New Journal Articles Look at Provisional 2020 COVID-19 Death Data

March 31, 2021


COVIDJAMA released a new journal article, “Provisional Mortality Data — United States, 2020,” which presents an overview of provisional U.S. death data for 2020, including overall death rates and those associated with COVID-19. In 2020, more than 3.3 million deaths occurred in the United States overall.).  As part of overall U.S. deaths, COVID-19 was the underlying cause of 345,000 deaths and was the underlying or contributing cause of 377,000 deaths. COVID-19 death rates were lowest among children aged 1–4 and 5–14 years and were highest among those aged 85 years or older. COVID-19 death rates were highest among males, older adults, AI/AN, and Hispanic persons. COVID-19–associated death rates were lowest for multiracial and Asian persons. COVID-19 ranked as the third leading cause of death, following heart disease (690,000 deaths) and cancer (598,000).

Another journal article was released in MMWR, “Death Certificate-based ICD-10 Diagnosis Codes for COVID-19 Mortality Surveillance—United States, January – December 2020,” which looks at the accuracy of death certificates for COVID-19 mortality surveillance in the United States.  Approximately 375,000 deaths during 2020 were attributed to COVID-19 on death certificates reported to CDC. Concerns have been raised that some deaths are being improperly attributed to COVID-19. Analysis of International Classification of Diseases, Tenth Revision (ICD-10) diagnoses on official death certificates might provide an expedient and efficient method to demonstrate whether reported COVID-19 deaths are being overestimated. CDC assessed documentation of diagnoses co-occurring with an ICD-10 code for COVID-19 (U07.1) on U.S. death certificates from 2020 that had been reported to CDC as of February 22, 2021.

Osteoporosis or Low Bone Mass in Older Adults: United States, 2017–2018

March 31, 2021

DB405_Cover1Questions for Neda Sarafrazi, Health Statistician and Lead Author of “Osteoporosis or Low Bone Mass in Older Adults: United States, 2017-2018.”

Q: Why did you decide to do a report on osteoporosis among older U.S. adults?

NS: Osteoporosis is the most common bone disease characterized by weakening of bone tissue, bone structure and strength and may lead to increased risk of fractures. Fractures are common among aging individuals. There are an estimated two million osteoporotic fractures each year in the United States.  Hip fractures are especially important and considered a major public health concern due to high morbidity, mortality and medical expenses and the toll on nation’s economy. 

Recent analysis of Medicare data suggests that the decline in hip fracture incidence among older US adults may have plateaued in 2012-2015.

Monitoring the prevalence of osteoporosis and low bone mass may inform public health programs that focus on reducing or preventing of osteoporosis and its consequences.

Healthy People 2020 has a goal of 5.3% or less for the prevalence of osteoporosis at the femur neck for adults aged 50 and over. In the United States, the prevalence of osteoporosis among adults aged 50 and over at the femur neck only was 6.3% and has not met the 2020 goal.

Q: Was there a specific finding in the data that surprised you from this report?

NS: I was hoping to see no change or a significant reduction in the prevalence of osteoporosis, but the prevalence is still significantly higher compare to a decade ago.

Q: Do you have trend data that goes further back than 2007?

NS: Yes, NHANES has been monitoring osteoporosis prevalence in U.S. since 1988 (NHANES III). 

Q: Do you have a 2017-2018 estimate of exactly how many Americans aged 50 and over have osteoporosis and low bone mass?

NS: In the United States, there are 13.4 million people aged 50 years and over with osteoporosis (11.2 million women and 2.2 million men).

In the United States, there are 47.6 million people aged 50 years and over with low bone mass (30.7 million women and 16.9 million men).

Q: What is the take home message for this report?

NS: We had a success story in diagnosis and treatment of osteoporosis in late 1990s and early 2000s. There was a decrease in annual incidence of hip fracture in US. Since 2012 this decline has been plateaued.   

Public health programs should focus on prevention, diagnosis, and treatment of osteoporosis and its consequences.


March 26, 2021


The CDC National Center for Health Statistics web page “Stats of the States” has been updated to include the latest state-based final data on selected vital statistics topics, including:

  • General fertility rates
  • Teen birth rates
  • Selected other maternal and infant health measures
  • Marriage & divorce rates
  • Leading causes of death
  • Other high profile causes of death.

The site’s map pages allow users to rank states from highest to lowest or vice versa.  This latest version of “Stats of the States” also includes two new topics:  Life expectancy by state and COVID-19 death rates by state (provisional data on a quarterly basis, through Q3 of 2020).  All death rates are adjusted for age.  Rates are featured in the maps because they best illustrate the impact of a specific measure on a particular state.

The main “Stats of the States” page can be accessed at:

QuickStats: Age-Adjusted Death Rates for Influenza and Pneumonia, by Urbanization Level and Sex — National Vital Statistics System, United States, 2019

March 26, 2021


In 2019, age-adjusted death rates for influenza and pneumonia were higher among males (14.4 per 100,000) than females (10.7) and among those who lived in rural counties (15.3) compared with those who lived in urban counties (11.7).

Among males, the age-adjusted death rate for influenza and pneumonia was 17.4 in rural counties and 13.9 in urban counties.

Among females, the age-adjusted death rate for influenza and pneumonia was 13.6 in rural counties and 10.2 in urban counties.

Source: National Center for Health Statistics, National Vital Statistics System, Mortality file.

PODCAST: Death Certificate Data & COVID-19, Part 3

March 26, 2021


HOST:  In Part Three of our conversation with Dr. Robert Anderson, the chief of mortality statistics at NCHS, we discussed the subject of excess deaths in the United States during the pandemic, and also the differences between when COVID-19 is listed as the underlying cause of death on the death certificate and those occasions when it is listed as a contributing cause but not the primary cause of death.

HOST:  So now you mentioned excess deaths – what are excess deaths, how has COVID-19 contributed to these excess deaths?

ROBERT ANDERSON:  So excess deaths are defined as the difference between the observed number of deaths in a specific time period and the expected or normal number of deaths in the same time period. So with the pandemic we’re looking at the total number of weekly deaths that occurred in 2020 and so far in 2021, and we’re comparing it with what we would expect in a comparable time period, essentially based on average weekly data from previous years.  The advantage of looking at excess deaths is that it’s not dependent on the accuracy of cause of death reporting – the focus is just on the total deaths, not deaths by cause.  Now at this point COVID-19 explains about 3/4 of total excess deaths and the other quarter likely includes three components: there are deaths that should have been attributed to COVID-19 but were instead attributed to some other cause for whatever reason.  Second, indirect deaths.  And these are deaths that can be attributed to the circumstances of the pandemic but not directly to the virus.  And this may be things like people not able to get health care during a crisis not related to the virus.  Or perhaps they’re afraid to seek care because the hospitals are full of people with COVID.  And then, three: a third component is other causes of excess deaths.  So you know there may be some excess deaths not associated with pandemic.  This could include things like deaths due to natural disasters.  This is generally going to be relatively small in comparison to what we’re dealing with the pandemic but these are sort of another category of excess deaths.

HOST:  There was some other speculation out there – rumors or what have you – that 2020 might have been actually a normal year in terms of total mortality in comparison to past years despite COVID-19.  How were people getting confused about that?

ROBERT ANDERSON:   Yeah the problem was that some folks were comparing incomplete counts for 2020 with complete counts for earlier years.  And so it did look like there were about a normal number of deaths.  The problem was that they weren’t including all of the deaths that occurred for 2020.  So we’ve made some changes to our website to try to make it more clear what the total number of deaths were for 2020.

HOST:  So NCHS ranks leading causes of death according to the underlying cause of death, and you mentioned earlier that in 92%, approximately, of COVID-19 related deaths, COVID-19 was listed as the underlying cause of death. And in roughly the other 8% of COVID-19 related deaths COVID-19 was not listed as the underlying cause of death.  Could you talk about that a little bit?

ROBERT ANDERSON:  Sure.  Let me start by saying that leading causes are ranked by the total number of deaths, and it’s based on a standard cause of death tabulation list that we typically used.  And if folks are interested in that we have a publication called “Deaths: Leading Causes for… insert the year – I think the most recent one that we have published right now is for 2018 -but you get the idea of exactly how NCHS does the rankings and how all of that came about.  Now when tabulating and comparing causes of death it’s important that we assign a single cause to each death so that we don’t double count.  We don’t want to have deaths falling into multiple categories, so we select a single cause.  And as we discussed earlier, certifiers typically report more than one condition on death certificates.  Now fortunately, as we also discussed, the death certificate is designed to elicit the single underlying cause, and that’s defined as the disease or injury that initiated that sequence of events leading to death.  That sequence gets reported in Part One on the certificate, and if completed correctly the underlying cause will be at the beginning of the sequence on the lowest use line in Part One.  So as I mentioned before you could have a sequence like respiratory distress due to viral pneumonia due to COVID-19.  That’s a logical sequence starting with the immediate cause – which is respiratory distress – and then working backwards through viral pneumonia, back to COVID-19, which is the underlying cause.  So that is the condition then that we would select for tabulation when comparing causes of death.  Now if the certificate is not completed correctly – and this does happen – we actually have a set of standardized selection rules to choose the best underlying cause for among those conditions listed.  These rules are part of ICD-10, which we used to code mortality, and they’re an international standard.  So the all those rules get applied regardless of the cause of death in the same way and as a result we would select an underlying cause from among those conditions, assuming that the certificate is not completed correctly.  Now with regard to the other 8 or 9 percent – I think it’s something on the order of 91 point-something percent, underlying cause and then about 8 point-something percent not underlying cause.  In cases where COVID-19 is not the underlying cause, we’re typically seeing it reported in Part Two as a significant contributing factor.  So if reported in Part Two, it may not be the underlying cause. It should be considered a significant factor that contributed to death.  And this is an important distinction – if COVID-19 is not a factor it’s not supposed to be reported on the death certificate.


HOST:  Still to come next week in our discussion with Dr. Robert Anderson:  How COVID-19 will be categorized among the other leading causes of death in the country, as well as more complicated scenarios facing certifiers on how to list COVID-19 on the death certificate.


HOST:  The rate of multiple births in the United states declined in 2019, according to the latest final birth data released this week by NCHS.  The new report also shows that more than 3 in 4 women began prenatal care during the first trimester of pregnancy.  The percentage of women who smoke during pregnancy declined in 2019 – to 6% of all women who gave birth. Medicaid was the source of payment for over 4 in 10 births that occurred in 2019.

Another report published this week by NCHS looks at drug overdose death rates in the U.S. on a state by state basis.  The report documents that the highest death rates from overdoses in 2019 were concentrated in jurisdictions that are in fairly close geographical proximity to one another: West Virginia, Delaware, DC, Ohio, Maryland and Pennsylvania.  Nebraska had the lowest overdose death rate in the nation in 2019.

Drug Poisoning Mortality, by State and by Race and Ethnicity: United States, 2019

March 25, 2021


NCHS released a Health E-Stat that provides information on drug overdose mortality by state (and the District of Columbia) and by race and ethnicity, and adds to findings from a recently published Data Brief on drug overdose death rates.


  • The age-adjusted rate for drug overdose deaths in the United States for 2019 was 21.6 per 100,000 standard population.
  • The five states with the highest rates were West Virginia (52.8), Delaware (48.0), District of Columbia (43.2), Ohio (38.3), and Maryland (38.2). 
  • The five states with the lowest rates were Nebraska (8.7), South Dakota (10.5), Texas (10.8),
    North Dakota (11.4), and Iowa (11.5).
  • The age-adjusted drug overdose death rate for the non-Hispanic white population in 2019 (26.2
    per 100,000 standard population) was 21.3% higher than the national rate.
  • The rate for the non-Hispanic black population (24.8) was 14.8% higher than the national rate.
  • The rate for the non-Hispanic American Indian or Alaska Native population (30.5) was 41.2% higher than
    the national rate.
  • The rate for the non-Hispanic Asian population (3.3) was 84.7% lower than the national rate.
  • The rate for the non-Hispanic Native Hawaiian or Other Pacific Islander population (9.5) was 56.0% lower than the national rate. The rate for the Hispanic population (12.7) was 41.2% lower than the national rate.

PODCAST: Death Certificate Data & COVID-19, Part 2

March 19, 2021



HOST:  The issue of when to classify a death as a COVID-19 death and when not to has been a source of confusion at times for the general public.  In Part Two of our discussion, Dr. Robert Anderson, the Chief of Mortality Statistics at NCHS,  attempts to provide some clarity on some of these topics:

HOST: Now in cases where a person dies from another condition such as terminal cancer… end-stage Alzheimer’s… something like that… but the person might contract COVID near the end of their life – is it then strictly a judgment call as to what role COVID-19 actually played in the death?

ROBERT ANDERSON:  There are certainly circumstances with the role of COVID-19 is not clear.  And in such cases the certifier does have to make a judgment call based on his or her training and expertise.  They have to sort out what the causal sequence leading to death was and whether COVID-19 started that sequence, whether it was just a contributing factor or whether it wasn’t a factor at all.  So they have it’s kind of sort things out and it’s not easy when you have somebody who has a terminal disease. I mean, essentially what they have to do is figure out: OK, what did this person die from?  What caused them to die when they died?  So, you know, let’s say somebody had terminal cancer and they had six months to live.  And then they got COVID-19, let’s say at the three month mark.  Then the certifier would have to decide: OK, well would this person have survived longer with the terminal cancer if it weren’t for COVID-19, and if the answer is no then the terminal cancer could probably be reported as the cause of death.  If the answer is yes, then COVID-19 could be reported as the cause of death.  But ultimately it comes down to the best medical opinion of the certifier.

HOST:  Another example that has confused people in the past: someone is in a car crash and maybe the victim had COVID or develops COVID, and people get confused – how can COVID be responsible for somebody who’s been injured in a car crash? What will you tell folks who are confused about that?

ROBERT ANDERSON:  Well it really depends on the circumstances.  In cases where the death is clearly the result of trauma caused by the crash, whether the decedent had COVID-19 or not should be irrelevant.  COVID-19 is not a factor in those cases.  Now, in these cases it should not be counted as COVID-19 deaths – because the trauma caused the death, not any sort of viral infection that person might have had.  However, we do know of cases where people have been hospitalized with serious but not life-threatening trauma from a car crash, who contracted COVID-19 in the hospital and then subsequently died as result of COVID-19.  So in a case like that the crash and the trauma might be a contributing factor, but the underlying cause was COVID-19.  So that was the primary cause of death because that’s what caused them to die when they died – it wasn’t the trauma.  So it’s complicated and it does depend on the circumstances.

HOST:  Is there any follow-up analysis planned on these types of deaths to suggest whether COVID was really the cause or just happened to be present?

ROBERT ANDERSON:  Following back on hundreds of thousands of cases that we that we have isn’t really practical, but we have done some work to look at the causal sequences to see if these generally make sense, and in the overwhelming majority of deaths the certifiers are clearly indicating that COVID-19 was the cause of death.  And so these are cases where certifiers are saying that the death was from COVID-19.  So instructions on death certificates in the guidance we provided make it clear that COVID-19 should be reported if it caused or contributed to death in some way.  A positive COVID-19 test is not by itself a sufficient criteria to warrant reporting on the death certificate – the certifier has to indicate the role of COVID-19 as a cause or contributor.  So to the extent instructions are followed we should only be counting deaths from COVID-19.

HOST:  On the other side, you have – during the initial surge in COVID-19 deaths in the early spring of 2020 – there was also a surge in non-COVID-19 deaths from causes such as heart disease and other leading causes of death.  Is that correct?

ROBERT ANDERSON:  Yeah, as COVID-19 deaths were surging in the spring there was also at the same time a surge in deaths due to some cardiovascular diseases, to pneumonia and diabetes and also dementia.  Those are the main conditions that surged at the same time.  And it’s possible that at least some of these deaths should have been attributed to COVID-19 but we’re not.

HOST:  Has there been any follow-up analysis of those non-COVID-19 deaths that conclude that there were even more COVID deaths than what the numbers say?

ROBERT ANDERSON:  Yeah we’ve done some analysis of excess deaths during the pandemic and I think we’re going to talk about that just a little bit later.  In addition, there is some work underway to try to quantify any underreporting, but it’s likely that we’re going to need more complete data by cause of death before we can say anything more definitively.  It’s likely that you’ll get under-reported COVID-19 deaths mixed with indirectly- related deaths and it’s fairly complicated to separate the two.


HOST:  Next week, in Part Three of our conversation with Dr. Robert Anderson, we’ll discuss “excess deaths” during the pandemic as well as other topics.

This week, NCHS published a trend report comparing death rates from overdoses in urban and rural counties over the past two decades.  The more recent data from 2019 show overdose death rates were higher in urban counties than in rural counties.  However, in five states death rates were higher in rural counties.  Those states were:  California, Connecticut, North Carolina, Vermont, and Virginia.

On the same day, NCHS published its latest monthly provisional data on drug overdose deaths in the country, for the one-year period ending in August of 2020.  The data show overdose deaths are nearly 27 percent higher during this period than they were during the same period a year ago.

On Thursday, NCHS reported that 37,595 Americans were killed in motor vehicle crashes in 2019.  This number was included in a new report on trends in death rates from motor vehicle crashes.  The report shows there has been a slight increase in death rates from motor vehicle crashes in recent years, after a sharp drop in the rates from 2006 to 2010.  Death rates in the highest risk group – 15-24 year-old males – have dropped over time to the point where rates are lower than for males age 25 and over.

Finally, today NCHS released a new analysis on emergency department visits for pneumonia and influenza from the 2016-2018 National Hospital Ambulatory Medical Care Survey. The report shows ER visit rates for pneumonia and influenza were higher for younger children than older children, and were also higher for the non-Hispanic black population than for other race/ethnic groups.

Emergency Department Visits for Influenza and Pneumonia: United States, 2016–2018

March 19, 2021

New NCHS report describes emergency department visit rates for patients with influenza and pneumonia (either influenza or pneumonia, or both) by selected patient characteristics.


  • The emergency department (ED) visit rate per 1,000 persons was 7.9 for patients with pneumonia, 4.4 for patients with influenza, and 12.2 for patients with either or both.
  • The ED visit rate for patients with influenza and pneumonia was higher among younger children than older children and increased with age among adults.
  • The ED visit rate for patients with influenza and pneumonia was highest among non-Hispanic black persons compared with persons from other race and ethnicity groups.
  • The ED visit rate for patients with influenza and pneumonia was higher for persons with Medicare (19.9 per 1,000 persons with Medicare) or Medicaid (26.2 per 1,000 persons with Medicaid) compared with persons with private insurance or uninsured persons.

Motor Vehicle Traffic Death Rates, by Sex, Age Group, and Road User Type: United States, 1999–2019

March 18, 2021

A new NCHS report provides national trends in motor vehicle traffic deaths by sex, age group, and type of road user (i.e., motor vehicle occupant, motorcyclist, pedestrian, or pedal cyclist) from 1999 through 2019 using the latest mortality data from the National Vital Statistics System.


  • Motor vehicle traffic death rates were stable from 1999 to 2006, declined on average by 8% each year from 2006 (14.5 per 100,000) to 2010 (10.7), and then increased from 2010 through 2019 (11.1).
  • Among males, differences in the rates by age group diminished over time; by 2019, the rate for males aged 15–24, the group with the highest rate in 1999, was lower than the rate for males aged 25–64 and 65 and over.
  • Among females, rates for all age groups decreased from 1999 through 2019.
  • Rates for motor vehicle occupants decreased by 37% from 12.0 in 1999 to 7.6 in 2019.

Provisional Monthly Drug Overdose Deaths from August 2019 to August 2020

March 17, 2021

Today, NCHS released the next set of monthly provisional drug overdose death counts.

Provisional data show that the reported number of drug overdose deaths occurring in the United States increased by 25.1% from the 12 months ending in August 2019 to the 12 months ending in August 2020, from 68,371 to 85,516. 

After adjustments for delayed reporting, the predicted number of drug overdose deaths showed an increase of 26.8% from the 12 months ending in August 2019 to the 12 months ending in August 2020, from 69,640 to 88,295. 

The reported number of opioid-involved drug overdose deaths in the United States for the 12-month period ending in August 2020 (62,972) increased from 47,772 in the previous year. The predicted number of opioid-involved drug overdose deaths in the United States for the 12-month period ending in August 2020 (65,030) increased from 48,747 in the previous year.

Recent trends may still be partially due to incomplete data. The reported and predicted number of drug overdose deaths involving synthetic opioids (excluding methadone; T40.4) and psychostimulants with abuse potential (T43.6) continued to increase compared to the previous year. Both reported and predicted overdose deaths involving cocaine increased compared to the previous year. The reported and predicted number of natural and semi-synthetic opioid deaths also increased compared to the previous year.