COVID-19 has killed more than 1 million people in the United States since the start of the pandemic, and life expectancy has been cut by nearly 2.5 years since 2020.
A very early look at data from 2022 suggests that there were significantly fewer COVID-19 deaths in the third year of the pandemic than there were in the first two. More than 267,000 people died of Covid-19 in 2022, according to preliminary data from Johns Hopkins University, compared with more than 350,000 Covid-19 deaths in 2020 and more than 475,000 Covid-19 deaths in 2021.
This first look at the data is based on deaths reported by states through January 9. The final count will differ from this early data as states continue to review death certificates and refine their reporting, and it will be months before the US Centers for Disease Control and Prevention releases preliminary mortality data to compare to other causes of death.
Despite the lower death toll, however, Covid-19 will likely remain the third leading cause of death in the US in 2022 for the third year in a row.
In 2021, as in many years before, the top causes of death in the US were heart disease and cancer, each killing more than 600,000 people. The fourth leading cause of death was drug overdoses and other unintentional injuries, which killed about 225,000 people.
If overall mortality trends hold steady into 2022, as they typically do, that would again leave Covid-19 squarely as the third most common cause of death.
Challenges determining underlying cause of death
All death certificates require some degree of subjective interpretation, experts say, and analyzing them takes time. Now three years into the pandemic, medical examiners and other certifiers have become well-versed in what constitutes a Covid-19 death, experts say, and the real-time data gives a pretty accurate snapshot of the state of things.
But it has always been an imperfect science.
"It's really part art, part science," said Robert Anderson, chief of the mortality statistics division of the CDC's National Center for Health Statistics. "Sometimes it's very difficult to determine the cause of death."
This is particularly true for people with multiple chronic conditions.
"Assume you have an elderly person who has hypertension and diabetes, and name your list of diseases that are potentially lethal. It might be very challenging to pick the one underlying cause of death," said Dr. Joyce deJong, president of the National Association of Medical Examiners. "So instead, they just list everything on there. And then it's essentially their entire medical history on the death certificate, but it doesn't necessarily tell you why they die."
Covid-19 deaths are no exception -- and, if anything, the quality of reporting Covid-19 deaths has improved throughout the pandemic, experts say.
"For those of us who certify deaths routinely (classifying Covid-19 deaths) is not necessarily much harder," said deJong, who is also a practicing forensic pathologist and medical examiner in Michigan.
There are "grey areas," she said, often related to when -- or if -- a person is tested for Covid-19. And there are "reasonable differences in medical opinion" in all cause of death reporting.
When it comes to Covid-19, deJong said, "maybe you're missing some and maybe you're over counting some, but probably the bulk of them are accurate."
Guidance from the federal government on how to report a Covid-19 death has stayed largely consistent, but the methods used to certify deaths -- Covid-19-related and otherwise -- can vary widely by state.
Autopsies are used in some cases, but not all; Sometimes a medical examiner certifies a death, other times it can be a coroner -- and they may be elected officials, or they may not.
A pre-pandemic report from the CDC found that more than a third of death certificates in 2018 listed an underlying cause of death considered to be "unsuitable" -- lacking data quality in some capacity -- most often because they were missing details such as the location of a cancerous tumor or the type of stroke a person had.
Anderson says that the CDC plans to update that analysis with more recent data sometime in the near future, but doesn't expect much to change.
As for Covid-19, "the more we've learned about the disease, the better the reporting has gotten, in my view."
Also, in some jurisdictions, the current public health emergency related to Covid-19 triggers an extra level of review for death certificates that they otherwise wouldn't get.
Analyzing trends in excess deaths -- the number of deaths beyond what would be expected -- also suggests that Covid-19 death reporting has improved. In the early months of the pandemic, there was a big spike in the number of deaths attributed to pneumonia, which has since leveled out, he said.
"And that tells me that certifiers now are familiar with Covid and how it progresses, and they're reporting it more correctly," Anderson said.
About 7,000 Covid-19 deaths have already been reported in 2023, according to JHU data.
Just 16% of the eligible population has gotten their updated booster -- which has been found to cut the risk of dying from Covid-19 down to a fraction of what it is for unvaccinated people -- and about one in five people in the US remain completely unvaccinated.
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