Racial and Ethnic Disparities in Age-Specific All-Cause Mortality during the COVID-19 Pandemic

Abstract

Importance: The end of the COVID-19 public health emergency (PHE) provides an opportunity to fully describe pandemic-Associated racial and ethnic mortality disparities. Age-specific excess mortality differences have important downstream implications, especially in minoritized race and ethnicity populations. Objectives: To characterize overall and age-specific all-cause excess mortality by race and ethnicity during the COVID-19 PHE and assess whether measured differences reflected changes from prepandemic disparities. Design, Setting, and Participants: This cross-sectional study analyzed data of all US residents and decedents during the COVID-19 PHE, aggregated by observed race and ethnicity (at time of death) and age. Statistical analysis was performed from March 2020 to May 2023. Exposures: COVID-19 PHE period (March 2020 to May 2023). Main Outcomes and Measures: All-cause excess mortality (incident rates, observed-To-expected ratios) and all-cause mortality relative risks before and during the PHE. Results: For the COVID-19 PHE period, data for 10643433 death certificates were available; mean (SD) decedent age was 72.7 (17.9) years; 944318 (8.9%) were Hispanic; 78973 (0.7%) were non-Hispanic American Indian or Alaska Native; 288680 (2.7%) were non-Hispanic Asian, 1374228 (12.9%) were non-Hispanic Black or African American, 52905 (0.5%) were non-Hispanic more than 1 race, 15135 (0.1%) were non-Hispanic Native Hawaiian or Other Pacific Islander, and 7877996 (74.1%) were non-Hispanic White. More than 1.38 million all-cause excess deaths (observed-To-expected ratio, 1.15 [95% CI, 1.12-1.18]) occurred, corresponding to approximately 23 million years of potential life lost (YPLL) during the pandemic. For the total population (all ages), the racial and ethnic groups with the highest observed-To-expected all-cause mortality ratios were the American Indian or Alaska Native (1.34 [95% CI, 1.31-1.37]) and Hispanic (1.31 [95% CI, 1.27-1.34]) populations. However, higher ratios were observed in the US population aged 25 to 64 years (1.20 [95% CI, 1.18-1.22]), greatest among the American Indian or Alaska Native (1.45 [95% CI, 1.42-1.48]), Hispanic (1.40 [95% CI, 1.38-1.42]), and Native Hawaiian or Other Pacific Islander (1.39 [95% CI, 1.34-1.44]) groups. In the total population aged younger than 25 years, the Black population accounted for 51.1% of excess mortality, despite representing 13.8% of the population. Had the rate of excess mortality observed among the White population been observed among the total population, more than 252000 (18.3%) fewer excess deaths and more than 5.2 million (22.3%) fewer YPLL would have occurred. Conclusions and Relevance: In this cross-sectional study of the US population during the COVID-19 PHE, excess mortality occurred in all racial and ethnic groups, with disparities affecting several minoritized populations. The greatest relative increases occurred in populations aged 25 to 64 years. Documented differences deviated from prepandemic disparities.