COVID-19 Exacerbated Racial and Ethnic Mortality Disparities

Using data from death certificates from the COVID-19 public health emergency period (March 2020 through May 2023), investigators found more than 1.38 million excess deaths had occurred, with several notable mortality disparities among the racial and ethnic minority patient populations represented, as well as patients aged 25 to 64 years. This was seen despite there being excess mortality across all racial and ethnic groups overall, and these findings marked deviations from the disparities seen even before the pandemic.

Findings were published in JAMA Network Open,¹ with incident rates and observed-to-expected ratios of mortality and all-cause mortality relative risk before and during the public health emergency being the principal outcomes of interest for this cross-sectional study. Data from 10 million-plus death certificates were available at the time of the authors’ analysis, and they defined excess mortality according to findings from previous research and modeling.^2,3

The races and ethnicities represented in this analysis were non-Hispanic American Indian or Alaska Native, non-Hispanic Asian, non-Hispanic Black or African American (Black), Hispanic or Latino of all races, non-Hispanic more than 1 race, non-Hispanic Native Hawaiian or Other Pacific Islander, and non-Hispanic White, and age-specific mortality rates were calculated for younger than 25 years, aged 25 to 64 years, and 65 years and older. The deaths that occurred in the group reporting more than 1 race were only included for US totals. The mean (SD) age at death was 72.7 (17.9) years.

“Our focus on all-cause mortality allowed a comprehensive perspective of the pandemic’s overall association with outcomes,” the study authors wrote, “capturing direct COVID-19 deaths (including miscategorized COVID-19–related deaths) and indirect consequences of the pandemic, including for populations frequently excluded from public-facing reports and dashboards.”

The lowest total of expected deaths was 12,225 (95% CI, 11,892-12,557) among those in the Native Hawaiian or Other Pacific Islander group, and the highest was predicted for those in the White group (7,028,654; 95% CI, 6,843,894-7,213,414). Overall, deaths among those reporting a White race/ethnicity (7,877,996; 74.1%) accounted for the most total deaths, followed by non-Hispanic Black or African American (1,374,228; 12.9%), Hispanic (944,318; 8.9%), non-Hispanic Asian (288,680; 2.7%), non-Hispanic American Indian or Alaska Native (78,973; 0.7%), non-Hispanic more than 1 race (52,905; 0.5%), and non-Hispanic Native Hawaiian or Other Pacific Islander (15,135; 0.1%).

The COVID-19 public health emergency lasted from January 27, 2020, through May 11, 2023, and data from March 2020 through May 11, 2023, were used for this new analysis that found mortality outcomes disparities by age and race/ethnicity. | Image Credit: © Colored Lights-stock.adobe.com

The 1.38 million excess deaths observed accounted for an estimated 23 million years of potential life lost, for an observed-to-expected mortality ratio of 1.15 (95% CI, 1.12-1.18). For all races and ethnicities, the highest observed-to-expected ratios was seen in patients reporting they were American Indian or Alaska Native and Hispanic, at 1.34 (95% CI, 1.31-1.37) and 1.31 (95% CI, 1.27-1.34), respectively, and the lowest ratios were observed in patients reporting a White race (1.12; 95% CI, 1.09-1.15) or more than 1 race (1.12; 95% CI, 1.07-1.17).

For all ages, the highest observed-to-expected ratio was seen among patients aged 25 to 64 years (1.20; 95% CI, 1.18-1.22), but this rose even higher among some of the race/ethnicity groups included in this analysis: to 1.39 (95% CI, 1.34-1.44) for those reporting they were Native Hawaiian or Other Pacific Islander, to 1.40 (95% CI, 1.38-1.42) reporting they were Hispanic, and to 1.45 (95% CI, 1.42-1.48) among those reporting they were American Indian or Alaska Native. Deaths among those aged 25 to 64 years represented approximately 13.1 years of potential life lost.

Drilling down to the specific age ranges:

• For those younger than 25 years, the highest baseline mortality disparity (1.96; 95% CI, 1.94-1.97) and largest relative risk increase during the pandemic (2.31; 95% CI, 2.29-2.33) were seen among the Black population.
• For those aged 25 to 64 years, the highest prepandemic mortality disparity (1.64; 95% CI, 1.62-1.66) and largest relative risk increase (2.10; 95% CI, 2.08-2.13) was seen among the American Indian or Alaska Native population.
• For those 65 years or older, 2 groups experienced significant increases in from their baseline relative risk:
  • Black: 1.07 (95% CI, 1.07-1.07) to 1.11 (95% CI, 1.11-1.12)
  • Hispanic: 0.72 (95% CI, 0.71-0.72) to 0.79 (95% CI, 0.79-0.79)

The authors highlight that despite accounting for just 13.8% of the younger-than-25 years cohort, the Black population represented 51.4% of the excess deaths in that age grouping, and even though the oldest patients in this study (65 years or older) had the highest incident rates of excess mortality, their observed-to-expected mortality ratios were still lower for all races and ethnicities vs the patients aged 25 to 64 years.

These findings add to the existing literature because the authors used age-stratified component excess mortality modeling instead of adjusting for age or using standard ranges, their data span the entire pandemic, they compared the prepandemic period to the pandemic period, and their exploratory analyses identified contemporaneous increases in non-COVID-19 causes of mortality, they wrote.

“We demonstrate that the pandemic appears to have exacerbated historical mortality disparities that have long been understood to reflect strata in social determinants of health, structural inequality, and racism, and which have persisted,” they concluded. “Given that race and ethnicity are social constructs, the magnitude of these findings cannot be explained by genetic differences. Nevertheless, biological (and modifiable) mechanisms must be considered.”

The conditions that create health disparities must be addressed before the next public health crisis, they stressed, and there need to be stepped-up, targeted efforts to protect high-risk groups (eg, evidence-based policies, resource distribution and infrastructure improvements) that address systemic inequities.

References

1. Faust JS, Renton B, Bongiovanni T, et al. Racial and ethnic disparities in age-specific all-cause mortality during the COVID-19 pandemic. JAMA Netw Open. 2024;7(10):e2438918. doi:10.1001/jamanetworkopen.2024.38918

2. Faust JS, Renton B, Chen AJ, et al. The uncoupling of all-cause excess mortality from COVID-19 cases and associated hospitalizations in late winter and spring of 2022 in a highly vaccinated state. medRxiv. 2022. doi:10.1101/2022.07.07.22277315

3. Faust JS, Du C, Liang C, et al. Excess mortality in Massachusetts during the Delta and Omicron waves of COVID-19. JAMA. 2022;328(1):74-76. doi:10.1001/jama.2022.8045