{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T11:52:17Z","timestamp":1774525937042,"version":"3.50.1"},"reference-count":49,"publisher":"BMJ","issue":"11","license":[{"start":{"date-parts":[[2021,11,15]],"date-time":"2021-11-15T00:00:00Z","timestamp":1636934400000},"content-version":"unspecified","delay-in-days":14,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2021,10,29]]},"published-print":{"date-parts":[[2021,11]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Cause-of-death discrepancies are common in respiratory illness-related mortality. A standard epidemiological metric, excess all-cause death, is unaffected by these discrepancies but provides no actionable policy information when increased all-cause mortality is unexplained by reported specific causes. To assess the contribution of unexplained mortality to the excess death metric, we parsed excess deaths in the COVID-19 pandemic into changes in explained versus unexplained (unreported or unspecified) causes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Retrospective repeated cross-sectional analysis, US death certificate data for six influenza seasons beginning October 2014, comparing population-adjusted historical benchmarks from the previous two, three and five seasons with 2019\u20132020.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>48 of 50 states with complete data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>16.3\u2009million deaths in 312 weeks, reported in categories\u2014all causes, top eight natural causes and respiratory causes including COVID-19.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcome measures<\/jats:title>\n                    <jats:p>Change in population-adjusted counts of deaths from seasonal benchmarks to 2019\u20132020, from all causes (ie, total excess deaths) and from explained versus unexplained causes, reported for the season overall and for time periods defined a priori: pandemic awareness (19 January through 28 March); initial pandemic peak (29 March through 30 May) and pandemic post-peak (31 May through 26 September).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Depending on seasonal benchmark, 287\u2009957\u2013306\u2009267 excess deaths occurred through September 2020: 179\u2009903 (58.7%\u201362.5%) attributed to COVID-19; 44\u2009022\u201349 311 (15.2%\u201316.1%) to other reported causes; 64\u2009032\u201377 054 (22.2%\u201325.2%) unexplained (unspecified or unreported cause). Unexplained deaths constituted 65.2%\u201372.5% of excess deaths from 19 January to 28 March and 14.1%\u201316.1% from 29 March through 30 May.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Unexplained mortality contributed substantially to US pandemic period excess deaths. Onset of unexplained mortality in February 2020 coincided with previously reported increases in psychotropic use, suggesting possible psychiatric or injurious causes. Because underlying causes of unexplained deaths may vary by group or region, results suggest excess death calculations provide limited actionable information, supporting previous calls for improved cause-of-death data to support evidence-based policy.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2021-050361","type":"journal-article","created":{"date-parts":[[2021,11,16]],"date-time":"2021-11-16T12:00:38Z","timestamp":1637064038000},"page":"e050361","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Unexplained mortality during the US COVID-19 pandemic: retrospective analysis of death certificate data and critical assessment of excess death calculations"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8704-7271","authenticated-orcid":false,"given":"Kathleen A","family":"Fairman","sequence":"first","affiliation":[{"name":"Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, Arizona, USA"},{"name":"Kathleen Fairman LTD, Phoenix, Arizona, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9736-0891","authenticated-orcid":false,"given":"Kellie J","family":"Goodlet","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, Arizona, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James D","family":"Rucker","sequence":"additional","affiliation":[{"name":"Kathleen Fairman LTD, Phoenix, Arizona, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roy S","family":"Zawadzki","sequence":"additional","affiliation":[{"name":"Department of Statistics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,11,16]]},"reference":[{"key":"2025121603025460000_11.11.e050361.1","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.14.137935"},{"key":"2025121603025460000_11.11.e050361.2","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1177\/0033354920953209","article-title":"Erroneous reporting of deaths attributed to pneumonia and influenza at 2 New York City teaching hospitals, 2013-2014","volume":"135","author":"Brown","year":"2020","journal-title":"Public Health Rep"},{"key":"2025121603025460000_11.11.e050361.3","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1093\/ije\/dyaa276","article-title":"International comparisons of COVID-19 deaths in the presence of comorbidities require uniform mortality coding guidelines","volume":"50","author":"Singh","year":"2021","journal-title":"Int J Epidemiol"},{"key":"2025121603025460000_11.11.e050361.4","unstructured":"U.S. Centers for Disease Control and Prevention . 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