Excess Deaths During the COVID-19 Pandemic: Implications for US Death Investigation Systems
Andrew Stokes, Dielle J. Lundberg, Jacob Bor, Kirsten Bibbins‐Domingo
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, vital statistics have had an important role in shaping the public health response, including recommendations for physical distancing and mask wearing, temporary lockdowns, and mobilization of health care systems.2 Racial and socioeconomic disparities in deaths attributed to COVID-19 have shown how structural racism contributed to vulnerability during the pandemic.3 Although monitoring death certificates for reference to COVID-19 is a useful method for detecting the mortality associated with severe acute respiratory syndrome coronavirus 2 infection, it is likely to result in an undercount if COVID-19 is missing on death certificates in cases in which COVID-19 contributed to death.4-6 In fact, between 15% and 34% of excess deaths that occurred in 2020 duringthe COVID-19 pandemic were not directly assigned to COVID-19 on death certificates.7 These deaths likely include COVID-19 deaths not assigned to COVID-19 and indirect deaths related to social and economic consequences of the pandemic. In rural areas, where coroners are more common, there is often less access to health care, including COVID-19 testing.9 Coroners may also be less likely to perform postmortem COVID-19 testing as a result of budget limitations. [...]prior research has identified partisan differences in attitudes toward COVID-19 and behaviors such as physical distancing and mask wearing.10 Thus, partisan differences could affect the likelihood that an individual or their family members seek COVID-19 testing while alive and whether coroners pursue postmortem testing. Because some states require testing for confirmation of a COVID-19 death, this could affect a state's COVID19 death count.11 Regardless ofthe cause, the possibility that the quality of death investigation systems may affect the reporting of COVID-19 deaths holds implications for the study of geographic variation in COVID-19 mortality, whichisanimportant tool for documenting disparities.