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November 13, 2023
Quarterly Opinion
Paula M. Lantz
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Like many population health professionals, I still spend a lot of time perusing online COVID-19 surveillance data and tracking systems at the local, state, national, and global level to keep a watchful eye on the pandemic. Population-based surveillance data on COVID-19 testing, cases, hospitalizations, deaths, and CoV-2 presence in wastewater have proved essential to understanding the acute waves, cumulative tolls, inequities, progress, and ongoing threats in the pandemic experience in the United States and globally. As we head toward the end of 2023, almost four years into the pandemic, I recently explored the publicly available COVID-19 mortality surveillance data for the United States. What I found is primarily very good news along with some red flags and signals that COVID-19 remains an ongoing threat to population health in the United States.
The lifting of the COVID-19 public health emergency declaration on May 11, 2023 ended the Centers for Disease Control and Prevention (CDC) authorization to mandate reporting of certain key data, including COVID-19 testing and incidence. A smaller set of reporting and surveillance metrics remain in place, with weekly COVID-19 hospital admissions per 100,000 and the percentage of COVID-19 associated deaths among all deaths now prioritized as the top two surveillance indicators. Mortality surveillance data on COVID-19 death counts, rates, and trends can be found on the COVID Data Tracker webpage, and in a few other places on the CDC’s voluminous website if one digs around long enough.
In the first four months of 2023, the reported COVID-19 death toll was almost 37,000, a number that rivals deaths from drug overdose during the same time period. However, as 2023 continued, COVID-19 mortality declined precipitously from earlier in the year. Through September 9, 2023, the provisional count of all US deaths involving COVID-19 was 48,615 compared to over 200,000 during the same time period in 2022. If current trends continue, the death toll for 2023 should be under 70,000 compared to 246,166 in 2022, 463,267 in 2021, and 385,676 in 2020. This would ceremoniously knock COVID-19 off the list of top 10 causes of death and lead to further recovery in the unprecedented and relatively higher declines in population life expectancy caused by the pandemic in the United States.1 Without question, this is extremely good news.
Beyond basic counts of death, the mortality picture is also showing positive progress. Sharp declines in COVID-19 mortality rates are observed across gender, racial, and ethnic groups. The highest mortality counts and rates remain among people ages 65 and older. Of the 48,615 COVID-19 deaths in 2023 through September 9, only 10.2% were in the 45-64 year age group and 2.1% were among people under age 45. The significant decrease in COVID-19 mortality is largely attributed to improved treatments and to widespread immunity from severe disease through both acquired infection and vaccination.
While the 2023 COVID-19 mortality scene is full of positive news, there are some red flags that warrant deeper scrutiny. The percent of COVID-19 deaths among all deaths was reported as 2.5% for the week of October 28, 2023, ranging from 0% to 4.8% across states. However, trend data on this metric—which has been a CDC priority surveillance indicator since May 2023— are nowhere to be found, which makes it impossible to interpret this key indicator in an absolute or relative sense. In addition, COVID-19 mortality started trending back upwards in August 2023, including in recent weeks when mortality data are still provisional and thus likely to increase even more. Weekly COVID-19 hospitalization rates also started increasing in summer 2023 after a spring decline. Among adults 65 years and older, COVID-19 hospitalization rates more than doubled between mid-July and the end of August 2023. Noteworthy is that only 23.5% of adults ages 65 and older hospitalized from COVID-19 in the first eight months of 2023 had received the bivalent vaccine. Although seasonal spikes in COVID-19 have been observed across countries, there is still a need for keen surveillance, vigilance, and public awareness.
Another concern is complacency. In a July 17, 2023 New York Times article on the mortality decline, David Leonhardt reported that “(a)fter three horrific years, in which Covid has killed more than one million Americans and transformed parts of daily life, the virus has turned into an ordinary illness.” Unfortunately, what is considered “ordinary illness” in the United States often comes with high levels of morbidity and mortality that are unequal across subpopulations and could be prevented or mitigated with stronger educational, community, and public policy interventions and political will.2 This includes diabetes, drug addiction and overdose, injury from firearms, and sexually transmitted infections to name just a few public health problems with the stamp of “American Ordinary” upon them.
Furthermore, COVID-19 remains anything but an ordinary threat to population health. Now is not the time to rest on public health laurels. The path of the pandemic in the United States and worldwide after the ending of public health emergency declarations is still quite uncertain. With the end of COVID-19 testing and case reporting, actual incidence rates are a total mystery. Even so, there is no question that the virus is widely circulating and mutating in communities around the globe. Immunity from acquired infection will wane over time, increasing susceptibility in the population; and vaccination rates remain too low to compensate. The uptake of the new COVID-19 vaccine has been sluggish at best. In late October 2023, CDC reported that national survey data indicate that only 7% of US adults had received the new vaccine and 40% say they probably or definitely will not get it.
From the perspective of mortality risk, it is most important for people ages 65 and older to be fully vaccinated. However, what doesn’t kill you does not always make you stronger. The impact on individual and population health of multiple COVID-19 infections and long COVID/ post-COVID conditions are not well understood. Although hard to measure, the estimated prevalence of long COVID among all US adults declined somewhat in 2022 but has remained stable at around 6% thus far in 2023.
The significant decline in COVID-19 mortality during 2023 is important and should be celebrated. However, the sharp decline in deaths during 2023 should not mask the toll that COVID-19 continues to take and the grave risk it still poses for population health. A common refrain in public policy is to not let the perfect be the enemy of the good. When it comes to this new phase of the COVID-19 pandemic, let’s not let the “ordinary” and the complacency that goes with it be the enemy of the population health good. Government leaders, public health professionals, the media, and the public still need to keep a strong focus on prevention (reducing transmission and virus reproduction rates), vaccination, equity, high-quality surveillance, and effective communication.
Paula Lantz, PhD, MS, MA, is the James B. Hudak professor of health policy and a professor of public policy at the Ford School of Public Policy at the University of Michigan. She also holds an appointment as professor of health management and policy in the School of Public Health. Lantz teaches and conducts research regarding the role of social policy in improving population health and reducing health inequities. She currently is conducting research regarding housing policy and health, including opportunities within the Medicaid program for assisting with housing security. An elected member of the National Academy of Social Insurance and the National Academy of Medicine, Lantz received an MA in sociology from Washington University, St. Louis, and an MS in epidemiology and PhD in social demography from the University of Wisconsin.
