County-Level Estimates of Excess Mortality associated with COVID-19 in the United States

AbstractThe coronavirus disease 2019 (COVID-19) pandemic in the US has been largely monitored on the basis of death certificates containing reference to COVID-19. However, prior analyses reveal that a significant fraction of excess deaths associated with the pandemic were not directly assigned to COVID-19 on the death certificate. The percent of excess deaths not assigned to COVID-19 is also known to vary across US states. However, few studies to date provide information on patterns of excess mortality and excess deaths not assigned to COVID-19 for US counties, despite the importance of this information for health policy and planning. In the present study, we develop and validate a generalized linear model of expected mortality in 2020 based on historical trends in deaths by county of residence between 2011 and 2019. We use the results of the model to generate county estimates of excess mortality and excess deaths not assigned to COVID-19 for each county in the US along with bootstrapped prediction intervals. Overall, the proportion of excess deaths assigned to COVID-19 was 81%, meaning that 19% of excess deaths were not assigned to COVID-19. The proportion assigned to COVID-19 was lower in the South (76%) and West (75%) as compared to counties in the Midwest (81%) and Northeast (94%). Across US Census Divisions, the proportion was especially low in the East South Central Division (67%). Rural counties across all divisions (67%) reported lower proportions of excess deaths assigned to COVID-19 than urban areas (83%). For instance, in the Middle Atlantic and Pacific Divisions respectively, only 47% and 39% of excess deaths were assigned to COVID-19 in nonmetro areas. In contrast, the New England Census Division stood out as the only division where directly assigned COVID-19 deaths actually exceeded excess deaths, meaning there were 1.23 directly assigned COVID-19 deaths for every 1 excess death. However, this finding did not extend to nonmetro areas within New England where only 64% of excess deaths were assigned to COVID-19. The finding that metro areas in New England reported higher direct COVID-19 mortality than excess mortality suggests that reductions in mortality from other causes of death may have occurred in these areas, at least among some populations. Across individual counties, the percentage of excess deaths not assigned to COVID-19 varied substantially, with some counties’ direct COVID-19 tallies capturing only a small fraction of total excess deaths, whereas in other counties the direct COVID-19 death rate far exceeded the number of estimated excess deaths. Taken together, our results suggest that regional inequalities in the mortality burden associated with COVID-19 are not fully revealed by data at the state level and that consideration of excess deaths across US counties is critical for a full accounting of the disparate regional effects of the pandemic on US mortality.

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Exposure of Domestic Cats to Three Zoonotic Bartonella Species in the United States

Pathogens ◽

10.3390/pathogens10030354 ◽

2021 ◽

Vol 10 (3) ◽

pp. 354

Author(s):

Lynn M. Osikowicz ◽

Kalanthe Horiuchi ◽

Irina Goodrich ◽

Edward B. Breitschwerdt ◽

Bruno Chomel ◽

...

Keyword(s):

New England ◽

The United States ◽

Severe Illness ◽

Domestic Cats ◽

Bartonella Species ◽

Serum Samples ◽

North Central ◽

Middle Atlantic ◽

South Central ◽

Central Regions

Cat-associated Bartonella species, which include B. henselae, B. koehlerae, and B. clarridgeiae, can cause mild to severe illness in humans. In the present study, we evaluated 1362 serum samples obtained from domestic cats across the U.S. for seroreactivity against three species and two strain types of Bartonella associated with cats (B. henselae type 1, B. henselae type 2, B. koehlerae, and B. clarridgeiae) using an indirect immunofluorescent assay (IFA). Overall, the seroprevalence at the cutoff titer level of ≥1:64 was 23.1%. Seroreactivity was 11.1% and 3.7% at the titer level cutoff of ≥1:128 and at the cutoff of ≥1:256, respectively. The highest observation of seroreactivity occurred in the East South-Central, South Atlantic, West North-Central, and West South-Central regions. The lowest seroreactivity was detected in the East North-Central, Middle Atlantic, Mountain, New England, and Pacific regions. We observed reactivity against all four Bartonella spp. antigens in samples from eight out of the nine U.S. geographic regions.

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Flattening the curve before it flattens us: hospital critical care capacity limits and mortality from novel coronavirus (SARS-CoV2) cases in US counties

10.1101/2020.04.01.20049759 ◽

2020 ◽

Cited By ~ 11

Author(s):

Charles C. Branas ◽

Andrew Rundle ◽

Sen Pei ◽

Wan Yang ◽

Brendan G. Carr ◽

...

Keyword(s):

Critical Care ◽

The United States ◽

Medical System ◽

Social Distancing ◽

Epidemic Curve ◽

Preventive Actions ◽

The Us ◽

Us Counties ◽

Novel Coronavirus ◽

Excess Deaths

ABSTRACTBackgroundAs of March 26, 2020, the United States had the highest number of confirmed cases of Novel Coronavirus (COVID-19) of any country in the world. Hospital critical care is perhaps the most important medical system choke point in terms of preventing deaths in a disaster scenario such as the current COVID-19 pandemic. We therefore brought together previously established disease modeling estimates of the growth of the COVID-19 epidemic in the US under various social distancing contact reduction assumptions, with local estimates of the potential critical care surge response across all US counties.MethodsEstimates of spatio-temporal COVID-19 demand and medical system critical care supply were calculated for all continental US counties. These estimates were statistically summarized and mapped for US counties, regions and urban versus non-urban areas. Estimates of COVID-19 infections and patients needing critical care were calculated from March 24, 2020 to April 24, 2020 for three different estimated population levels – 0%, 25%, and 50% – of contact reduction (through actions such as social distancing). Multiple national public and private datasets were linked and harmonized in order to calculate county-level critical care bed counts that included currently available beds and those that could be made available under four surge response scenarios – very low, low, medium, and high – as well as excess deaths stemming from inaccessible critical care.ResultsSurge response scenarios ranged from a very low total supply 77,588 critical care beds to a high total of 278,850 critical care beds. Over the four week study period, excess deaths from inaccessible critical care ranged from 24,688 in the very low response scenario to 13,268 in the high response scenario. Northeastern and urban counties were projected to be most affected by excess deaths due to critical care shortages, and counties in New York, Colorado, and Virginia were projected to exceed their critical care bed limits despite high levels of COVID-19 contact reduction. Over the four week study period, an estimated 12,203-19,594 excess deaths stemming from inaccessible critical care could be averted through greater preventive actions such as travel restrictions, publicly imposed contact precautions, greater availability of rapid testing for COVID-19, social distancing, self-isolation when sick, and similar interventions. An estimated 4,029-11,420 excess deaths stemming from inaccessible critical care could be averted through aggressive critical care surge response and preparations, including high clearance of ICU and non-ICU critical care beds and extraordinary measures like using a single ventilator for multiple patients.ConclusionsUnless the epidemic curve of COVID-19 cases is flattened over an extended period of time, the US COVID-19 epidemic will cause a shortage of critical care beds and drive up otherwise preventable deaths. The findings here support value of preventive actions to flatten the epidemic curve, as well as the value of exercising extraordinary surge capacity measures to increase access to hospital critical care for severely ill COVID-19 patients.

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Excess mortality in the United States in the 21st century

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.2024850118 ◽

2021 ◽

Vol 118 (16) ◽

pp. e2024850118

Author(s):

Samuel H. Preston ◽

Yana C. Vierboom

Keyword(s):

United States ◽

Excess Mortality ◽

The United States ◽

Mortality Rates ◽

Years Of Life Lost ◽

Death Rates ◽

Loss Of Life ◽

The Us ◽

Specific Mortality ◽

Excess Deaths

We use three indexes to identify how age-specific mortality rates in the United States compare to those in a composite of five large European countries since 2000. First, we examine the ratio of age-specific death rates in the United States to those in Europe. These show a sharp deterioration in the US position since 2000. Applying European age-specific death rates in 2017 to the US population, we then show that adverse mortality conditions in the United States resulted in 400,700 excess deaths that year. Finally, we show that these excess deaths entailed a loss of 13.0 My of life. In 2017, excess deaths and years of life lost in the United States represent a larger annual loss of life than that associated with the COVID-19 epidemic in 2020.

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Heterogeneity in the Effectiveness of Non-pharmaceutical Interventions During the First SARS-CoV2 Wave in the United States

Frontiers in Public Health ◽

10.3389/fpubh.2021.754696 ◽

2021 ◽

Vol 9 ◽

Author(s):

William K. Pan ◽

Daniel Fernández ◽

Stefanos Tyrovolas ◽

Giné-Vázquez Iago ◽

Rishav Raj Dasgupta ◽

...

Keyword(s):

New England ◽

Effect Sizes ◽

County Level ◽

Middle Atlantic ◽

South Central ◽

The Us ◽

Central South ◽

Doubling Times ◽

East West ◽

Pharmaceutical Interventions

Background: Attempts to quantify effect sizes of non-pharmaceutical interventions (NPI) to control COVID-19 in the US have not accounted for heterogeneity in social or environmental factors that may influence NPI effectiveness. This study quantifies national and sub-national effect sizes of NPIs during the early months of the pandemic in the US.Methods: Daily county-level COVID-19 cases and deaths during the first wave (January 2020 through phased removal of interventions) were obtained. County-level cases, doubling times, and death rates were compared to four increasingly restrictive NPI levels. Socio-demographic, climate and mobility factors were analyzed to explain and evaluate NPI heterogeneity, with mobility used to approximate NPI compliance. Analyses were conducted separately for the US and for each Census regions (Pacific, Mountain, east/West North Central, East/West South Central, South Atlantic, Middle Atlantic and New England). A stepped-wedge cluster-randomized trial analysis was used, leveraging the phased implementation of policies.Results: Aggressive (level 4) NPIs were associated with slower COVID-19 propagation, particularly in high compliance counties. Longer duration of level 4 NPIs was associated with lower case rates (log beta −0.028, 95% CI −0.04 to −0.02) and longer doubling times (log beta 0.02, 95% CI 0.01–0.03). Effects varied by Census region, for example, level 4 effects on doubling time in Pacific states were opposite to those in Middle Atlantic and New England states. NPI heterogeneity can be explained by differential timing of policy initiation and by variable socio-demographic county characteristics that predict compliance, particularly poverty and racial/ethnic population. Climate exhibits relatively consistent relationships across Census regions, for example, higher minimum temperature and specific humidity were associated with lower doubling times and higher death rates for this period of analysis in South Central, South Atlantic, Middle Atlantic, and New England states.Conclusion and Relevance: Heterogeneity exists in both the effectiveness of NPIs across US Census regions and policy compliance. This county-level variability indicates that control strategies are best designed at community-levels where policies can be tuned based on knowledge of local disparities and compliance with public health ordinances.

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Associations between Google Search Trends for Symptoms and COVID-19 Confirmed and Death Cases in the United States

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18094560 ◽

2021 ◽

Vol 18 (9) ◽

pp. 4560

Author(s):

Mostafa Abbas ◽

Thomas B. Morland ◽

Eric S. Hall ◽

Yasser EL-Manzalawy

Keyword(s):

Functional Data ◽

Time Series Data ◽

Principal Component ◽

State Level ◽

The United States ◽

Functional Principal Component Analysis ◽

Series Data ◽

Dynamic Correlation ◽

The Us ◽

Google Search

We utilize functional data analysis techniques to investigate patterns of COVID-19 positivity and mortality in the US and their associations with Google search trends for COVID-19-related symptoms. Specifically, we represent state-level time series data for COVID-19 and Google search trends for symptoms as smoothed functional curves. Given these functional data, we explore the modes of variation in the data using functional principal component analysis (FPCA). We also apply functional clustering analysis to identify patterns of COVID-19 confirmed case and death trajectories across the US. Moreover, we quantify the associations between Google COVID-19 search trends for symptoms and COVID-19 confirmed case and death trajectories using dynamic correlation. Finally, we examine the dynamics of correlations for the top nine Google search trends of symptoms commonly associated with COVID-19 confirmed case and death trajectories. Our results reveal and characterize distinct patterns for COVID-19 spread and mortality across the US. The dynamics of these correlations suggest the feasibility of using Google queries to forecast COVID-19 cases and mortality for up to three weeks in advance. Our results and analysis framework set the stage for the development of predictive models for forecasting COVID-19 confirmed cases and deaths using historical data and Google search trends for nine symptoms associated with both outcomes.

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The effects of global changes upon regional ozone pollution in the United States

Atmospheric Chemistry and Physics ◽

10.5194/acp-9-1125-2009 ◽

2009 ◽

Vol 9 (4) ◽

pp. 1125-1141 ◽

Cited By ~ 44

Author(s):

J. Chen ◽

J. Avise ◽

B. Lamb ◽

E. Salathé ◽

C. Mass ◽

...

Keyword(s):

Urban Areas ◽

The United States ◽

Base Case ◽

Global Changes ◽

Ozone Pollution ◽

Modeling Framework ◽

Voc Emissions ◽

The Us ◽

The Future ◽

Future Case

Abstract. A comprehensive numerical modeling framework was developed to estimate the effects of collective global changes upon ozone pollution in the US in 2050. The framework consists of the global climate and chemistry models, PCM (Parallel Climate Model) and MOZART-2 (Model for Ozone and Related Chemical Tracers v.2), coupled with regional meteorology and chemistry models, MM5 (Mesoscale Meteorological model) and CMAQ (Community Multi-scale Air Quality model). The modeling system was applied for two 10-year simulations: 1990–1999 as a present-day base case and 2045–2054 as a future case. For the current decade, the daily maximum 8-h moving average (DM8H) ozone mixing ratio distributions for spring, summer and fall showed good agreement with observations. The future case simulation followed the Intergovernmental Panel on Climate Change (IPCC) A2 scenario together with business-as-usual US emission projections and projected alterations in land use, land cover (LULC) due to urban expansion and changes in vegetation. For these projections, US anthropogenic NOx (NO+NO2) and VOC (volatile organic carbon) emissions increased by approximately 6% and 50%, respectively, while biogenic VOC emissions decreased, in spite of warmer temperatures, due to decreases in forested lands and expansion of croplands, grasslands and urban areas. A stochastic model for wildfire emissions was applied that projected 25% higher VOC emissions in the future. For the global and US emission projection used here, regional ozone pollution becomes worse in the 2045–2054 period for all months. Annually, the mean DM8H ozone was projected to increase by 9.6 ppbv (22%). The changes were higher in the spring and winter (25%) and smaller in the summer (17%). The area affected by elevated ozone within the US continent was projected to increase; areas with levels exceeding the 75 ppbv ozone standard at least once a year increased by 38%. In addition, the length of the ozone season was projected to increase with more pollution episodes in the spring and fall. For selected urban areas, the system projected a higher number of pollution events per year and these events had more consecutive days when DM8H ozone exceed 75 ppbv.

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The Contributions of Oscar Halecki to American Historical Scholarship

Nationalities Papers ◽

10.1080/00905997608407790 ◽

1976 ◽

Vol 4 (2) ◽

pp. 89-97

Author(s):

Thaddeus V. Gromada

Keyword(s):

World War Ii ◽

Civil Rights ◽

New England ◽

The United States ◽

Urban Centers ◽

Oil Refineries ◽

Middle Atlantic ◽

Steel Mills ◽

Social Opportunities ◽

The One

Most of the one and one-half million Poles who immigrated to the United States before World War II were people of rural, Catholic, Slavic stock in search of greater economic and social opportunities. They settled in urban centers primarily in the middle Atlantic, mid-Western, and New England states where they formed communities (Polonias) around the steel mills, coal and iron mines, slaughter houses and meat packing plants, oil refineries, shoe and textile factories, granaries and milling plants. Their labor was an important element in the industrialization of America. They were among the millions of unknown persons from eastern and southern Europe, as Michael Novak put it, “who have strengthened family and neighborhood life in America, and from 1930's to the present have made possible the longest strides in the nation's history in economic matters and civil rights.” Very few scholars and intellectuals, however, could be found among these Polish immigrants. When Polish scholars, intellectuals, or artists emigrated from partitioned Poland, usually after unsuccessful revolutions, they settled in France or some other European country.

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International Religious Freedom Promotion and US Foreign Policy

Religions ◽

10.3390/rel11050260 ◽

2020 ◽

Vol 11 (5) ◽

pp. 260 ◽

Cited By ~ 1

Author(s):

Lee Marsden

Keyword(s):

United States ◽

Religious Freedom ◽

State Level ◽

The United States ◽

Human Right ◽

National Interests ◽

Politics And Religion ◽

The Us ◽

The World ◽

Political Background

The freedom to practice one’s religious belief is a fundamental human right and yet, for millions of people around the world, this right is denied. Yearly reports produced by the US State Department, United States Commission on International Religious Freedom, Open Doors International, Aid to the Church in Need and Release International reveal a disturbing picture of increased religious persecution across much of the world conducted at individual, community and state level conducted by secular, religious, terrorist and state actors. While religious actors both contribute to persecution of those of other faiths and beliefs and are involved in peace and reconciliation initiatives, the acceptance of the freedom to practice one’s faith, to disseminate that faith and to change one’s faith and belief is fundamental to considerations of the intersection of peace, politics and religion. In this article, I examine the political background of the United States’ promotion of international religious freedom, and current progress on advancing this under the Trump administration. International Religious Freedom (IRF) is contentious, and seen by many as the advancement of US national interests by other means. This article argues that through an examination of the accomplishments and various critiques of the IRF programme it is possible, and desirable, to discover what works, and where further progress needs to be made, in order to enable people around the world to enjoy freedom of thought, conscience and religion.

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Dissecting the Financial Relationship between Industry and Academic Neurosurgery

Neurosurgery ◽

10.1093/neuros/nyaa257 ◽

2020 ◽

Author(s):

Mustafa Motiwala ◽

Michael J Herr ◽

Sripraharsha S Jampana Raju ◽

Jock Lillard ◽

Sonia Ajmera ◽

...

Keyword(s):

United States ◽

New England ◽

Geographic Location ◽

Bimodal Distribution ◽

The United States ◽

Median Number ◽

Career Stage ◽

Entire Cohort ◽

South Central ◽

And Gender

Abstract BACKGROUND Established by the Centers for Medicare and Medicaid Services (CMS), the Open Payments Database (OPD) has reported industry payments to physicians since August 2013. OBJECTIVE To evaluate the frequency, type, and value of payments received by academic neurosurgeons in the United States over a 5-yr period (2014-2018). METHODS The OPD was queried for attending neurosurgeons from all neurosurgical training programs in the United States (n = 116). Information from the OPD was analyzed for the entire cohort as well as for comparative subgroup analyses, such as career stage, subspecialty, and geographic location. RESULTS Of all identified neurosurgeons, 1509 (95.0%) received some payment from industry between 2014 and 2018 for a total of 106 171 payments totaling $266 407 458.33. A bimodal distribution was observed for payment number and total value: 0 to 9 (n = 438) vs > 50 (n = 563) and 0-$1000 (n = 418) vs >$10 000 (n = 653), respectively. Royalty/License was the most common type of payment overall (59.6%; $158 723 550.57). The median number (40) and value ($8958.95) of payments were highest for mid-career surgeons. The South-Central region received the most money ($117 970 036.39) while New England received the greatest number of payments (29 423). Spine surgeons had the greatest median number (60) and dollar value ($20 551.27) of payments, while pediatric neurosurgeons received the least (8; $1108.29). Male neurosurgeons received a greater number (31) and value ($6395.80) of payments than their female counterparts (11, $1643.72). CONCLUSION From 2014 to 2018, payments to academic neurosurgeons have increased in number and value. Dollars received were dependent on geography, career stage, subspecialty and gender.

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Crisis Standards of Care Implementation at the State Level in the United States

Prehospital and Disaster Medicine ◽

10.1017/s1049023x20001089 ◽

2020 ◽

Vol 35 (6) ◽

pp. 599-603 ◽

Cited By ~ 1

Author(s):

Colton Margus ◽

Ritu R. Sarin ◽

Michael Molloy ◽

Gregory R. Ciottone

Keyword(s):

United States ◽

Large Scale ◽

State Level ◽

The United States ◽

The State ◽

Pediatric Care ◽

Standards Of Care ◽

Institute Of Medicine ◽

Full Spectrum ◽

The Us

AbstractIntroduction:In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed.Problem:Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed.Methods:An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning.Results:Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17).Conclusion:Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.

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