How big is COVID-19?

Current mortality is within expectations for an above-average flu season.

May 25, 2020

-updated July 03, 2020-

Richard Cross, Ph.D.

Abstract:
US Total Mortality reported by the Center for Disease Control’s “Pneumonia and Influenza
Mortality Surveillance from the National Center for Health Statistics Mortality Surveillance
System” 1 for the current year are within expectations for the marginally above average flu
season. The excess mortality in a state-by-state analysis indicates total mortality within the
expected range of mortality increase across most states, but excess mortality in the New York
City area has been at levels comparable to the 1918 Spanish Flu, and the adjacent New
Jersey/New England regions experienced mortality well above predicted levels. Media focus on
the most affected areas, and on narrow time frames with the COVID-19 effect peaked,
concealed both the generally high-normal levels of mortality for the current CDC Season in
other regions.

Overview2
We compute the cumulative Total Mortality for each year by week across the last six seasons
beginning on the week ending on Oct. 5, 2013 and ending on May 30, 2020. In this report are
the cumulative sums of Total Mortality across both 30 and 35 weeks. This approach places the
total impact of COVID-19 within the context of the entire season relative to the previous six
seasons which begin in the first week of October each year. It also expands the COVID-19
impact range beyond the 8 to 12 week window in early Spring 2020 where the COVID-19 impact
peaked in the Northeast. This approach also allows for updating of the total COVID-19 impact
throughout the remainder of the current summer and into the fall as additional CDC data
updates become available, thus placing the COVID-19 effect within the context of the entire 12
month season.

One recent report in JAMA3 estimates COVID-19 excess mortality within a narrower 8 week
window beginning March 1, 2020; this approach is useful in estimating the total mortality
within the context of high burden on the hospitals; excess deaths were estimated from Poisson
1
All Total Mortality reported weekly for the season are taken from the National Center for Health Statistics
Mortality Surveillance System: Pneumonia and Influenza Mortality Surveillance. Seasonal Reports.
https://gis.cdc.gov/grasp/fluview/mortality.html
2
Definitions for core terms, Mortality, Excess Mortality, etc., are provided in the End Notes.
3
Woolf SH, Chapman DA, Sabo RT, Weinberger DM, Hill L. Excess Deaths From COVID-19 and Other Causes, March-
April 2020. JAMA. Published online July 01, 2020. doi:10.1001/jama.2020.11787

1
modeling (which assumes independence of event-deaths) using previous 6 year total mortality
data. Woolf et al. found an observed total of 505k deaths reported in the US and estimated that
87k were excess deaths, and 65% were attributed to COVID-19. This estimation is an excess
mortality 20% above expectations (P-Score of 0.20).

The approach in this report is different in order to predict the total COVID-19 effect within the
context of a wider window of analysis that shows the COVID-19 effect within the entire season.
We make no assumptions about event independence, and accumulate total death counts week
over week (deaths due to all causes, across all ages), and predict total mortality for the current
season for two points, at the end of April (week 30) and the end of May (week 35). The starting
point for each year begins in October, and ends in both April and May. Because of the CDC
updating process, the April results are likely to be the most stable value for the period than
those in May which are closer to the date of data acquisition (June 29, 2020). Ending in April
(week 30) was the observed Total Mortality of 1.778m deaths with an expected mortality of
1.737m; ending in May 30 (week 35) the observed Total Mortality 2.075m, deaths with an
expected mortality of 2.007m deaths. These estimates constitute excess mortality of 41.1k and
67.9k respectively, with associated P-Scores of 0.024, and 0.034. Because of problems
associated with attributing cause of death, we make no estimate on specific COVID-19 cause of
death. By way of comparison, our findings on the restricted range of estimation from the first
week of March through the end of April would yield a P-Score of 0.146 with the current
provisional data.4 State-level tabulated results are reported in the End Notes in Table 2.

TABLE 1: Observed Total Mortality – US CDC

Mar 1 -
Season Oct - May Oct - Apr
Apr 25

2013-14 406,847 1,777,805 1,533,202

2014-15 424,395 1,921,781 1,671,364
2015-16 430,848 1,851,309 1,598,369
2016-17 443,267 1,929,766 1,670,416
2017-18 442,390 1,969,795 1,711,357
2018-19 450,444 1,948,997 1,681,539
2019-20 528,943 2,075,650 1,778,840
Predicted 461,471 2,007,755 1,737,746
Excess 67,472 67,895 41,094
P-Score 0.146 0.034 0.024

4
The deviation of our restricted P-Score estimation from that of the Woolf et al. research would be related most
like to the different date of data acquisition, as well as the difference in modeling approach; in either case, both
values indicate high levels of excess mortality several times larger than the 35 week estimate.

2
Magnitude:
To place the COVID-19 event in a broader historical context, we observe that over the last 120
years there have been numerous flu events, of which four have been specified by the CDC as
pandemic.5

The most notable of these was the H1N1 “Spanish Flu” of 1918. The magnitude of this event in
the US is depicted in the Figure 1 “Trends in US Total Mortality”, indicating a spike of excess
mortality that is the largest in US records over the last 120 years. The excess mortality deviated
41% above a yearly baseline mortality trend between 1916 and 1921; the associated P-Score for
1918 would be 0.407, and the Mortality Rate (which adjusts for the total population) was an
enormous 1800/100k. The Total Mortality from the 1918 event was not exceeded until 1968,
when the US population had nearly doubled. It was also 1968 that saw a significant spike in
mortality associated with the H3N2 “Hong Kong Flu” pandemic, with an excess mortality P-
Score of 0.018 for the entire year, several times lower than the 1918 event. The H2N2
pandemic of 1957 showed a P-score 0.040 increase above baseline within the US. It is in this
latter group of pandemics that we can position the total yearly effect of the COVID-19 event.

Figure 1:
Trends in US Total Mortality
1900 - 2019
3,000,000 2000

1800

2,500,000
1600

1400
2,000,000

Total Mortality Rate/100k

Mortality N 1200
Total Mortality N

Mortality Rate

1,500,000 1000

800

1,000,000
600

400
500,000

200

- 0
1900 1920 1940 1960 1980 2000 2020
Year

5
https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html

3
Despite this current high level of mortality in some US sectors, research6 finds historically wide
variation of pandemic effects across settings. This variation in mortality between states or
regions could have been anticipated with a study of previous pandemics, such as the Spanish
Flu, that showed a wide variation in levels between adjacent countries; for example, Spanish Flu
in Europe (1918 – 1920) averaged 78% above baseline, an enormous increase in mortality. But
most importantly, the variation of excess mortality between countries was large, ranging from a
low of 33% in Finland, to a high of 170% in Italy. Serious influenza such as the “Asian Flu” of the
1950s and 60s, were mild by comparison. In developed countries today, no epidemic levels
come anywhere close to these numbers, and the COVID-19 mortality rate variation between
countries remains large.7 The rapid development of public health initiatives in sanitation,
combined with the wide use of electricity and the development of medications for treating
primary and secondary infection and steroids to lower inflammation, have produced an
enormous impact on health, and lower susceptibility to pandemic lethality.

The Figure 1 also shows that the trend in Total Mortality Rate had been falling for over 100
years with one multi-year increase during the Great Depression. However, beginning in 2010,
there has been year-over-year 1.5% to 2% increase in Total Mortality Rate for nine consecutive
years; this would be the first time within the last century that there were more than 3 years
consecutively to show increased mortality rate year-over-year. In the Great Depression, from
1933 through 1939, showed the next most consistent increase. The more recent increase in
mortality inflation will affect the estimated mortality predictions and explain in part why the P-
scores noted above are relatively small, since the linear prediction take into account the trend
in yearly changes in Total Mortality.

Regional variation:

The relative impact on total mortality of the COVID-19 event in the New York City region was in
a class by itself. Figure 2 shows the increased cumulative total mortality increase as measured
by the P-Score compared to previous 6-year mortality trends for each state; this is a more
sensitive indicator of mortality change for each state since each state’s current mortality is
based upon the previous six years mortality trend for that state. In Figure 2, New York City
(NYC) mortality excess is 68% and is the highest across all locales with the current data. By week
34 in the current season, NYC is so far outside the mortality space of the other regions that it
inhabited a different mortality universe altogether. It was widely reported as well that New
Jersey experienced a high level of COVID-19 deaths, which translated into a seasonal excess
mortality of 28 percent greater than its own expected increase, but yet this is still far below
NYC.

6
S Ansart, C Pelat et al. (2009). Mortality Burden of the 1918-1919 Influenza Pandemic in Europe. Influenza Other
Respir Viruses, May;3(3):99-106.

7
For example, Worldometeres.info reports in early July, COVID-19 mortality at 58/100k in Italy, 54/100k in
Sweden, and the highest mortality of country over 1m population, 84/100k in Belgium. Both Belgium and Italy had
strict lockdown orders, whereas Sweden was relatively open.

4
 Figure 2: (CDC: State Custom Data)8 9
Week 35 Departure from Expected Total Mortality
by State/City
New York City 0.68
New Jersey 0.28
District of Columbia 0.20
Massachusetts 0.15
New York 0.14
Rhode Island 0.09
Michigan 0.09
Illinois 0.08
Louisiana 0.08
Maryland 0.07
Colorado 0.06
( Sweden ) 0.06
Indiana 0.03
Minnesota 0.03
Mississippi 0.03
Iowa 0.02
Virginia 0.02
Wisconsin 0.02
South Caroli na 0.02
Arizona 0.01
Georgia 0.01
Texas 0.01
Delaware 0.01
Connecticut 0.01
California 0.01
North Dakota 0.00
Tennessee 0.00
Florida 0.00
Oregon 0.00
New Mexico 0.00
Nebraska 0.00
Vermont 0.00
New Hampshire 0.00
Washington 0.00
Nevada 0.00
*Pennsylvania 0.00
Utah -0.01
Kansas -0.01
Wyoming -0.01
Alabama -0.01
Missouri -0.01
Maine -0.01
Montana -0.02
Arkansas -0.02
South Dakota -0.02
Alaska -0.02
Ohio -0.03
Kentuck y -0.03
Idaho -0.03
Hawaii -0.03
*Ok lahoma -0.03
*West Virginia -0.06
*North Carolina -0.08

-0.10 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80
P- Score

*States are flagged as being under-reported by the CDC; values likely to be unstable.

The NYC mortality outcome is a strong indicator that powerful additional hazards were
operating in New York City region, and it also suggests that the actions by the government on
confinement contributed to this “perfect storm” and there are news media reports that one
8
Sweden Mortality source is SBC:
https://www.scb.se/en/About-us/news-and-press-releases/highest-mortality-this-millennium-noted-in-sweden/
9
At Week 35 reporting, CT, PA, & NC had insufficient reporting to produce reliable estimates. All indexes may be
subject to updating.

5
significant factor was the forced admission of COVID positive patients into high risk facilities
with extreme confinement regimens. In addition, there was one report early on that pointed to
the correlation between infection rate and subway use which would be related to population
density. The extent to which enforced confinement, transportation concentration and
population density contributed to total mortality will take some time to unravel, but a recent
report by JP Morgan researchers Marko Kolanovic and Bram Kaplan, found a downward trend
of infection rate as state and local governments began to ease lockdown restrictions: “This
means that the pandemic and COVID-19 likely have its own dynamics unrelated to often
inconsistent lockdown measures that were being implemented…”10

Figure 2 also shows the extent to which the majority of states did not show exceptionally large
increases from previous mortality trends even those with limited lockdown restrictions. The
majority of states experienced some level of lockdown, with Arkansas, Nebraska, Iowa, North
and South Dakota, and Wyoming having very limited restrictions. We also see in Figure 2 that
none of the limited lockdown states were ranked in the upper half of reported P-Scores.

DISCUSSION:

CDC data indicate that the COVID-19 disease has shown high mortality risk for certain elderly,
and other medically compromised persons, especially in the NYC area.11 Even so, how is it that
current total US mortality for the 2019-2020 flu season is on track to meet a normal annualized
mortality adjusting for mortality inflation and seasonal variation? Or, how is this possible
within the context of the COVID-19 pandemic?

Consideration must be given to the possibility that deaths attributable to COVID-19 are not
usually excess mortality above the historical baseline but are included within the baseline
mortality. A vanishingly small percentage of people who die from COVID-19, have been healthy
before they contracted COVID-19 disease. Rather, the vast majority of COVID-19-related deaths
occur in people who from an actuarial perspective would have died this year or soon thereafter
from a pre-existing morbidity. In the elderly, survival length is much shorter than the rest of the
population, and the many additional hazards that the general population face and readily
survive (such as COVID-19), will in certain groups reduce survival length by weeks or months; in
a few instances the hazard will reduce survival by years. In persons with limited life expectancy,
hazards can be from novel disease, such as COVID-19, but hazards may also occur within the
environment, and increased confinement may pose a hazard.

The efficacy of the state lockdowns in reducing mortality is not clear, and probably varies from
regions to region. Apart from the New England region, there appear no conspicuous
effects/deviations from the main expected increase line for states that locked down early and
with more stringent requirements, compared to those who had few lockdown restrictions (e.g.,
10
https://thepoliticalinsider.com/new-study-coronavirus-infection-rates-declined-in-states-that-have-reopened/
11
The most recently updated CDC numbers on COVID-19 deaths show the general passover of younger people; off
all COVID deaths, persons under 44 years of age constituted 2.5 percent of all COVID-19 deaths. 80.5% of COVID-
19 deaths were of persons 65 and older. Source: https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-
by-Sex-Age-and-S/9bhg-hcku (downloaded July 3, 2020.)

6
AR, IA, NB, SD, ND, WY.) By this standard, there is little obvious difference across the entire
country except for the Northeast. By way of an international comparison, within the same time
window, Sweden was widely criticized for remaining open, and its mortality (P-score 0.06)
seems above average, but much lower than what was expected given the absence of
mandatory restrictions.12

States who opened sooner, (e.g., FL, TX, and GA) were all similarly situated close to predicted
mortality, but their hospitalization rates varied considerably. For example, the U Minn tracking
project reported that as of July 01, 2020, the hospitalization rate of AR (64.9/100k), FL
(89.3/110k), SD(105.2/100k)–all limited lockdown states compared favorably to MN
(97.9/100k), CO (129.1) and MA (219/100k)—all high lockdown states. Whereas GA
(146.0/100k) had an elevated rate of hospitalization compared to the other low lockdown
states.13 TN (54.5/100k) had one of the lowest hospitalization rates.

Fear factor:

A major contributor to the fear of the COVID-19 arose from the repeated reporting looking at
daily and weekly changes, changes that were reported out of the context of total mortality by
all causes and reported at a frequency and limited time frame that magnifies uncertainty in the
public.

Consider that the CDC seasonal mortality reports over the last few years, show baseline weekly
deaths average around 53k deaths. In winter months when expected mortality at its highest
point, weekly mortality averages peaked as high as 67.5k deaths in the second week of January
2018, the hardest “flu season” in many years, followed by the previous January high of 61.7k.
Most people would be surprised to see how many persons die in a week in the US, especially
around Christmas time.

Weekly mortality is quite variable, week over week as Figure 3 suggests, although there is a
regular seasonal pattern of mortality with the low in June or July (the longest solar exposure,
and most limited confinement) and the highest mortality following the shortest days of solar
exposure. The extent to which confinement, respective reductions in mobility and solar
exposure affect death rates are not well-understood, but it is evident that seasonal variation is
a hazard condition for people and that in the elderly, the winter introduces additional hazard
associated with increased confinement. This fact is supported by the lower total mortality gains
in southern latitude states, (as shown in Figure 2) even in areas with anticipated major
outbreaks (Louisiana) and large elderly population (Florida) that showed modest mortality
increase.

Figure 3 also shows that our current flu season (2019-20 in the dashed line) was above the
average week-over-week mortality in the early months of the winter flu season, but by the
second week of December, the 2017-18 season outpaced it. However, in early April 2020, the
12
Unconfirmed reports are that restrictions were placed on all elder-care facilities.
13
https://carlsonschool.umn.edu/mili-misrc-covid19-tracking-project (dated accessed on July 3, 2020)
7
major entry of COVID-19 event outstripped all weekly mortality levels back to 2013-14. The
peak April 2020 weekly mortality of 77.3k (week 28), exceeded by 9.8k deaths the top Jan’18
level—a substantial excess mortality for that limited time frame.

Media focus of attention was naturally on New York City, with the high population density, but
also, the media capital of the world. Because of the high population density, NYC probably
biased the CDC recommendations for the social-economic lockdown, to prevent the hospitals
nationally from being overloaded with COVID-19 patients. The quick retreat of the spike from
mid to late April hinted that the lockdown succeeded, or possibly that the medical interventions
were more effective than at first anticipated. The effect of the lockdown in other regions will
take some time to determine and will probably rely on COVID-19 antibody survey data. All
regions outside of New England showed lower levels of mortality; the potential long-term
effects of confinement on cumulative mortality and morbidity across states may prove
problematic. In that the virus had already been released into the public by early March, the
efficacy the extended lockdowns would be doubtful, except for mitigating hospitalizations
stress in cities with high population density.

Figure 3:
CDC US Total Weekly Mortality
90,000
2013-14 to Current
by Season
80,000 77,313

70,000 67,495

61,737

60,000

50,000
MORTALITY N

40,000

2013-14
30,000 2014-15
2015-16
2016-17
20,000
2017-18
2018-19
10,000 2019-20

Average '13-19

-
Oct Nov Dec Jan Feb Mar Apr May
MONTH IN FLU SEASON

Much of the COVID-19 fear was sustained by media repetition and focus on daily and weekly
COVID-19 infection rates and putative COVID-19 mortality that spiked in April. Daily and weekly
mortality changes are quite variable, and the COVID-19 mortality estimates are partially
confounded with total mortality, whereas cumulative weekly estimates of total mortality are
highly regular. The growth pattern for COVID-19 mortality was shown day after day, but it was
never placed within the context of the total cumulative mortality, and this gave rise to the
impression that all the reported COVID-19 death counts were in fact directly caused by the
8
disease, along with an additional false impression that the COVID-19 mortality was pushing the
total mortality well above average for the year. These impressions may turn out to be false.

END NOTES/ /TABLES:

-CDC weekly data are drawn from the CDC “Custom Data” portal, using the following selection
filters:
a. Surveillance Area: “National”
b. Season: “Select All”
c. Age Group: “Select All”
d. State-level estimations are drawn from the same Portal using the Surveillance
Area: “State”.
e. The week within the Flu Season is computed by using the calendar WEEK field in
the CDC data and creating a variable with the following Excel formula: = if(WEEK
> 39, then WEEK – 39, Else WEEK + 13)
f. All computations performed using MSExcel.
-COVID-19 counts are from worldometers.info.

REFERENCES

Total Yearly US mortality 1959 – 2017: https://usa.mortality.org

S Ansart, C Pelat et al. (2009). Mortality Burden of the 1918-1919 Influenza Pandemic in Europe.
Influenza Other Respir Viruses, May;3(3):99-106.

Woolf SH, Chapman DA, Sabo RT, Weinberger DM, Hill L. Excess Deaths From COVID-19 and
Other Causes, March-April 2020. JAMA. Published online July 01, 2020.
doi:10.1001/jama.2020.11787

Farrington, C.P., N.J Andrews, A.D. Beale and M.A. Catchpole. (1996). A statistical algorithm for
the early detection of outbreaks of infectious disease. Journal of the Royal Statistical Society A
159: 547-563.

Angela Noufaily, Doyo Enki, Paddy Farrington, Paul Garthwaite, Nick Andrews and Andre
Charlett (2013). An Improved Algorithm for Outbreak Detection in Multiple Surveillance
Systems. Journal of Public Health Informatics 5(1)

Definitions:

Season: A CDC defined one-year period that begins in the first week of
October each year.

Week: The time point into the Season over which Total Mortality is
accumulated.

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Total Deaths: As defined by the NCHS/CDC report of compiled “Total Deaths”
per week. These values are subject to revision each week.

Total Mortality (TMyear): Sum of Total Deaths (due to all causes) across the number of
weeks into each flu season; i.e., TMyear n = ∑/001
-23 (𝑇𝑜𝑡𝑎𝑙 𝐷𝑒𝑎𝑡ℎ𝑠- )

Expected Mortality: Linear least squares: Pred_TMyear7 = B*(TMyear 1,6) + Int.

Excess Total Mortality: Observed TMyear 7 - Pred_TMyear7

P-Score: A proportion of excess mortality:

( TMyear 7 -- Pred_TMyear7) / Pred_TMyear7
The P-Score * 100, can also be interpreted as a percentage above
baseline mortality.

Table 2- Week 35 CDC Departure from Predicted Total Mortality

State Observed Predicted P-Score

Alabama 36789 37041 -0.007
Alaska 3064 3143 -0.025
Arizona 42130 41571 0.013
Arkansas 22041 22455 -0.018
California 187866 186932 0.005
Colorado 28561 27003 0.058
Connecticut 22113 21479 0.030
Delaware 6563 6446 0.018
District of Columbia 3975 3327 0.195
Florida 142029 141678 0.002
Georgia 59570 58641 0.016
Hawaii 7555 7807 -0.032
Idaho 9605 9882 -0.028
Illinois 80806 74777 0.081
Indiana 46821 45458 0.030
Iowa 21304 20837 0.022
Kansas 18676 18851 -0.009
Kentucky 32922 33797 -0.026
Louisiana 33628 31046 0.083
Maine 10157 10335 -0.017
Maryland 37546 35220 0.066
Massachusetts 46825 40585 0.154
Michigan 73096 67151 0.089
10
 Minnesota 31742 30922 0.027
Mississippi 22699 22178 0.024
Missouri 42489 42913 -0.010
Montana 6949 7071 -0.017
Nebraska 11451 11513 -0.005
Nevada 17397 17455 -0.003
New Hampshire 8792 8853 -0.007
New Jersey 65925 51269 0.286
New Mexico 13161 13179 -0.001
New York 79861 69915 0.142
New York City 61915 36623 0.691
North Carolina 62107 65527 -0.052
North Dakota 4471 4420 0.011
Ohio 83871 86153 -0.026
Oklahoma 26968 27939 -0.035
Oregon 25193 25166 0.001
Pennsylvania 91428 92093 -0.007
Rhode Island 7489 6895 0.086
South Carolina 35496 34837 0.019
South Dakota 5481 5582 -0.018
Tennessee 49150 48950 0.004
Texas 140096 138337 0.013
Utah 12688 12771 -0.007
Vermont 4027 4046 -0.005
Virginia 48973 47916 0.022
Washington 39830 39881 -0.001
West Virginia 15408 16145 -0.046
Wisconsin 37504 36884 0.017
Wyoming 3477 3505 -0.008

Corresponding: Richard Cross serverp1954@comcast.net

Conflict of Interest Disclosures: No disclosures are reported.

Funding/Support: This study was unfunded.

11