May
21, 2021 Jeremy S. Faust, MD, MS1; Chengan Du, PhD2; Katherine
Dickerson Mayes, MD, PhD3; et alShu-Xia Li, PhD4; Zhenqiu Lin, PhD4; Michael L. Barnett, MD,
MS5; Harlan M. Krumholz, MD,
SM2
Author
Affiliations Article Information JAMA. 2021;326(1):84-86. doi:10.1001/jama.2021.8012
The
initial COVID-19 outbreak in the US caused disruptions in usual behavioral
patterns.1-3 To assess associated changes in
external causes of death, we analyzed monthly trends from 2015 to 2020 in
deaths resulting from drug overdoses, homicide, unintentional injuries, motor
vehicle crashes, and suicide in the first 6 months of the pandemic.
Methods
We
measured monthly excess mortality (the gap between observed and expected
deaths) from 5 external causes using provisional national-level underlying
cause death certificate data published by the National Center for Health
Statistics (NCHS) through August 2020 (released March 2021). Data from March to
August 2020 were aggregated by the NCHS into 5 groups: drug overdose (all
intents), assault (homicide), unintentional injuries, motor vehicle crashes,
and intentional self-harm (suicide) (see the Supplement for ICD-10 codes).4,5
To
forecast all-cause and cause-specific expected monthly deaths from March to
August 2020, we used seasonal autoregressive integrated moving average (sARIMA)
models developed with cause-specific monthly mortality counts and US population
data from January 2015 to February 2020. We plotted observed and expected
deaths monthly with 95% CIs estimated from sARIMA models.
We
estimated the contribution of individual cause-specific mortality to all-cause
non–COVID-19 excess mortality by dividing cause-specific mortality by total
non–COVID-19 excess mortality from March to August 2020 (see the Supplement). Confidence intervals for the
percent contribution to non–COVID-19 excess mortality were determined by
subtracting the observed number of deaths from the upper and lower 95%
thresholds for the expected number of deaths. For excess mortality counts, any
figure not crossing 0 was considered statistically significant. For
observed-to-expected ratios (OERs) of cause-specific mortality, statistical
significance was defined as a 95% CI that excluded the null value of 1.00.
Analyses
were conducted using R version 4.0.2. This study used publicly available data
and was not subject to institutional review approval per HHS regulation 45 CFR
46.101(c).
Results
From
March to August 2020, there were 256 635 (95% CI, 161 450-351 823) all-cause
excess deaths (1 661 271 observed; 1 404 634 expected) and 174 334 COVID-19
deaths (underlying cause). For the study period, OERs for 3 external causes of
death were significantly higher than expected (drug overdoses, homicides,
unintentional injuries), 1 unchanged (motor vehicle crashes), and 1 lower
(suicides) (Table).
There
were 10 443 excess drug overdoses (95% CI, 6115 to 14 771; Figure, A), accounting for 12.7% of non–COVID-19
excess mortality (95% CI, 7.4% to 17.9%); 2014 excess homicide deaths (95% CI,
1086 to 2942) (Figure, B), accounting for 2.4% of non–COVID-19
excess mortality (95% CI, 1.3% to 3.6%); and 7497 excess deaths due to
unintentional injuries (95% CI, 694 to 14 300) (Figure, C), accounting for 9.1% of non–COVID-19
excess mortality (95% CI, 0.8% to 17.4%). There was no significant change in
motor vehicle crash deaths overall (725; 95% CI, −1090 to 2540) but fewer than
expected motor vehicle crash deaths occurred in April (−523; 95% CI, −815 to
−231), and significant increases were recorded monthly from June to August
(1550; 95% CI, 611 to 2489) (Figure, D). Suicide deaths were statistically
significantly lower than projected by 2432 deaths (95% CI, 1071 to 3792 fewer
deaths) (Figure, E).
Discussion
Provisional
mortality data showed that deaths from some but not all external causes
increased during the pandemic, representing thousands of lives lost and
exceeding prepandemic trends.
Explanations
for these changes are unknown. Drug overdoses and homicides may have been
related to economic stress. Pandemic-associated changes in access to substance
use disorder treatments may have exacerbated mortality from overdoses.6 Decreases in motor vehicle crash
deaths in April coincided with less traffic, despite increases in drivers
testing positive for drugs and alcohol and lower seatbelt use.3 Increases in motor vehicle crash
deaths in June to August occurred as traffic increased (though still below 2019
levels), likely reflecting higher-risk behaviors.3 Lower than projected suicide deaths
are paradoxical with reported increases in depressive and other mental health
symptoms during the pandemic. Additional data are needed to understand the
mechanism behind this finding.
This
study has limitations, including death certificate accuracy and that 2020 data
published by NCHS are considered preliminary. However, substantial changes to
March to August 2020 data are unlikely. Also, the true number of non–COVID-19
medical deaths may have been lower than projected during the pandemic period,
as evidenced by the observation that in May, the total excess deaths due to
drug overdoses, assaults, and unintentional injuries exceeded the apparent
number of all non–COVID-19 excess deaths.
Section
Editor: Jody W. Zylke,
MD, Deputy Editor.
Article Information
Corresponding Author: Jeremy S. Faust, MD, MS, Department of
Emergency Medicine, Brigham and Women’s Hospital, 10 Vining St, Boston, MA
02115 (jsfaust@gmail.com).
Accepted for Publication: May 3, 2021.
Published Online: May 21, 2021. doi:10.1001/jama.2021.8012
Author Contributions: Dr Faust had full access to all of the
data in the study and takes responsibility for the integrity of the data and
accuracy of the data analysis.
Concept and design: Faust, Du, Lin, Krumholz.
Acquisition, analysis, or interpretation of
data: Faust, Du, Mayes, Li,
Lin, Barnett.
Drafting of the manuscript: Faust.
Critical revision of the manuscript for
important intellectual content: All authors.
Statistical analysis: Faust, Du, Lin.
Administrative, technical, or material
support: Faust, Mayes.
Supervision: Li, Lin, Krumholz.
Conflict of Interest Disclosures: Dr Lin reported working under contract
from the Centers for Medicare & Medicaid Services (CMS) to develop and
maintain measures for hospital performance that are publicly reported. Dr
Krumholz reported receiving personal fees from UnitedHealth, IBM Watson Health,
Element Science, Aetna, Facebook, Siegfried & Jensen Law Firm, Arnold &
Porter Law Firm, Martin/Baughman Law Firm, F-Prime, and National Center for
Cardiovascular Diseases, Beijing; being the co-founder of HugoHealth, a
personal health information platform, and Refactor Health, an AI-augmented data
management company; receiving contracts from CMS through Yale New Haven
Hospital to develop and maintain measures of hospital performance; and
receiving grants from Medtronic and FDA, Medtronic and Johnson & Johnson,
and Shenzhen Center for Health Information. No other disclosures were reported.
References
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