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Changes in Death Rates During the COVID-19 Pandemic in King County, WA January 1 – December 31, 2020

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Changes in Death Rates During the COVID-19 Pandemic in King County, WA January 1 – December 31, 2020 Report date: February 3, 2021 Changes in Death Rates during the COVID-19 Pandemic in King County, WA January 1 – December 31, 2020 Background KEY POINTS The first known COVID-19 related death in King County, Washington (WA) occurred in late February 2020. State and 1) There were 14,893 deaths among King local mitigation measures designed to protect the health and County residents between January 1 and safety of residents were implemented in March 2020, with a December 31, 2020. Age-adjusted death phased re-opening process beginning in June that was rates in King County are 12% higher in 2020 subsequently scaled back in November as case counts compared to the last three years (2017- increased. COVID-19 mitigation measures included closing 2019). schools, businesses and recreation facilities; cancellation of 2) Deaths rates were significantly higher elective medical procedures and guidance to avoid non- throughout the year by age, race/ethnicity, urgent medical care; stay-home orders and guidance to gender, and region of the county. Notable practice social distancing with non-household members. increases occurred among American Indian These mitigation efforts have prevented deaths and / Alaska Native (38%) and Hispanic/Latinx 1 hospitalizations, and also resulted in isolation, grief, and residents (37%). economic hardship2 for some individuals. Research after 3) King County death rates were higher in previous recessions3 and pandemics showed changing 2020 compared to 2017-2019: patterns of death following the events. For example, the • 61% increase in drowning Centers for Disease Control (CDC) found that, in the United • 36% increase in homicide States, job loss or financial problems (in a non-pandemic year) • 23% increase in diabetes-related deaths contributed to 16% of all suicide deaths.4 In prior recessions, • 23% increase in overdose deaths suicide rates increased 1.3% for every 1% rise in the • 19% increase in unintentional injuries unemployment rate.5 Other research suggests that COVID-19 • 7% increase in cardiovascular deaths related medical care avoidance and delays may also 4) Overall King County deaths rates were not contribute to excess deaths.6 statistically significantly different for deaths due to cancer, dementia, suicide, Earlier investigations by Public Health – Seattle & King County traffic-related or firearm-related deaths. (PHSKC) and other researchers revealed an increase in the Increases were noted in some demographic number of deaths in 2020, and the observed excess deaths groups. 1 Mortazavi SS, Assari S, Alimohamadi A, Rafiee M, Shati M. Fear, Loss, Social Isolation, and Incomplete Grief Due to COVID-19: A Recipe for a Psychiatric Pandemic. Basic Clin Neurosci. 2020;11(2):225-232. doi:10.32598/bcn.11.covid19.2549.1 2 Witteveen D, Velthorst E. Economic hardship and mental health complaints during COVID-19. PNAS 2020;117(44):27277-27284. https://doi.org/10.1073/pnas.2009609117 3 Davalos ME, French MT. This recession is wearing me out! Health-related quality of life and economic downturns. J Ment Health Policy Econ. 2011 Jun;14(2):61-72. PMID: 21881162. 4 https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_cid=mm6722a1_w 5 Oyesanya M, Lopez-Morinigo J, Dutta R. Systematic review of suicide in economic recession. World J Psychiatr. 2015;5(2):243–54. https://doi.org/10.5498/wjp.v5.i2.243. 6 https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a4.htm 1 were not fully explained by deaths due to COVID-19 illness.7,8 This suggests that the pandemic may have given rise to deaths through non-biological means, such as delayed care seeking for chronic or acute illnesses or increases in stress and anxiety resulting in negative health outcomes. This analysis seeks to understand whether there have been changes in death rates for the leading causes of death and causes of death that may have been indirectly impacted by mitigation measures. Because COVID-19 infection rates and the social and economic impacts of mitigation measures have fluctuated over the course of 2020, we looked at deaths in three-month increments over the course of the year, as well as year-to-date deaths. We also examined deaths for various populations since disease and risk factors are not equitably distributed across the county. Please refer to our online tool for additional exploration. Death Rates Below we present a high-level summary of death rates due to all causes and select causes of death from January 1 through December 31, 2020. Specific causes of death were selected to focus on leading causes of death as well as those potentially impacted by COVID-19 mitigation measures. All estimates were calculated without regard to COVID-19 infection status. For COVID-related deaths and an excess deaths analysis, see the 2020 year-end Summary Report on Deaths Associated with COVID-19. We analyzed deaths among King County residents from 2017-2020 using death certificate data, comparing 2020 provisional death data to the average number of deaths per year in 2017-2019. Causes of death were defined using text information from death certificates (see Technical Appendix for definitions and additional details). This analysis framework considers multiple causes of death rather than solely the underlying cause of death due to use of timely provisional data. For example, a traffic fatality due to diabetic shock would be identified in this report as a diabetes-related death, an unintentional injury death, and a traffic death. The cause of death definitions and analytic framework used in this analysis prohibits comparison with existing lists of the leading causes of death. This report uses rate ratios to compare 2020 deaths rates to 2017-2019 death rates. A ratio of less than 1 represents a decreased death rate in 2020 compared to 2017-2019; a ratio greater than 1 represents an increased death rate in 2020, and a ratio equal to 1 represents a stable death rate. Unless otherwise noted, death rates and ratios for specific age groups are crude death rates, and all other death rates and ratios are age-adjusted. Unless another time frame is specified, all ratios and percent increases refer to the comparison of the entirety of 2020 to the entirety of 2017-2019. The text identifies findings that were statistically significant. All-Cause Deaths During 2020, there were 14,893 King County deaths compared to an annual average of 13,137 deaths during 2017-2019. The King County age-adjusted all-cause death rate increased by 12% in 2020 compared to 2017-2019. The three-month rolling averages reflects a similar pattern in all-cause deaths compared to COVID-19’s local epidemic curve: death rates were similar to previous years in January through March, but from March through May 2020 the death rate was 17% higher than the previous 7 See https://www.kingcounty.gov/depts/health/covid-19/data/~/media/depts/health/communicable- diseases/documents/C19/deaths-associated-with-covid-19-current.ashx. 8 https://jamanetwork.com/journals/jama/fullarticle/2771761# 2 years, and from June-December death rates were between 9% and 16% higher than in previous years (Figure 1). This is not due to COVID-19 deaths alone; as of December 31, 1,126 King County residents had died due to COVID-19. Figure 1. King County all-cause death rate ratios over time, comparing 2020 vs. 2017-2019 When the bar crosses the line at 1.00, there was no difference between the 2020 and 2017-2019 rates. Although older adults had the highest rate of death, residents ages 18-24 and 25-44 years had the highest percent increase in death rates (31% and 23%, respectively). Geographically, death rates increased among residents of Seattle (8%), East King County (7%), and South King County (5%). Increased deaths rates were observed among American Indian/Alaska Native (AIAN) (38%), Asian (20%), Black (14%), Hispanic (37%) and white (7%) racial and ethnic groups (Figure 2). Native Hawaiian / Pacific Islander (NHPI) death rates increased 18% but did not reach statistical significance. AIAN death rates were elevated at the beginning and end of the year, whereas Hispanic death rates were elevated February through November. 3 Figure 2. King County age-adjusted all-cause death rate ratios, 2020 vs. 2017-2019 Specific Causes of Death Causes of death are presented in order from highest to lowest crude death rates. Cardiovascular Disease In King County in 2020 there were 5,387 cardiovascular disease (CVD) related deaths compared to an average of 4,958 during 2017-2019. King County age-adjusted CVD death rates increased 7% in 2020. The rate increased among AIAN (67%), Hispanics (24%), whites (5%), and males (8%). Those 45-64 years (14%), 65-74 years (11%), and residents of East King County (9%) also experienced increased CVD death rates in 2020. During specific three-month periods, increased CVD death rates were observed for those under 24, 75+, females, Hispanics, NHPI, and residents of South King County. Cancer In King County in 2020 there were 3,102 cancer related deaths compared to an average of 3,078 during 2017-2019. Though the countywide cancer death rate did not significantly change compared to 2017- 2019, it decreased by 10% in South King County. Time-limited decreases in cancer deaths were also observed for males (12% during January through March), Asians (23% during March through May), and East King County (18% during June through August). 4 Dementia In 2020 there were 1,778 dementia deaths (including Alzheimer’s) in King County, compared to an average of 1,694 during 2017-2019. The King County-wide age-adjusted dementia death rate did not change significantly between 2017-2019 and 2020. However, the dementia death rate increased 27% among Asian residents and 14% among residents of South King County.
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