The Us Midlife Mortality Crisis Continues: Excess Cause-Specific Mortality During 2020

Abstract

COVID-19 has prematurely ended many lives, particularly among the oldest Americans, but the pandemic has also had an indirect effect on health and non-COVID mortality among the working-age population, who have suffered the brunt of the economic consequences. This analysis quantifies the changes in mortality for selected causes of death during the COVID 19 pandemic up to December 31, 2020, and investigates whether the levels of excess mortality varied by age group. The data comprise national-level monthly death counts by age group and selected causes of death from January 1999 to December 2020 combined with annual mid-year population estimates over the same period. A negative binomial regression model was used to estimate monthly cause-specific excess mortality during 2020 controlling for the pre-pandemic mortality patterns by age, calendar year, and season. To determine whether excess mortality varied by age, we tested interactions between broad age groups and dichotomous indicators for the pre-pandemic (January-February) and the pandemic (March-December) portions of 2020. In relative terms, excess all cause mortality (including COVID-19) peaked in December at ages 25-44 (RR=1.58 relative to 2019, 95% CI=1.50-1.68). Excluding COVID-19, all of the excess mortality occurred between ages 15 and 64, peaking in July among those aged 25-44 (RR=1.45, 95% CI 1.37-1.53). We find notable excess mortality during March-December 2020 for many causes (i.e., influenza/pneumonia, other respiratory diseases, diabetes, heart disease, cerebrovascular disease, kidney disease, and external causes), but almost exclusively among young and midlife (aged 25-74) Americans. For those aged 75 and older, there was little excess mortality from causes other than COVID-19 except from Alzheimer's disease. Excess non-COVID mortality may have resulted, at least partly, from incorrectly classified COVID-19 deaths, but neither misclassification nor an atypical flu season that disproportionately affected younger people is likely to explain the increase in mortality from external causes, which was evident even during January-February 2020. Exploratory analyses suggest that drug-related mortality may be driving the early rise in external mortality. The growth in drug overdoses well before there was any hint of a pandemic suggests it is probably not solely an indirect effect of COVID-19, although the pandemic may have exacerbated the problem.

Bounce backs amid continued losses: Life expectancy changes since COVID-19

“…41 In 2020, the largest share of non-COVID excess deaths in USA males was from external causes (primarily due to drug overdoses and homicides), nearly 80% of which occurred at working ages. 42 Preliminary data show continued increases in deaths due to drug overdoses in 2021. 43 Differences in vaccine uptake by age may also have contributed to the shift to younger mortality in the USA By July 1st when vaccines where readily available in the USA, only 66.9% of 50–64 year-olds were fully vaccinated compared to 82.3% of 65–74 year-olds.…”

“…31 In 2020, the largest share of non-COVID excess deaths in USA males was from external causes (primarily due to drug overdoses and homicides), nearly 80% of which occurred at working ages. 32 Preliminary data show continued increases in deaths due to drug overdoses in 2021. 33 However, part of the effect may be due to under-registration of COVID-19 deaths among the working age population.…”

Reductions in US life expectancy during the COVID-19 pandemic by race and ethnicity: Is 2021 a repetition of 2020?

“…NVSS estimates of life expectancy loss in 2020, which exceed our estimates based only on COVID-19 deaths, provide insights into the effect of omitting changes in numbers of deaths from other causes (1,2,19). A comparison of cause-specific death rates between 2019 and 2020 indicates a net rise in mortality from non-COVID-19 causes in 2020, often referred to as “excess” deaths: increases in several causes (e.g., drug overdoses and other unintentional injuries, homicides, diabetes, heart disease) had a larger overall impact on life expectancy than decreases in other causes (e.g., cancer, Alzheimer’s disease, chronic lower respiratory diseases) (1,2,32,33). Given that the risk of COVID-19 fatality is increased in the presence of numerous co-morbidities (e.g., cancer, Alzheimer’s disease), mortality rates from some of these chronic diseases may have decreased because severely ill individuals, particularly those with compromised immune systems, succumbed to COVID-19 rather than their underlying condition.…”

“…The disproportionate impact of COVID-19 on the survival of vulnerable populations has also received extensive attention: the Latino and Black populations experienced declines in life expectancy over twice as large as that for Whites (1). Risk factors for COVID-19 infection and mortality, such as crowded living conditions, frontline jobs with high exposure to infection and low pay, dependence on public transportation, low access to quality healthcare, and high rates of select chronic conditions, still characterize these groups, suggesting continued racial/ethnic disparities in COVID-19 mortality (7–11). A strategically-targeted vaccine distribution had the potential to reduce racial/ethnic disparities in COVID-19 mortality in 2021 (12), but many individuals faced barriers to vaccination in the early months, including difficulty scheduling vaccine appointments online, lack of transportation to vaccination sites, and lack of time off work to get vaccinated and recover from side effects (13, 14).…”

Evolution of Mortality by Age Group in Patients With COVID-19 Above 60 Years of Age

“…Many lives ended prematurely and especially among older Americans, but the pandemic also had an indirect effect on non-COVID19 health and mortality among the working-age population, which was impacted by the economic consequences. Mortality rates increased during the two waves of COVID-19 then declined [3].…”