Both the USA and Europe experienced substantial excess mortality in 2020 and 2021 related to the COVID-19 pandemic. Methods used to estimate excess mortality vary, making comparisons difficult. This retrospective observational study included data on deaths from all causes occurring in the USA and 25 European countries or subnational areas participating in the network for European monitoring of excess mortality for public health action (EuroMOMO). We applied the EuroMOMO algorithm to estimate excess all-cause mortality in the USA and Europe during the first two years of the COVID-19 pandemic, 2020-2021, and compared excess mortality by age group and time periods reflecting three primary waves. During 2020-2021, the USA experienced 154.5 (95% Uncertainty Interval [UI]: 154.2-154.9) cumulative age-standardized excess all-cause deaths per 100,000 person years, compared with 110.4 (95% UI: 109.9-111.0) for the European countries. Excess all-cause mortality in the USA was higher than in Europe for nearly all age groups, with an additional 44.1 excess deaths per 100,000 person years overall from 2020-2021. If the USA had experienced an excess mortality rate similar to Europe, there would have been approximately 391 thousand (36%) fewer excess deaths in the USA.

The National Center for Health Statistics' (NCHS's) National Vital Statistics System (NVSS) collects, processes, codes, and reviews death certificate data and disseminates the data in annual data files and reports. With the global rise of COVID-19 in early 2020, the NCHS mobilized to rapidly respond to the growing need for reliable, accurate, and complete real-time data on COVID-19 deaths. Within weeks of the first reported US cases, NCHS developed certification guidance, adjusted internal data processing systems, and stood up a surveillance system to release daily updates of COVID-19 deaths to track the impact of the COVID-19 pandemic on US mortality. This report describes the processes that NCHS took to produce timely mortality data in response to the COVID-19 pandemic. (Am J Public Health. 2021;111(12):2133-2140. https://doi.org/10.2105/AJPH.2021.306519).

The COVID-19 pandemic has disproportionately affected Hispanic or Latino, non-Hispanic Black (Black), non-Hispanic American Indian or Alaska Native (AI/AN), and non-Hispanic Native Hawaiian or Other Pacific Islander (NH/PI) populations in the United States. These populations have experienced higher rates of infection and mortality compared with the non-Hispanic White (White) population (1-5) and greater excess mortality (i.e., the percentage increase in the number of persons who have died relative to the expected number of deaths for a given place and time) (6). A limitation of existing research on excess mortality among racial/ethnic minority groups has been the lack of adjustment for age and population change over time. This study assessed excess mortality incidence rates (IRs) (e.g., the number of excess deaths per 100,000 person-years) in the United States during December 29, 2019-January 2, 2021, by race/ethnicity and age group using data from the National Vital Statistics System. Among all assessed racial/ethnic groups (non-Hispanic Asian [Asian], AI/AN, Black, Hispanic, NH/PI, and White populations), excess mortality IRs were higher among persons aged ≥65 years (426.4 to 1033.5 excess deaths per 100,000 person-years) than among those aged 25-64 years (30.2 to 221.1) and those aged <25 years (-2.9 to 14.1). Among persons aged <65 years, Black and AI/AN populations had the highest excess mortality IRs. Among adults aged ≥65 years, Black and Hispanic persons experienced the highest excess mortality IRs of >1,000 excess deaths per 100,000 person-years. These findings could help guide more tailored public health messaging and mitigation efforts to reduce disparities in mortality associated with the COVID-19 pandemic in the United States,* by identifying the racial/ethnic groups and age groups with the highest excess mortality rates.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected racial and ethnic minority groups [1–5]. COVID-19 infection and mortality rates are higher among Hispanic/Latino, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native (AI/AN) populations than non-Hispanic White populations [5]. Although most U.S. COVID-19 deaths have occurred among adults aged ≥65 years, younger persons represent a larger percentage of COVID-19 deaths in Hispanic/Latino, non-Hispanic Black, and non-Hispanic AI/AN populations [1]. These racial/ethnic groups also have younger age distributions across the population generally [3], and face increased risk of COVID-19 infection and related morbidity and mortality as a result of many different factors such as the degree of occupational exposure, housing or residential risk factors, the prevalence of preexisting health conditions, reduced access to care, and structural racism [1], [2], [3], [4].

Estimates of excess deaths, defined as the number of persons who have died from all causes, above the expected number of deaths for a given place and time, can provide a comprehensive account of mortality likely related to the COVID-19 pandemic, including deaths that are both directly and indirectly associated with COVID-19. Since April 2020, CDC’s National Center for Health Statistics (NCHS) has published weekly data on excess deaths associated with the COVID-19 pandemic (1). A previous report identified nearly 300,000 excess deaths during January 26–October 3, 2020, with two thirds directly associated with COVID-19 (2). Using more recent data from the National Vital Statistics System (NVSS), CDC estimated that 545,600–660,200 excess deaths occurred in the United States during January 26, 2020–February 27, 2021.

Approximately 375,000 deaths during 2020 were attributed to COVID-19 on death certificates reported to CDC (1). Concerns have been raised that some deaths are being improperly attributed to COVID-19 (2). 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. Among 378,048 death certificates listing U07.1, a total of 357,133 (94.5%) had at least one other ICD-10 code; 20,915 (5.5%) had only U07.1. Overall, 97.3% of 357,133 death certificates with at least one other diagnosis (91.9% of all 378,048 death certificates) were noted to have a co-occurring diagnosis that was a plausible chain-of-event condition (e.g., pneumonia or respiratory failure), a significant contributing condition (e.g., hypertension or diabetes), or both. Overall, 70%-80% of death certificates had both a chain-of-event condition and a significant contributing condition or a chain-of-event condition only; this was noted for adults aged 18-84 years, both males and females, persons of all races and ethnicities, those who died in inpatient and outpatient or emergency department settings, and those whose manner of death was listed as natural. These findings support the accuracy of COVID-19 mortality surveillance in the United States using official death certificates. High-quality documentation of co-occurring diagnoses on the death certificate is essential for a comprehensive and authoritative public record. Continued messaging and training (3) for professionals who complete death certificates remains important as the pandemic progresses. Accurate mortality surveillance is critical for understanding the impact of variants of SARS-CoV-2, the virus that causes COVID-19, and of COVID-19 vaccination and for guiding public health action.

Giving birth to a child during the adolescent years frequently is associated with long-term adverse consequences for the mother and her child (1--3) that often are attributable in part to fragile family structure and limited social support and financial resources. Compared with infants born to adult women, infants born to adolescent females are at elevated risk for preterm birth, low birth weight, or death during infancy (4--6). An estimated 82% of pregnancies in 2001 among adolescents were unintended (7,8). | | To analyze trends and variations in adolescent pregnancy and birth rates, CDC analyzed birth data from the National Vital Statistics System (NVSS) for 1991--2008. Data for 1991--2007 are final; data for 2008 are preliminary (4,6). Data by maternal race/ethnicity are based on information reported by the mother during the birth registration process. Race and ethnicity are reported separately on birth certificates. Birth rates were calculated by using population estimates prepared by the U.S. Census Bureau. Percentage change over time was calculated by comparing the rates for the beginning and end points in each time period. In analyzing differences over time and among groups, only statistically significant differences are noted. Significance testing is based on the z-test at the 95% confidence level (4,6). Additional information is available elsewhere (4,6). Data regarding adolescent pregnancy are not as current or complete as NVSS data regarding adolescent births. Birth data are based on NVSS and are shared with CDC through the Vital Statistics Cooperative Program (VSCP). National data on adolescent pregnancy and childbirth according to such attributes as educational attainment and disability status are not available because this information is not collected consistently and completely in NVSS and the National Abortion Surveillance System. Abortion estimates are from abortion surveillance information collected from the majority of states by CDC; these estimates are adjusted to national totals by the Guttmacher Institute (9). Information on fetal losses is derived from the pregnancy history data collected from multiple cycles of the National Survey of Family Growth (NSFG), conducted by CDC's National Center for Health Statistics (9). The most recent pregnancy estimates that include data on live births, induced abortions, and fetal losses are for 2005 (9).

KEY FINDINGS: In 2008, state-specific teenage birth rates varied widely, from less than 25.0 per 1,000 15-19 year olds to more than 60.0. Rates for non-Hispanic white and Hispanic teenagers were uniformly higher in the Southeast and lower in the Northeast and California. The highest rates for non-Hispanic black teenagers were reported in the upper Midwest and in the Southeast. The race and Hispanic origin-specific birth rates by state as well as the population composition of states by race and Hispanic origin contribute to state variations in overall teenage birth rates.

The U.S. preterm birth rate (less than 37 weeks of gestation) rose by more than one-third from the early 1980s through 2006 (1). This rise has been a cause of great concern (2,3). Preterm infants are at increased risk of life-long disability and early death compared with infants born later in pregnancy (2,4). Many reasons, such as changes in maternal demographics and increases in multiple births, have been suggested for the growth in preterm births (5). Another factor cited is the heightened use of obstetric interventions such as induction of labor and cesarean delivery earlier in pregnancy (5,6,7). Although it is not possible to know whether an infant would be born preterm if labor was not induced or delivered by cesarean, studies suggest that increased use of these procedures before 37 completed weeks of gestation may have influenced the upswing in preterm birth rates (6,7). Preliminary 2007 and 2008 birth certificate data reveal a shift in the long upward trend in preterm births (8,9). This report describes this change.

The number of births in the United States increased between 2006 and 2007 (preliminary estimate of 4317119) and is the highest ever recorded. Birth rates increased among all age groups (15 to 44 years); the increase among teenagers is contrary to a long-term pattern of decline during 1991-2005. The total fertility rate increased 1% in 2007 to 2122.5 births per 1000 women. This rate was above replacement level for the second consecutive year. The proportion of all births to unmarried women increased to 39.7% in 2007, up from 38.5% in 2006, with increases noted for all race and Hispanic-origin groups and within each age group of 15 years and older. In 2007, 31.8% of all births occurred by cesarean delivery, up 2% from 2006. Increases in cesarean delivery were noted for most age groups and for non-Hispanic white, non-Hispanic black, and Hispanic women. Multiple-birth rates, which rose rapidly over the last several decades, did not increase during 2005-2006. The 2007 preterm birth rate was 12.7%, a decline of 1% from 2006. The low-birth-weight rate also declined in 2007 to 8.2%. The infant mortality rate was 6.77 infant deaths per 1000 live births in 2007, which is not significantly different from the 2006 rate. Non-Hispanic black infants continued to have much higher rates than non-Hispanic white and Hispanic infants. States in the southeastern United States had the highest infant and fetal mortality rates. The United States continues to rank poorly in international comparisons of infant mortality. Life expectancy at birth reached a record high of 77.9 years in 2007. Crude death rates for children aged 1 to 19 years decreased by 2.5% between 2006 and 2007. Unintentional injuries and homicide were the first and second leading causes of death, respectively, accounting for 53.7% of all deaths to children and adolescents in 2007.