What are excess deaths?
Excess deaths are the number of deaths over the expected average, while taking into account monthly variation and population growth by year. Death certificates filed through the Virginia Department of Health’s (VDH) Office of Vital Records (OVR) are used to make these calculations. Typically, all-cause mortality, which means looking at total death certificates due to any cause or manner of death (essentially looking at all deaths in the state), are used to make these calculations.
How were the total excess deaths examined during the COVID-19 pandemic?
In 2019, nearly 70,000 deaths occurred in Virginia according to data obtained from death certificates from VDH OVR. Using these same data from 2015 to 2019 by month of death and accounting for monthly variation and population growth, it was estimated that Virginia would have experienced 70,750 expected deaths in Virginia in 2020 if the COVID-19 pandemic never occurred. These estimations were calculated through March 2021.
These expected deaths were compared to preliminary totals of actual death certificates filed by month of death for 2020 and for the start of 2021. Adjusting this review from the start of the pandemic in March 2020, data were examined through February 2021 and accounted for one year of preliminary data. It was estimated that from March 2020 to February 2021, Virginia would have expected to see 70,704 total deaths but instead actually experienced a preliminary total of 82,772 deaths of all cause-mortality; an excess of 12,068 deaths, or 17.1% from the expected total (Figure 1).
What types of deaths made up the excess death category?
Some known and unknown increases in specific categories of death made up the 12,068 excess deaths during March 2020 to February 2021.
- The largest portion of the total excess deaths was made up of confirmed COVID-19 deaths (9,847 or 81.6%) based on death certificates filed or VDH disease investigations where, after review, it was determined that COVID-19 was a cause or contributor to death (how VDH counts COVID-19 deaths is listed here). COVID-19 deaths are natural deaths, and pursuant to the Code of Virginia § 32.1-283, the vast majority of these deaths do not fall under jurisdiction of the Office of the Chief Medical Examiner (OCME) unless other circumstances of the death make it an OCME case.
- When reviewing the other categories of excess deaths that made up the total excess deaths, one must review deaths that fall under OCME jurisdiction and natural deaths that do not fall under OCME jurisdiction.
- For the OCME cases, two general categories of OCME deaths were examined among the total excess: drug overdose deaths and non-drug overdose deaths. First, while 2019 set the record for the largest number of fatal drug overdoses ever seen in Virginia, like most other states, Virginia experienced a large increase in fatal drug overdoses beginning in March 2020 and continuing throughout the pandemic. Using the same methodology calculations of expected deaths to excess deaths, it was estimated that Virginia experienced 673 excess drug deaths by month of death when comparing 2019 totals (5.6% of total excess deaths). Similarly, using 2019 numbers by month and comparing preliminary totals of all OCME cases but removing excess drug deaths, a category of non-drug overdose excess OCME deaths by month were identified (n=909 or 7.6% of total excess deaths).
- For the excess deaths not under OCME jurisdiction, COVID-19 deaths and excess OCME cases (both drug overdose and non-drug overdose deaths) were compared to the total number of excess deaths (n=12,068), resulting in a category of unknown natural deaths not under OCME jurisdiction (n=629 or 5.2% of total excess deaths) (Figure 2).
What are the implications of the excess deaths during the pandemic?
Undoubtedly, the COVID-19 pandemic will go down as one of the most significant world events in recent history. The physical health, mental health, and livelihood of billions of people across the globe have been significantly impacted by COVID-19. In the United States, life expectancy, the rank order of leading causes of death, mortality rates, and various other statistical measures of public health are expected to change based on this single event.
Although 81.6% of the excess deaths were due to COVID-19, the remaining 18.4% were deaths not directly related to COVID-19 infection. Among the excess OCME cases, fatal drug overdoses, which were already declared an epidemic in Virginia in 2016, were exacerbated during the pandemic with a preliminary estimate of over a 45% increase in overdose deaths in 2020 compared to 2019. Various hypotheses about reasons for this increase have been considered, but a deeper dive into these theories is needed by the academic community.
The total annual homicides for 2020 also contributed to the excess non-drug overdose OCME cases. Total homicides in 2020 reached the highest number recorded in Virginia in the last few decades with a preliminary total of 541 homicides; an increase of 80 additional homicides from 2019, or a 17.4% increase. Deaths at home where the person who died had not been treated by a physician in the last year, making the death an OCME case by Code of Virginia, also increased in 2020 compared to past years.
Interestingly, but also thankfully, annual statewide suicide numbers did not increase or decrease in 2020 when compared to numbers in past years. Given that drug overdoses have many of the same risk factors as suicide, one would assume that if one of these events increased during the pandemic, so would the other; however, that was not demonstrated statewide in Virginia OCME data.
Lastly, the category of unknown natural deaths not under OCME jurisdiction needs further investigation into the commonalities in this category. This review was based on preliminary OCME data in comparison to preliminary all-cause mortality data from all death certificates filed in the state, so additional investigation from VDH OVR or other researchers needs to be performed on the non-OCME natural excess deaths. Further investigations into this unknown category of excess deaths is needed to focus prevention efforts in an attempt to prevent additional deaths during and after the COVID-19 pandemic.
Data notes and limitations
Data calculations used VDH OVR data from 2015-2019 to estimate monthly 2020 and 2021 expected numbers of deaths while accounting for monthly variation and population growth. Data was extracted March 18, 2021 and analyzed from March 2020 to February 2021 and accounted for one year of preliminary data at the time of publication. All data presented should be considered preliminary and subject to change.