key: cord-0910900-smed9v1n authors: Jacobson, Sheldon H.; Jokela, Janet A. title: Non-Covid-19 Excess Deaths by Age and Gender in the United States During the First Three Months of the Covid-19 Pandemic date: 2020-10-10 journal: Public Health DOI: 10.1016/j.puhe.2020.10.004 sha: b61ee8edc628ac2156e3897ebd6cffb452972e2e doc_id: 910900 cord_uid: smed9v1n Objectives The first three months of the Covid-19 pandemic has disrupted healthcare systems, creating an environment by which deaths have occurred that are not directly due to Covid-19, but have occurred due to the healthcare and societal environment resulting from Covid-19. The objective of this research is to quantify such excess deaths, partitioned by age group and gender. Study Design Data analysis. Methods Excess deaths by age and gender are estimated using provisional death data available from the CDC over the time period March 1, 2020 through May 30, 2020. Previous year fatality and population data are used as the benchmark. Results Several of the eighteen age and gender cohorts experienced statistically significant excess deaths. The results also indicate that for one of the age and gender cohorts, Covid-19 has been protective. Conclusions There have been more excess deaths in several age group and gender cohorts during the first three months of the pandemic, beyond direct deaths directly attributable to Covid-19. These Non-Covid excess deaths are most apparent in the 25 to 44 age group for females, and 15 to 54 age group for men. Further research is needed to assess the cause of such excess deaths, and introduce safeguards to reduce such deaths in the future. The COVID-19 pandemic has resulted in over 7 million infections and over 210,000 deaths in the US. In mid-March, state governments began to close their economies and encouraged citizens to stay home to suppress the spread of the virus. The purpose of such shelter-in-place orders was to better facilitate physical distancing to reduce community virus transmission, blunt the anticipated surge in demand of hospital ICU beds and ventilators, and gain time to provide sufficient personal protective equipment (PPE) for healthcare workers. The preponderance of cases and deaths from mid-March 2020 through mid-June 2020 were in large, densely populated urban areas such as New York City, Chicago, and Detroit. This surge mostly sidestepped rural communities during this period, creating an uneven impact of COVID-19 across the nation. Given the speed at which COVID-19 spread in early March 2020 and the uncertainty of its virulence, the aggressive step of closing the US economy was prudent and widely accepted. Hsiang et al. [1] estimated that without such actions, 4.8 million additional confirmed cases would have occurred in the US alone through May 2020. Using a 5% case fatality rate, this would have translated into 240,000 additional deaths. Through mid-June, data collected and disseminated by the CDC has demonstrated a clearer picture of which population cohorts are most vulnerable to COVID-19 (such as those over 65 years of age and those with underlying health conditions). This has provided a roadmap for protecting at risk people while progressing towards reopening communities and local economies. To limit the spread of the virus without shelter-inplace orders, in addition to testing and contact tracing, public health countermeasures of hand hygiene, physical distancing, and face coverings provide the best available defenses to limit virus transmission and protect the most vulnerable populations. The CDC disseminates a weekly summary of provisional deaths from all causes and COVID-19 deaths, broken down by age and gender [2] . The disruptive social and economic upheavals created by the COVID-19 pandemic have led to excess deaths that are either directly or indirectly attributable to COVID-19. The CDC reports estimates of such excess deaths [3] . This paper uses CDC estimates for 2019 deaths as a baseline to estimate excess deaths specified by age and gender cohorts. This analysis provides an alternative perspective by which to estimate excess deaths and the health impact of COVID-19. Provisional death data reported by the CDC from March 1, 2020 through May 30, 2020 are used to estimate the mean and standard error of the number of weekly deaths, both from all causes and those attributed to COVID-19, across 18 cohorts, broken down by age and gender (male and female) [2] . Label the data from this 13-week period as 2020 weekly deaths. Point and standard error estimates for the expected number of deaths per week for each age and gender cohort are computed based on CDC data for 2018 death rates [4] and 2019 United State Census Bureau population estimates [5] , labelled hybrid 2019 weekly deaths. This represents the most recent age-based mortality and population data available, hence can serve as a benchmark for assessing 2020 excess deaths. The standard errors were estimated using the 2018 monthly deaths for each age and gender [4] , the most recent death data available from the CDC. For each age and gender cohort, a one-sided Student-t test was used to test the null hypothesis that the expected 2020 non-COVID-19 weekly deaths is equal to the expected hybrid 2019 weekly deaths, versus the alternative hypothesis that it is greater. The 2020 non-COVID-19 weekly death estimates are computed by subtracting 2020 COVID weekly deaths from all 2020 weekly deaths. A pooled standard error estimator for the Student-t test was computed by taking the square root of the sum of the standard error squared for the 2020 non-COVID-19 weekly deaths plus the standard error squared for the 2018 weekly deaths (rescaled used the 2018 monthly deaths). Table 1 shows estimates for the expected 2020 weekly female deaths, 2020 COVID-19 weekly female deaths, 2020 Non-COVID-19 females deaths, 2019 hybrid weekly female deaths , pooled standard error estimator for weekly female deaths , and p-values for the Student-t test statistic. The data in Table 2 are depicted in a similar manner for males. year age group for females, which indicates that the 2020 non-COVID-19 average J o u r n a l P r e -p r o o f weekly deaths is smaller, hence COVID-19 was protective for these young girls (p-value < 0.001 labelled with a * in Table 1 ). The data does not explain why there is a statistically significant increase in expected 2020 non-COVID-19 weekly deaths compared to expected hybrid 2019 weekly deaths. Czeisler et al. [6] discuss delays or avoidance of non-COVID-19 medical care during the pandemic, which could contribute to excess deaths beyond those attributed to COVID- For all but one age and gender cohort, there were more 2020 average weekly deaths compared to the hybrid 2019 average weekly deaths. One possible explanation for this is that 2019 weekly deaths are not uniformly distributed across the year, which is highly likely. Another explanation is that since 2020 has a higher population than 2019, there may naturally be more deaths, though this increase is likely to be negligible compared to the actual number of deaths. To overcome these limitations, we used a p-value cutoff of 0.001 (rather than 0.05) to assess statistical significance, and a cutoff of 0.05 to assess J o u r n a l P r e -p r o o f statistical insignificance, while all other values in between were classified as statistically inconclusive. The CDC provides weekly updates of provisional death reports [2] , which continue to be adjusted for the March 1, 2020 through May 30, 2020 time period as new data become available. Therefore, the values reported in Table 1 will continue to change, albeit slightly as at the time of the analysis. Since only new deaths are added, this will tend to result in p-values getting marginally smaller. The key takeaway from this analysis is that excess deaths across multiple age and gender cohorts occurred beyond what has been attributed to COVID-19. These excess deaths indicate that people across many age and gender cohorts have died unexpectedly. Over the ensuing months, possible explanations for such excess deaths may become more apparent. The authors declare no conflicts of interest. No ethical approval and funding were required for this study. The analysis uses only publicly available data reported in the literature. The J o u r n a l P r e -p r o o f effect of large-scale anti-contagion policies on the COVID-19 pandemic Provisional COVID-19 deaths counts by Sex, Age, and week Excess Deaths Associated with COVID-19" Accessed Underlying Cause of Death 1999-2018 on CDC WONDER Online Database, released in 2020. Data are from the Multiple Cause of Death Files, 1999-2018, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program 20th Century Statistics Delay or Avoidance of Medical Care Because of COVID-19 -Related Concerns -United States Highlights • Covid-19 has disrupted society and health care systems, creating a fertile environment for excess deaths not directly due to the virus Estimating such excess deaths by age group and gender provides a picture of such effects using 2019 death estimates as a baseline. The data also suggest that Covid-19 was protective for one age group and gender cohort The authors wish to thank two anonymous reviewers for their comments on an earlier version of the paper, resulting in a significantly improved manuscript.