As at Monday, October 12, Nigeria Centre for Disease Control (NCDC) said Africa’s most populous country logged a total of 60,430 positive cases of COVID-19, discharged 51,943 patients, and recorded 1,115 deaths.
But, an earth-shaking finding is showing that total deaths recorded during the pandemic far exceeded those attributed to the virus. In the US, for every two deaths attributed to COVID-19, a third American died as a result of the pandemic, according to new data in the Journal of the American Medical Association.
Since COVID-19’s spread to the US earlier this year, death rates have been rising significantly. But deaths attributed to COVID-19 only account for about two-thirds of the increase in March and April, according to a study in the Journal of the American Medical Association.
Researchers at Virginia Commonwealth University and Yale University found that, from March 1 to April 25, US saw 87,001 excess deaths—or deaths above the number that would be expected based on averages from the previous five years.
The study, Excess Deaths from COVID-19 and Other Causes, March-April 2020, showed that only 65% of the excess deaths that occurred in March and April were attributed to COVID-19, meaning more than one-third are linked to other causes.
In 14 states, including two of the most populated—California and Texas—more than half of the excess deaths were tied to an underlying cause other than COVID-19, said lead author Steven Woolf, M.D., director emeritus of VCU’s Center on Society and Health.
This data, Woolf said, suggests the COVID-19 death counts reported to the public underestimate the true death toll of the pandemic in the US.
“There are several potential reasons for this under-count”, said Woolf, a professor in the Department of Family Medicine and Population Health at VCU School of Medicine.
“Some of it may reflect under-reporting; it takes a while for some of these data to come in. Some cases might involve patients with COVID-19 who died from related complications, such as heart disease, and those complications may have been listed as the cause of death rather than COVID-19.
“But a third possibility, the one we’re quite concerned about, is indirect mortality—deaths caused by the response to the pandemic”, Woolf said. “People who never had the virus may have died from other causes because of the spillover effects of the pandemic, such as delayed medical care, economic hardship or emotional distress.”
Woolf and his team found that deaths from causes other than COVID-19 rose sharply in the states that had the most COVID-19 deaths in March and April. Those states were Massachusetts, Michigan, New Jersey, New York—particularly New York City—and Pennsylvania. At COVID-19’s peak for March and April (the week ending April 11), diabetes deaths in those five states rose 96% above the expected number of deaths when compared to the weekly averages in January and February of 2020. Deaths from heart disease (89%), Alzheimer’s disease (64%) and stroke (35%) in those states also spiked.
New York City’s death rates alone rose a staggering 398% from heart disease and 356% from diabetes, the study stated.
Woolf said he and his team suspect that some of these were indirect deaths from the pandemic that occurred among people with acute emergencies, such as a heart attack or stroke, who may have been afraid to go to a hospital for fear of getting the virus.
Those who did seek emergency care, particularly in the areas hardest hit by the virus, may not have been able to get the treatment they needed, such as ventilator support, if the hospital was overwhelmed by the surge.
Others may have died from a chronic health condition, such as diabetes or cancer, that was exacerbated by the effects of the pandemic, said Woolf, VCU’s C. Kenneth and Dianne Wright Distinguished Chair in Population Health and Health Equity. Still others may have struggled to deal with the consequences of job loss or social isolation.
“We can’t forget about mental health”, Woolf said. “A number of people struggling with depression, addiction and very difficult economic conditions caused by lockdowns may have become increasingly desperate, and some may have died by suicide.
‘’People addicted to opioids and other drugs may have overdosed. All told, what we’re seeing is a death count well beyond what we would normally expect for this time of year, and it’s only partially explained by COVID-19.”
Woolf and his co-authors, Derek Chapman, Ph.D., Roy Sabo, Ph.D., and Latoya Hill of VCU, and Daniel M. Weinberger, Ph.D., of Yale University, state that further investigation is needed to determine just how many deaths were from COVID-19 and how many were indirect deaths “caused by disruptions in society that diminished or delayed access to health care and the social determinants of health (e.g., jobs, income, food security).”
Woolf, also a family physician, said this paper’s results underscore the need for health systems and public officials to make sure services are available not only for COVID-19 but for other health problems. His study showed what happened in the states that were overwhelmed by cases in March and April. Woolf worries that the same spikes in excess deaths may now be occurring in other states that are being overwhelmed.
“The findings from our VCU researchers’ study confirm an alarming trend across the U.S., where community members experiencing a health emergency are staying home—a decision that can have long-term, and sometimes fatal, consequences”, said Peter Buckley, M.D., interim CEO of VCU Health System and interim senior vice president of VCU Health Sciences. “Health systems nationwide need to let patients know it is safe and important to seek care in a health emergency, whether it’s through telehealth or in person.”
Woolf, who serves in a community engagement role with the C. Kenneth and Dianne Wright Center for Clinical and Translational Research, said resources should be available for those facing unemployment, loss of income and food and housing insecurity, including help with the mental health challenges, such as depression, anxiety or addiction that these hardships could present.
“Public officials need to be thinking about behavioral health care and ramping up their services for those patients in need”, Woolf said. “The absence of systems to deal with these kinds of other health issues will only increase this number of excess deaths.”
However, the study, led by researchers at Virginia Commonwealth University, shows that deaths between March 1 and Aug. 1 increased 20% compared to previous years—maybe not surprising in a pandemic. But deaths attributed to COVID-19 only accounted for 67% of those deaths.
“Contrary to sceptics who claim that COVID-19 deaths are fake or that the numbers are much smaller than we hear on the news, our research and many other studies on the same subject show quite the opposite”, said lead author Steven Woolf, M.D., director emeritus of VCU’s Center on Society and Health.
The study also contains suggestive evidence that state policies on reopening early in April and May may have fueled the surges experienced in June and July.
“The high death counts in Sun Belt states show us the grave consequences of how some states responded to the pandemic and sound the alarm not to repeat this mistake going forward,” said Woolf, a professor in the Department of Family Medicine and Population Health at the VCU School of Medicine.
Total death counts in the US are remarkably consistent from year to year, as the study notes. The study authors pulled data from the Centers for Disease Control and Prevention for 2014 to 2020, using regression models to predict expected deaths for 2020.
The gap between reported COVID-19 deaths and all unexpected deaths can be partially explained by delays in reporting COVID-19 deaths, miscoding or other data limitations, Woolf said. But the pandemic’s other ripple effects could explain more.
“Some people who never had the virus may have died because of disruptions caused by the pandemic”, said Woolf, VCU’s C. Kenneth and Dianne Wright Distinguished Chair in Population Health and Health Equity. “These include people with acute emergencies, chronic diseases like diabetes that were not properly cared for, or emotional crises that led to overdoses or suicides.”
For example, the study specifically showed that the entire nation experienced significant increases in deaths from dementia and heart disease. Woolf said deaths from Alzheimer’s disease and dementia increased not only in March and April, when the pandemic began, but again in June and July when the COVID-19 surge in the Sun Belt occurred.
This study, with data from March to Aug. 1, builds on a previously published JAMA
States like New York and New Jersey, which were hit hard early, were able to bend the curve and bring death rates down in less than 10 weeks. Meanwhile, states such as Texas, Florida and Arizona that escaped the pandemic at first but reopened early showed a protracted summer surge that lasted 16-17 weeks—and was still underway when the study ended.
“We can’t prove causally that the early reopening of those states led to the summer surges. But it seems quite likely”, said Woolf. “And most models predict our country will have more excess deaths if states don’t take more assertive approaches in dealing with community spread. The enforcement of mask mandates and social distancing is really important if we are to avoid these surges and major loss of life.”
Woolf paints a grim picture, warning that long-term data may show a broader impact of the pandemic on mortality rates. Cancer patients who have had their chemotherapy disrupted, women who have had their mammograms delayed—preventable, early deaths may increase in the coming years, he said.
“And death is only one measure of health”, Woolf said. “Many people who survive this pandemic will live with lifelong chronic disease complications. Imagine someone who developed the warning signs of a stroke but was scared to call 9-1-1 for fear of getting the virus. That person may end up with a stroke that leaves them with permanent neurological deficits for the rest of their life.”
Diabetes complications that aren’t being managed properly could lead to kidney failure and dialysis. And behavioural health issues, like emotional trauma, are going untreated. Woolf worries most about the lasting effects on children—long-term, generational outcomes.
“This isn’t a pandemic involving a single virus”, said Peter Buckley, M.D., dean of the VCU School of Medicine. “This is a public health crisis with broad and lasting ripple effects. VCU researchers have been diligent in their investigations into both treatment of COVID-19 and in understanding the long-term repercussions of the pandemic, so that fellow doctors, policymakers and community members can fight these battles on multiple fronts.”
Co-authors on Woolf’s paper include: Derek Chapman, Ph.D., Latoya Hill, DaShaunda Taylor and Roy Sabo, Ph.D., of VCU; and Daniel Weinberger, Ph.D., of Yale University.
The study complements another VCU researcher’s recent data showing an alarming surge in opioid overdoses at VCU Medical Center during the pandemic. Taylor Ochalek, Ph.D., a postdoctoral research fellow at the Wright Center, found a 123% increase in nonfatal overdoses between March and June this year, as compared to last, in a study also published in JAMA.
Woolf notes that the CDC has released provisional overdose deaths under a broad label called “external causes,” which also includes car crashes and homicides, making research like Ochalek’s all the more important.
“Car crashes decreased because fewer people were driving during the lockdowns”, Woolf said. “We worry that the broad umbrella category of ‘external causes’ may hide an increase in deaths from overdoses, because the opioid epidemic didn’t go away.”
The CDC, Woolf added, has rushed out provisional mortality data this year because of the pandemic. More reliable, granular detail will come out later and allow researchers to unpack the detailed contributors to excess deaths and secondary health impacts of the pandemic.
Researchers across multiple disciplines at VCU are studying the secondary health impacts of the pandemic—from substance use disorders and intimate partner violence to diminished access to regular medical care—all of which could contribute to loss of life, according to Woolf’s study.
