New excess mortality estimates show rise in U.S. rural mortality in second year of COVID-19 pandemic

According to a new study conducted by the Boston University School of Public Health (BUSPH) and the University of Pennsylvania (UPenn).

The new study presents the first-ever monthly estimates of excess mortality rates for each US county during the first two years of the pandemic.

Excess mortality, which compares observed deaths to the number of deaths that would be expected under normal conditions over a given period, provides a reliable estimate of the true impact of the pandemic on mortality over time and across regions. geographical, which is not affected by the variability of the causes. death assignment practices.

Published in the journal Scientists progressresults show that the high excess mortality rates that plagued large metropolitan areas in the Northeast and Mid-Atlantic regions during the early months of the pandemic began to shift to non-metropolitan areas of the south and west as early as August 2020, with the largest increases occurring during the outbreak of the highly contagious Delta variant in spring and summer 2021.

The study identifies a total of 1,179,024 excess deaths from March 2020 to February 2022, including 634,830 estimated excess deaths from March 2020 to February 2021 and 544,194 estimated excess deaths from March 2021 to February 2022.

This excess mortality data is now publicly available for researchers and the general public to view in a one-of-a-kind online database and interactive tool that the researchers created to serve as a resource for people to further examine the social, structural and political drivers of excess mortality during the pandemic.

“Despite the availability of vaccines, there were almost as many excess deaths as there were in the first year, before the era of vaccines,” says the study’s corresponding author, Dr Andrew Stokes, assistant professor of global health. at BUSPH. “While the pandemic slowed after the first year in major metropolitan areas, rural areas continued to experience a significant burden of excess deaths throughout the second year of the pandemic.”

The reasons for the high and sustained numbers are manifold, says Stokes. “The emergence of rural disadvantage reflects a combination of social, structural and political factors, including a lack of state policies designed to protect communities most at risk of death from COVID-19, state disinvestment in rural health care and social programs, and vaccine hesitation fueled by a toxic mix of partisanship and misinformation.”

“Detailed information on the impact of the pandemic can help policy makers make informed choices about appropriate measures to help communities recover from the negative impacts of COVID-19,” says the study’s lead author. , Eugenio Paglino, Ph.D. studying demography at UPenn. “This information was lacking in the United States, and we sought to fill that gap with this study.”

“Excess mortality statistics can also be extremely useful as part of a toolkit for detecting future outbreaks and intervening before they turn into full-blown pandemics; they can provide early signs of disease spread and help prioritize areas to direct resources to,” says Dr. Ioannis Paschalidis, director of the Hariri Institute for Computing and Computational Science and Engineering at Boston University. , and principal investigator of a joint National Science Foundation project with Dr. Stokes focused on pandemic prevention.

Dr Nahid Bhadelia, Founding Director of the Boston University Center for Emerging Infectious Diseases Policy and Research (CEID), says: “Studies like this help to understand how excess mortality analyzes can highlight areas where we need to focus on pandemic preparedness investments in the future, in terms of training, public health education and access to care.

For the study, Dr. Stokes, Paglino and colleagues from BUSPH, UPenn, The University of Washington School of Public Health, RTI International and The Robert Wood Johnson Foundation estimated excess all-cause mortality for 3,127 counties, looking at the mortality by county, month, census division, and metropolitan and non-metropolitan areas between the first and second year of the pandemic.

The total number of excess deaths between March 2020 and February 2022 aligns with national excess death counts from the Centers for Disease Control & Prevention, as well as the World Health Organization. But by evaluating county-level estimates, this new study exposes the communities hardest hit and reveals how the burden of mortality has evolved amid policy changes, vaccine development and new variants of COVID-19 in the world. during this period.

“Excessive state-level death rates mask additional heterogeneity in which some counties within those states were particularly vulnerable, based on rurality, partisanship, and other factors,” Stokes says. “Across the state of Florida, for example, some counties had exceptionally high death rates during Delta, far exceeding the state average. This county-level idea also dispels some stories in the media that Florida has had “tremendous success” during the pandemic, he says.

Other notable discoveries:

• Among major metropolitan areas, the decline in excess mortality between the first and second year of COVID-19 was particularly notable in the mid-Atlantic, New England, and Pacific regions.
• The increase in excess mortality in non-metropolitan areas was greatest in the Pacific, New England, and Mountain regions.

• The regions with the highest excess mortality in non-metropolitan areas during the second year were the mountains, the South Atlantic, the central-southeast and the central-southwest.

• The regions with the highest cumulative excess mortality at the end of February 2022 were the non-metropolitan areas of the South, the large metros of the West, the medium and small metros of the South, the large metros of the South and the non-metropolitan areas of the West.

“Much of the focus on addressing the impacts of the COVID-19 pandemic on mortality, including inequalities by race, ethnicity, socioeconomic status and disability, has is focused on urban areas,” says study co-author Dielle Lundberg, Ph.D., a health services student at the University of Washington School of Public Health. “The substantial variation in rural mortality across the country suggests that investments are needed not only in rural health, but also to address rural health inequities between and within rural areas.”

For example, counties with high percentages of Indigenous residents such as the Navajo Nation in Arizona reported consistently high excess mortality rates throughout the first two years of the pandemic, despite highly coordinated community responses around vaccination. This underscores the disproportionate social, structural and political determinants of the rural health of Indigenous peoples and their ongoing impact on COVID-19 exposure and mortality.

These geographic changes have created a growing gap in mortality between urban and rural areas over the past 20 to 30 years, says study co-author Dr Irma Elo, a sociology professor at the University of Pennsylvania.

“When the pandemic started in major metropolitan areas in the mid-Atlantic, the rest of the country didn’t think it would be affected and saw it as a ‘big city’ problem,” Dr. Elosays said. . “But what our results really show is that no one is immune to this pandemic. The spread may take time, but it reaches every corner of the country. Investments in rural health and social infrastructure are urgently needed to prevent further excess deaths from occurring in the future.”