector: March 2020 through November 2021 date: 2022-02-15 journal: nan DOI: 10.1101/2022.02.14.22270958 sha: 899a354fe7cc93e1fe56d4ecde339dfd1d6aeaca doc_id: 825878 cord_uid: 3v9f4msm Background During the first year of the pandemic, essential workers faced higher rates of SARS-CoV-2 infection and COVID-19 mortality than non-essential workers. It is unknown whether disparities in pandemic-related mortality across occupational sectors have continued to occur, amidst SARS-CoV-2 variants and vaccine availability. Methods We obtained data on all deaths occurring in the state of California from 2016 through 2021. We restricted our analysis to California residents who were working age (18--65 years at time of death) and died of natural causes. Occupational sector was classified into 9 essential sectors; non-essential; or not in the labor market. We calculated the number of COVID-19 deaths in total and per capita that occurred in each occupational sector. Separately, using autoregressive integrated moving average models, we estimated total, per-capita, and relative excess natural-cause mortality by week between March 1, 2020, and November 30, 2021, stratifying by occupational sector. We additionally stratified analyses of occupational risk into regions with high versus low vaccine uptake, categorizing high-uptake regions as counties where at least 50% of the population completed a vaccination series by August 1, 2021. Findings From March 2020 through November 2021, essential work was associated with higher COVID-19 and excess mortality compared with non-essential work, with the highest per-capita COVID-19 mortality in agriculture (131.8 per 100,000), transportation/logistics (107.1), manufacturing (103.3), and facilities (101.1). Essential workers continued to face higher COVID-19 and excess mortality during the period of widely available vaccines (March through November 2021). Between July and November 2021, emergency workers experienced higher per-capita COVID-19 mortality (113.7) than workers from any other sector. Essential workers faced the highest COVID-19 mortality in counties with low vaccination rates, a difference that was more pronounced during the period of the Delta surge in Summer 2021. Interpretation Essential workers have continued to bear the brunt of high COVID-19 and excess mortality throughout the pandemic, particularly in the agriculture, emergency, manufacturing, facilities, and transportation/logistics sectors. This high death toll has continued during periods of vaccine availability and the delta surge. In an ongoing pandemic without widespread vaccine coverage and anticipated threats of new variants, the US must actively adopt policies to more adequately protect essential workers. Individuals working in essential occupations (ie, in sectors deemed essential to local or regional functions and thus exempt from public health stay-at-home orders or other restrictions to in-person work) have faced higher risk of SARS-CoV-2 infection and COVID-19 mortality during the pandemic. [1] [2] [3] [4] An analysis of data from the UK Biobank project, for example, found higher risk of severe COVID-19 disease among essential workers than among non-essential workers. 2 Another study using data from the American Community Survey linked to mortality records from the Social Security Administration found that people without work-from-home options had larger increases in mortality during 2020 than people working in occupations that had the option to work from home. 5 It is unknown whether such disparities have continued to occur amidst SARS-CoV-2 variants and vaccine availability. We previously reported on COVID-19 and excess mortality by occupation in California from the start of the pandemic (March 2020) through November 2020. 1 We found that essential work was associated with higher COVID-19 and excess mortality during this period compared with non-essential work and that four essential sectors-food and agriculture, manufacturing, transportation and logistics, and facilitiesexperienced particularly high excess mortality. The present study adds three major updates. One, we extend the time window of interest through November 2021, through an era that includes SARS-CoV-2 variants and vaccine availability. Two, we further disaggregate data for two essential sectors sectors we have previously combined: health/emergency and food/agriculture. We note here that different policies and behaviors between sectors-such as between health workers and emergency workers (first responders)-may have translatated to differences in risk. Three, we report on differences in COVID-19 mortality between regions of low or high vaccination. Data on occupation are recorded on death certificates via free-text responses. For example, a family member or friend might indicate that a decedent was a "cook" during most of the decedent's life. We converted these free-text data to US Census codes using the National Institute for Occupational Safety and Health's Industry & Occupation Computerized Coding System. A team of 3 researchers then categorized each unique code into one of 11 occupational sectors: agriculture, emergency services, facilities, government/community, health, manufacturing, restaurant, retail, transportation/logistics, not essential, and unemployed/missing (this category includes homemakers, retirees, and students). Our choice of sectors was guided by the 13 sectors identified by California officials as comprising the state's essential workforce. In a secondary analysis, we stratified by California counties with low or high vaccine uptake among working-age individuals, using data from the Centers for Disease Control and Prevention. 9 We defined counties with low vaccination as counties with 50% of the population fully vaccinated by August 1, 2021. While this definition was somewhat arbitrary, we note here that differentiation between the high and low counties-as explored via time series of the vaccine uptake in each county (not shown)-was consistent over time. For each analytic group of interest (usually the entire state or a specific occupational sector), we repeated the following procedure. We calculated the number of COVID-19 deaths occurring in total and per capita in each week, over the entire time window, and in each phase. We obtained subgroup-specific population estimates, for the per-capita numbers, from the 2019 American Community Survey. Separately, we fit dynamic harmonic regression models with autoregressive integrated moving average errors for the number of weekly deaths, 10 using deaths occurring among the group between January 3, 2016 and February 29, 2020. Using the final model, we forecast the number of deaths for each unit of time, along with corresponding 95% prediction intervals (PI). To obtain the total number of excess deaths for the entire time window and during each phase, we subtracted the total number of expected (forecast) deaths from the total number of observed deaths. We obtained a 95% PI for the total by simulating the model 10,000 times, selecting the 97.5% and 2.5% quantiles, and subtracting from the total number of observed deaths. In addition to the estimated number of excess deaths, we calculated and report per-capita excess deaths: 5 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 15, 2022. ; the observed number of deaths minus the expected number of deaths, divided by the estimated population size. We also calculated and report the observed number of deaths divided by the expected number of deaths. These ratios represent relative excess mortality. For example, a ratio of 1.5 would indicate that there were 50% more deaths observed during the pandemic than we would have expected had the pandemic not occurred. For both measures, the comparison is between the pandemic and non-occurrence of the pandemic. The reference group is non-occurrence of the pandemic. We focus our presentation of our findings on COVID-19 mortality, and view the estimates of excess mortality as sensitivity checks of the COVID-19 numbers, particularly given discrepancies between COVID-19 and estimated excess mortality early in the pandemic (which we believe to be primarily due to unrecognized or unreported COVID-19 deaths). Our reported per-capita numbers are annualized numbers, obtained by dividing the per-capita measure by the number of the weeks and multiplying by 52. Because differences between occupational sectors could be impacted by differences in age and sex, we also performed age-and sex-stratified sensitivity analyses. Our use of the death data was approved by the State of California Committee for the Protection of Human We conducted all analyses in R. not have to choose between financial benefits and health risks. 24 Finally, protections in workplace settings remain crucial. Given that SARS-CoV-2 can be transmitted via aerosols, 25, 26 we urge for free provision of masks-preferably N95 masks or similarly effective masks 27,28 -to essential workers and improved ventilation in workplace settings. 29 We acknowledge challenges related to measurement of occupation on death certificates, and questions relating to whether risks are necessarily related to workplace exposures. These are addressed in our prior manuscript at length. 1 More than one year after we first reported disparities in COVID-19 mortality across occupational sectors, 1 and even after widespread availability of vaccination, these disparities continue to occur. The patterns are clear: though there have been a large number of COVID-19 deaths among non-essential workers, essential workers continue to bear the brunt of the COVID-19 pandemic. However, not all essential workers face the same elevated risk. Contrary to popular messaging, health sector workers faced lower risk of COVID-19 and excess mortality than workers in several non-health sectors (agriculture, emergency, facilities, manufacturing, and transportation/logistics) both prior to and after vaccine availability. These findings challenge notions about the basis of occupational risk during the pandemic, suggesting that increased occupational risk of COVID-19 death may have more to do with workplace safety, worker protections, and worker power, than mere proximity to COVID-19. Further, even in counties with high vaccination, essential sectors experienced elevated risks of COVID-19 mortality and excess mortality, suggesting that vaccine uptake alone has been insufficient to erase previously documented disparities in COVID-19 death. We urge for decisive and collaborative action, using a diverse toolkit, to reduce and eliminate disparities across occupational groups. Weekly COVID-19 deaths per 100,000, annualized 14 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 15, 2022. ; https://doi.org/10.1101/2022.02.14.22270958 doi: medRxiv preprint Weekly COVID-19 deaths per 100,000, annualized 15 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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