Introduction to the Greenhalgh Report

Excess Death – Increased Rates in Virginia

Released November 28, 2022

An unprecedented level of increased non-COVID illness

and death during the pandemic concerned me and my
constituents. As a member of the House of Delegates, I
realized I was in a unique position to discover the truth.
In June 2022, I arranged an online meeting with several staff members of the
VDH, including representatives from the offices of the State Health
Commissioner, the Chief Medical Examiner, and Vital Records. I presented my
research and they found it compelling.
I requested a broad ranging analysis of Virginia’s data to determine why our
citizens were getting sicker and dying of non-COVID conditions during the
pandemic. My goal was not to prove any position but to gather as much
information as possible and let the data speak, with no preconceived outcome.
With the approval of State Health Commissioner Colin Greene, six analysts
worked for two months to produce the Greenhalgh Report.
The Report is an exploration of the excess deaths over time with regards to
causes of death, race/ethnicity, age, and COVID-19 vaccination status. I hope to
see several deeper studies into the findings and validations produced by the
Greenhalgh Report.
I am extremely proud of Virginia for being, to the best of my knowledge, the
first state to complete an unbiased study of excess deaths during the pandemic,
and willing to dig even deeper.
Moving forward, a second study is required to analyze the dramatic increase in
cases where citizens did not die, but acquired serious illnesses contracted
during the pandemic. A feasibility study is now underway by the VDH, to
determine the resources required to analyze possible associations between
COVID-19 vaccination and the development of certain new acute and chronic
conditions.

Delegate Karen Greenhalgh

Representing Virginia Beach
DelKGreenhalgh@House.Virginia.Gov
Analysis of Excess Deaths and
COVID-19 Vaccinations
October 28, 2022

Table of Contents
Table of Contents 2
Acronyms 4
Introduction 4
Executive Summary 4
Methods 5
Metrics and Definitions 6
Results 9
Part I: Forecasting and Excess Mortality 9
Figure 1.1 – Number of Observed and Forecasted All-Cause Mortality by Week of Death,
2019-2021 9
Figure 1.2 – Estimated Number of Excess Deaths Compared to COVID-19 Deaths by
Week of Death, 2020-2021 10
Table 1.1 – Forecasted Number of Statewide Annual Death Counts of Virginia Residents
by Year of Death and Grouped Causes of Death, 2015-2021 11
Part II: Mortality and COVID-19 Vaccination 14
Table 2.1 – Statewide Average Annual Number of Virginia Resident Deaths, Age-
Adjusted Death Rates, and Excess Mortality by Grouped Causes of Death 14
Table 2.2 – Statewide Average Annual Virginia Resident Deaths, Age-Adjusted Death
Rates, and Excess Mortality by Race/Ethnicity 19
Table 2.3 – Statewide Average Annual Virginia Resident Deaths, Age-Adjusted Death
Rates, and Excess Mortality by VDH Health Planning Region of Residence 20
Table 2.4 – Statewide Average Annual Counts of Virginia Resident Deaths by Place of
Death 21
Table 2.5 – Statewide Annual Death Counts of Virginia Residents by Year of Death and
Grouped Causes of Death 23

Page 2
 Table 2.6 – Statewide Age-Adjusted Rates of Virginia Resident Deaths by Year of Death
and Grouped Causes of Death 24
Tables 2.7a, 2.7b, and 2.7c – Statewide Person Years, Death Counts, and Age-Adjusted
Death Rates by at Least One COVID-19 Vaccination Received by Age Group 26
Proposed Tables on Death Rates by Vaccine Manufacturer, Cause of Death, and Chronic
Disease 29
Discussion 30
Works Cited 31

Page 3
Acronyms

Acronym Definition

CDC Centers for Disease Control and Prevention

COVID-19 Coronavirus disease caused by the SARS-CoV-2 virus

COVID-19 pandemic period; defined as the two years from January 1, 2020 to
CPP
December 31, 2021

ICD-10 International Classification of Disease, 10th edition

NCHS National Center for Health Statistics

Pre-pandemic period; defined as the five years from January 1, 2015 to

PPP
December 31, 2019

VDH Virginia Department of Health

Introduction
This report summarizes key indicators and statistics concerning causes of death and
demographics over many years with a component examining COVID-19 vaccinations. It
compares two periods; 1) the first two pandemic years – referred to as the current pandemic
period (CPP), and 2) the last five preceding non-pandemic years – referred to as the pre-
pandemic period or (PPP). It compares excess deaths and the distribution across age, race
and ethnicity, location of death (hospital, home, long-term care facility, etc.), and health
planning regions of the Commonwealth. Table 2.7 pertains to COVID-19 vaccination(s) and
death.

Executive Summary
Like most states in the United States, Virginia experienced an excess number of deaths
during the COVID-19 pandemic. Although many of the excess deaths in Virginia were
associated with COVID-19, other causes of death not directly associated with COVID-19
increased during the pandemic period.

In comparing average annual totals between the pre-pandemic period (2015-2019) and the
current pandemic period (2020-2021), Virginia residents had a 10.3% higher number of heart
disease-related deaths, a 30.5% higher number of unintentional injury (accidental) deaths,
and a 3.4% increase in cancer deaths. Also of note was an increase of 22.0% in other causes
of death not identified in the CDC’s 15 leading causes of death, plus homicide.

Page 4
Among all-cause mortality in relation to the COVID-19 vaccination, the all-cause
standardized death rate in 2021 was 2.7 times higher for Virginia residents with no recorded
dose of COVID-19 vaccine (1,390.5) than Virginia residents who received at least one dose of
COVID-19 vaccine (507.2). This was seen across all age groups with the greatest disparity
observed among people 25 to 34 years of age, where Virginia residents with no record of a
first dose had a death rate of 31.7, which was 4.9 times the death rate of people who received
at least one dose (6.5).

In summary, this analysis confirms that excess deaths, while driven by COVID-19, were also
higher for other common causes of death in Virginia during the pandemic. Additional, more
in-depth research and further review of the extensive scientific literature about these non-
COVID-19-related excess deaths is recommended and could explore hypotheses about the
breakdown of healthcare systems during the pandemic, fewer people accessing care and
postponing health services, stressed healthcare systems affecting patient care due to
facilities managing a surge in COVID-19 patients, disparities, and others. Some of these
factors, disparities in particular, could also be explored to better understand why people with
at least one dose of vaccine appear to be at a lower risk of dying from all causes.

Methods
The methods used for this analysis are summarized here with a focus on data sources used
and definitions of metrics.

Forecasting & Excess Deaths – Estimating the impact of the pandemic on mortality, as well
as possible other causes of death that may have been affected by the pandemic, may be
assessed through the examination of excess mortality. Generally, excess mortality is the
difference between observed counts of death and forecasted counts of death based on
historic trends; in this analysis, as if the COVID-19 pandemic never occurred. Forecasting in
general can be performed through a variety of different mathematical processes. In this
analysis, the exponential smoothing method was applied to historical (2015-2019) mortality
data among Virginia residents by week to estimate all-cause mortality totals by week for
2020. Forecasted totals for 2021 used historical data from 2016-2019 and the forecasted
totals for 2020 to estimate weekly counts for 2021. This same methodology was applied to
weekly death totals by cause of death to estimate annual counts by grouped cause of death.
COVID-19 deaths by week were also compared to excess mortality calculations by week.

Deaths by vaccination status – This analysis performed a matched pairs analysis by

probabilistic record linkage of death certificates to COVID-19 vaccination records using
encrypted personal identifiers. This created a master dataset for one year of death data and
COVID-19 vaccination data that was used to explore summary statistics related to deaths
and vaccinations.

Page 5
In addition to the matched dataset, this analysis also relies on the public health datasets listed
below:

Mortality Data
Mortality data was obtained from the Virginia Department of Health’s (VDH) Office of Vital
Records. These data are collected from death certificates filed in the state of Virginia, as well
as from Virginia residents that die outside of Virginia.

Population data
Data on Virginia’s population and demographics were obtained from the Postcensal
Population Estimates. These population projections are derived from the National Center for
Health Statistics (NCHS) with the approval of the U.S. Bureau of the Census. The NCHS
categorizes (“U.S. Census Populations with Bridged Race Categories,” 2019) these estimates
by locality within the state, age, race, Hispanic origin, and gender. At the time of this analysis,
the NCHS did not estimate and release a Postcensal Population Estimate for 2021. The 2020
Postcensal Estimate was used in 2021 rate calculations.

COVID-19 Vaccination Data

Data on COVID-19 vaccinations were obtained from the Vaccine Immunization Information
System (VIIS), which contains all data on COVID-19 vaccinations that were administered in
the state of Virginia.

ICD-10 Codes and Keywords of Chronic Conditions

Data on chronic conditions and International Classification of Diseases 10th Revision (ICD-
10) codes were obtained from the Center for Medicare & Medicaid Services' (CMS) "30 CCW
Chronic Conditions (2017 forward)" file for identifying chronic conditions in mortality data.
Keywords were derived from CMS code descriptions.

Metrics and Definitions

Age-adjusted death rates – rates per 100,000 residents standardized to account for the
varying age distributions of different subpopulations.
Calculation – the number of deaths among the defined population (e.g.; by the cause
of death, race/ethnicity, etc.) by age group, divided by residential population estimates
of that same population, multiplied by 100,000. This results in a crude rate by age
groups which is then multiplied by the year 2000 standard population proportions
(Anderson & Rosenberg, 1998). The outcomes of this calculation by age group are
summed up and provide an overall age-adjusted rate of the defined population.
Average annual # of deaths – average number of deaths per year over the defined number
of years being examined.

Page 6
 Calculation – the sum total of all deaths over multiple years of data, divided by the
number of years defined.
Current Pandemic Period (CPP) – the first two pandemic years, spanning 2020-2021.
Excess mortality – the difference between observed counts of death and
expected/forecasted counts of death.
Calculation – observed counts minus expected/forecasted counts.
Expected/forecasted counts of death – generally, this is the number of expected events to
occur, based on historical trends and data.
Calculation – forecasting can be done through a variety of different mathematical
methods. The forecasting for this analysis used the exponential smoothing
forecasting based on the AAA version (additive error, additive trend and additive
seasonality) of the Exponential Triple Smoothing (ETS) algorithm, which smoothes out
minor deviations in past data trends by detecting seasonality patterns and confidence
intervals.
Observed counts of death – the actual numbers of deaths experienced during the defined
time frame.
Percent change – the percent difference between two values.
Calculation – the numerical difference between two values divided by the value of the
older number.
Person-Years – a statistical method for calculating rates that measures exposure using an
element of time.
Calculation – calculates the time from exposure to outcome of interest and uses that
measure as denominator to calculate rates.
Pre-Pandemic Period (PPP) – the last five preceding non-pandemic years, spanning 2015-
2019.
Rate of change – describes how one value changed compared to another value. In this
publication, it compared age-adjusted rates of one year compared to another.
Calculation – age-adjusted rate divided by another age-adjusted rate.
Seasonality – refers to cyclical or patterned changes to the number or types of events based
on different times or seasons of the year.
Underlying Cause of Death – terminology that classifies the immediate and other causes of
death listed on the death certificate. It may be defined as the disease or injury that initiated
the train of morbid events leading directly to death or the circumstances of the accident or
violence that produced the fatal injury.
Virginia Residents with No Recorded Dose of COVID-19 – this is an estimate of Virginia's
population that is unvaccinated for COVID-19. It is calculated by subtracting the number of
people with at least one dose from the statewide population. This overestimates the number
of unvaccinated people in Virginia because a significant number of residents received their

Page 7
first dose out-of-state and reporting was not available with compatible age breakdowns.
Some federal doses are excluded for the same reason.

Page 8
Results

Part I: Forecasting and Excess Mortality

The COVID-19 pandemic was the most significant public health emergency since the 1918
influenza pandemic. Data from CDC indicates that over one million people in the U.S. died
from COVID-19 in the two and half years since the pandemic began (March 2020 to
September 2022).

Figure 1.1 – Number of Observed and Forecasted All-Cause Mortality by Week of

Death, 2019-2021

Summary
All-cause mortality statistics generally fluctuate by month or season, known as seasonality,
where more deaths typically occur in the winter months than other times of the year, which
are often driven by the severity of the influenza season and other respiratory infections. Prior
to 2020, mortality data in Virginia has generally followed this pattern.

Forecasting of all-cause mortality by week for 2020 and 2021 indicated that 2020 and 2021
would have followed the same seasonal pattern if the COVID-19 pandemic never occurred.
However, comparing the actual observed counts of death to the forecasted numbers
denoted an abnormal pattern in mortality driven mostly by COVID-19 deaths.

Atypical increases in all-cause mortality were seen in weeks 14-22 of 2020 (end of March
through May) and in weeks 28 through the end of the year in 2021. There was also a
substantial increase in observed all-cause mortality in the winter of 2020 through the first
few months of 2021.

Page 9
 Figure 1.1 – Number of Observed and Forecasted All-Cause Mortality by Week of Death,
2019-2021

Figure 1.2 – Estimated Number of Excess Deaths Compared to COVID-19 Deaths

by Week of Death, 2020-2021

Summary
As explained previously, estimating excess mortality is simply the difference in forecasted
counts compared to observed counts by week. This difference resulted in most weeks in
2020 and 2021 having a higher number of excess deaths than would have been expected,
with a few weeks having a lower number than expected. Over the two year pandemic period,
it was estimated that there were a total of 19,526 excess deaths among Virginia residents
over what would have been expected if the pandemic never occurred.

Comparing estimated excess mortality to COVID-19 deaths by week indicated a very strong
Pearson R correlation coefficient, r(103) = 0.86, p<0.001. This means that excess mortality
was strongly driven by COVID-19 deaths among Virginia residents.

Page 10
Figure 1.2 – Estimated Number of Excess Deaths Compared to COVID-19 Deaths by Week
of Death, 2020-2021

Table 1.1 – Forecasted Number of Statewide Annual Death Counts of Virginia

Residents by Year of Death and Grouped Causes of Death, 2015-2021

Summary
The exponential smoothing method to forecast all-cause mortality in Virginia for 2020 and
2021 was also performed on the CDC’s leading grouped causes of death. This method
estimated the counts of leading grouped causes of death in Virginia if the pandemic never
occurred. In general, mortality counts increase each year as the population grows and ages,
which is evident in this forecast.

Page 11
Table 1.1 – Forecasted Number of Statewide Annual Death Counts of Virginia Residents by Year of Death and Grouped Causes
of Death, 2015-2021
COVID-19 Pandemic Period
Pre-Pandemic Period (PPP)
(CPP)
(2015-2019)
Leading Causes of Death* (2020-2021)
Five Years
Two Years

2015 2016 2017 2018 2019 2020 2021

Heart Disease 13,864 13,779 14,832 14,526 15,061 15,005 15,752

Cancer 14,736 14,667 15,037 15,142 15,046 15,303 15,308

COVID-19 0 0 0 0 0 0 0

Unintentional Injury (Accident) 3,339 3,507 3,886 3,800 3,997 4,137 4,275

Stroke 3,334 3,415 3,549 3,771 3,823 4,023 4,130

Chronic Lower Respiratory Diseases 3,335 3,177 3,359 3,467 3,665 3,730 3,946

Alzheimer's Disease 2,228 2,387 2,548 2,594 2,632 2,760 2,808

Diabetes 2,021 2,028 1,966 2,281 2,352 2,446 2,620

Nephritis, Nephrotic Syndrome, and 1,442 1,509 1,617 1,563 1,662
Nephrosis 1,666 1,744

Liver Disease 921 855 972 944 1,038 1,004 1,124

Suicide 1,100 1,132 1,158 1,198 1,137 1,177 1,167

Parkinson's Disease 631 736 835 878 894 981 1,019

Influenza and Pneumonia 1,368 1,110 1,242 1,279 1,103 1,177 1144

Sepsis 1,161 1,186 1,242 1,121 1,086 1076 1,027

Hypertension and Renal Diseases 675 678 682 788 817 859 919

Homicide 372 434 451 419 435 448 442

Page 12
Other Causes (Various) 14,040 15,659 15,101 15,584 15,594 16,219 15,809

All Deaths 64,567 66,259 68,477 69,355 70,342 72,011 73,235

* The leading causes of death listed are not inclusive of all deaths. Deaths of varying causes with small annual totals are omitted from the breakdown among
the leading causes, but are included in the overall total ('All Deaths')

Page 13
Part II: Mortality and COVID-19 Vaccination

Table 2.1 – Statewide Average Annual Number of Virginia Resident Deaths, Age-
Adjusted Death Rates, and Excess Mortality by Grouped Causes of Death

Summary
Table 2.1 summarizes the 14 leading causes of death, including homicide and COVID-19
(NCHS - Age-adjusted Death Rates for Selected Major Causes of Death, 2022), by the
average number of annual deaths before (PPP) and during the pandemic (CPP). The age-
adjusted death rates describe the rate per 100,000 residents by each cause of death. The
percent change is the numerical difference in the two periods, divided by the PPP total,
resulting in a percentage of change. The proportion of total is the breakdown of the total
difference by causes of death (also illustrated in Figure 2.1). Lastly, the rate of change
describes the change in age-adjusted rates in the CPP compared to the PPP.

Page 14
 Table 2.1 – Statewide Average Annual Number of Virginia Resident Deaths, Age-Adjusted Death Rates, and Excess Mortality by Grouped
Causes of Death
COVID-19 Pandemic
Pre-Pandemic Period
Period Change from
(2015-2019)
(2020-2021) PPP to CPP
Leading Causes of Death Five Years
Two Years
Avg. Annual Age-Adjusted Avg. Annual Age-Adjusted Difference in Avg. % Proportion Rate of
# of Deaths Death Rate # of Deaths Death Rate Annual # of Deaths Change of Total Change

Heart Disease 14,412.4 149.8 15,899.0 154.2 1,486.6 10.3% 9.8% 1.0

Cancer 14,925.6 151.1 15,428.5 145.9 502.9 3.4% 3.3% 1.0

COVID-19 0.0 0.0 7,168.0 69.2 7,168.0 NA 47.0% NA

Unintentional Injury (Accident) 3,705.8 41.6 4,835.5 53.4 1,129.7 30.5% 7.4% 1.3

Stroke 3,578.4 37.8 4,029.5 39.4 451.1 12.6% 3.0% 1.0

Chronic Lower Respiratory Diseases 3,400.6 35.3 3,291.0 31.3 -109.6 -3.2% -0.7% 0.9

Alzheimer's Disease 2,477.8 26.7 2,703.0 27.0 225.2 9.1% 1.5% 1.0
Diabetes 2,129.6 21.8 2,595.0 24.8 465.4 21.9% 3.1% 1.1
Nephritis, Nephrotic Syndrome, and Nephrosis 1,558.6 16.3 1,622.5 15.7 63.9 4.1% 0.4% 1.0

Liver Disease 946.0 9.4 1,176.0 11.4 230.0 24.3% 1.5% 1.2

Suicide 1,145.0 12.9 1,165.0 13.1 20.0 1.7% 0.1% 1.0

Parkinson's Disease 794.8 8.6 1,088.0 10.8 293.2 36.9% 1.9% 1.2

Influenza and Pneumonia 1,220.4 12.8 1,043.5 10.2 -176.9 -14.5% -1.2% 0.8

Sepsis 1,159.2 12.0 406.0 9.7 -753.2 -65.0% -4.9% 0.8

Hypertension and Renal Diseases 728.0 7.6 897.5 8.7 169.5 23.3% 1.1% 1.1

Homicide 422.2 5.1 550.0 6.6 127.8 30.3% 0.8% 1.3

Page 15
Other Causes (Various) 15,195.6 162.0 18,535.5 185.0 3,339.9 22.0% 21.9% 1.1
All Deaths 67,800.0 710.8 83,042.5 816.2 15,242.5 22.5% 100.0% 1.1
* The leading causes of death listed are not inclusive of all deaths. Deaths of varying causes with small annual totals are omitted from the breakdown among the
leading causes, but are included in the overall total ('All Deaths')

Page 16
What this table means
The average annual number of deaths during the pandemic was higher than the previous five year
average, increasing from 67,800 to 83,042.5 (22.5% increase), more than 30,000 deaths in the
two year span over the average numbers prior to the pandemic. In general, the number of deaths
increases each year as the population increases and ages. However, the number of deaths
observed was greater than would be expected due to population growth alone. The top five
leading causes of death contributed to 70.4% of all excess deaths observed between the two
time periods. COVID-19 contributed 47.0% of all excess deaths.

The age-adjusted death rate allows for comparison across time and between causes of death.
The annual average age-adjusted death rate rose from 710.8 to 816.2, meaning there were more
annual deaths per 100,000 people during the pandemic than during the previous five years. When
looking at the percent change between PPP and CPP by cause of death, chronic lower respiratory
diseases, influenza and pneumonia, and sepsis were all lower during the CPP than before the
pandemic. Conversely, Parkinson's disease, unintentional injury (accident), homicide, liver
diseases, hypertension and renal diseases, and diabetes all increased over 20% between the two
averaged time periods. However, percent change must also take into account the actual numbers
of difference. As an example, a value of two in one year and three in another year accounts for a
50% increase but is not as impactful as a difference of 2,000 in one year and 3,000 in another
year (also a 50% increase). Thus, heart disease-related deaths had the largest numerical increase
between the two periods (nearly 3,000 extra deaths over the two years, a 10.3% increase),
followed by unintentional injuries (accidents) with 2,260 additional deaths over the two years, a
30.5% increase. COVID-19 deaths also had a substantial number of additional deaths during the
pandemic (well over 14,000 additional deaths) compared to the PPP because COVID-19 was a
novel virus that emerged in 2020.

Age-adjusted mortality rates increased among most causes of death. In respiratory categories;
chronic lower respiratory diseases, influenza and pneumonia, and sepsis all decreased. In a
majority of respiratory cases, the decreases were offset by COVID-19 being classified as the
primary cause of death. Homicides and unintentional injuries (accidents) had the highest rates of
change between the two periods.

The numerical difference and the rate of all other causes (various), which represented 22.0% of
the increase among the difference between the two periods. This grouping is for all other causes
of death that do not fall into the CDC’s 14 leading causes, plus homicide and COVID-19. These
other various causes of death are categorized by the anatomical system or medical event as
defined in standard ICD-10 coding. Similar to the 14 leading grouped causes of death, plus
homicide and COVID-19, most all other causes (various) increased between the PPP and CPP.
Among this category, mental and behavioral health-related deaths, as well as endocrine,
nutritional, and metabolic diseases showed the largest increase in aggregate mortality counts
between the two periods, as well as the largest percent increase.

Page 17
Figure 2.1: Proportion of Total Difference Between PPP and CPP by Grouped Cause of Death, 2020-2021

Page 18
 Table Limitations
This table uses two periods of time (PPP and CPP) for a comparison of change. The annual number
of people that die will normally increase each year as the population grows and ages. This table does
not take into account those naturally occurring changes and simply looks at two points in time.

Table 2.2 – Statewide Average Annual Virginia Resident Deaths, Age-Adjusted Death
Rates, and Excess Mortality by Race/Ethnicity

Summary
This table is formatted similarly to Table 2.1 and summarizes the average annual number of deaths
and the age-adjusted death rates before (PPP) and during the pandemic (CPP), as well as the
numerical difference between periods, the rates of change, and percent changes. This table
presents race and ethnicity as exclusive categories to see what differences may exist in death
counts and rates between groups. American Indian or Alaska Natives are a very small population,
which can lead to unstable rates; however, they are included here for representation.

Table 2.2 – Statewide Average Annual Virginia Resident Deaths, Age-Adjusted Death Rates, and
Excess Mortality by Race/Ethnicity

Pre-Pandemic Period COVID-19 Pandemic

(PPP) Period (CPP) Change from
(2015-2019) (2020-2021) PPP to CPP
Race or Ethnicity Five Years Two Years
Group
Average Age- Average Age- Difference in
% Rate of
Annual # Adjusted Annual # Adjusted Average Annual
Change Change
of Deaths Death Rate of Deaths Death Rate # of Deaths
Asian or Pacific
1,145.8 256.8 2,201.0 407.4 1,055.2 92.1% 1.6
Islander

Black 13,474.2 849.5 17,640.0 1,026.0 4,165.8 30.9% 1.2

Hispanic 1,318.0 349.7 2,255.5 493.9 937.5 71.1% 1.4

American Indian or
101.4 367.1 137.0 448.2 35.6 35.1% 1.2
Alaska Native

White 51,228.0 721.5 60,625.0 814.9 9,397.0 18.3% 1.1

Other/Not Reported
532.6 ND 184.0 ND -348.6 -65.5% ND
/Unknown

Total 67,800.0 710.8 83,042.5 816.2 15,242.5 22.5% 1.1

* Race and ethnicity are exclusive of each other

** ND represents no denominator for which to calculate rate

Page 19
What this table means
Across all race and ethnicity groups, death counts and rates were higher during the pandemic (CPP).
By number, the White population had an increase of nearly 20,000 extra deaths (average of 10,000
per year) during CPP compared to PPP; however, in 2021, over 66% of the Virginia population was
estimated as White and thus would account for a larger number of deaths than other demographic
groups (and a smaller percent change).

Among the rates, Black residents of Virginia had the highest rate of death during the pandemic
(1,026.0 deaths per 100,000 persons) followed by White residents (814.9). The Asian or Pacific
Islander population had the lowest mortality rate both before the pandemic and during the CCP in
Virginia. Although, comparing the rate differences among the two periods by the demographic
groups, Asian or Pacific Islander (1.6) and Hispanic populations (1.4) had the highest rates of change
between the two periods.

Table Limitations
This table simply looks at all-cause mortality stratified by race/ethnicity. This table does not examine
race/ethnicity differences among leading causes of death between the two periods or the variations
within these two periods. COVID-19 mortality rates fluctuated over time. In Virginia, Black residents
had the highest mortality rate of all demographic groups, followed by White residents (Virginia
COVID-19 Cases & Testing Dashboards, 2022).

Table 2.3 – Statewide Average Annual Virginia Resident Deaths, Age-Adjusted Death
Rates, and Excess Mortality by VDH Health Planning Region of Residence

Summary
Similar to Tables 2.1 and 2.2, this table summarizes the average annual number of deaths and the
age-adjusted death rates before (PPP) and during the pandemic (CPP), but they are stratified by
VDH Health Planning Regions1 of the decedent's residence. This table also calculates the percent
change, proportion of total, and the rate of change between the two periods.

1
VDH Health Planning Regions: https://www.vdh.virginia.gov/content/uploads/sites/182/2020/08/VA-
regions_districts_localities.pdf
Page 20
 Table 2.3 – Statewide Average Annual Virginia Resident Deaths, Age-Adjusted Death Rates, and
Excess Mortality by VDH Health Planning Region of Residence

Pre-Pandemic COVID-19 Pandemic

Period (PPP) Period (CPP) Change from
Health (2015-2019) (2020-2021) PPP to CPP
Planning Five Years Two Years
Region of Age- Age- Difference
Residence Average Average
Adjusted Adjusted in Average % Proportion Rate of
Annual # Annual #
Death Death Annual # Change of Total Change
of Deaths of Deaths
Rate Rate of Deaths

Central 13,249.4 781.0 16,368.5 914.1 3,119.1 23.5% 20.5% 1.2

Eastern 16,262.0 772.5 19,843.0 898.1 3,581.0 22.0% 23.5% 1.2

Northern 10,685.0 490.4 13,107.0 539.8 2,422.0 22.7% 15.9% 1.1

Northwest 11,367.6 715.8 13,849.0 813.1 2,481.4 21.8% 16.3% 1.1

Southwest 16,209.6 864.1 19,864.0 1,026.2 3,654.4 22.5% 24.0% 1.2

Total 67,800.0 710.8 83,042.5 816.2 15,242.5 22.5% 100.0% 1.1

* Over the seven years, there were a total of 169 deaths from unknown/unreported health planning regions
and are thus excluded from regional breakdown but included in the overall total

What this table means

The eastern and southwest planning regions had the highest numbers of deaths during the PPP
(16,262.0 and 16,209.6, respectively) and the CPP (19,843.0 and 19,864.0, respectively). The
southwest health planning region had the highest mortality rates in the state during both time
periods (864.1 and 1,026.2, respectively). Conversely, the northern planning region consistently had
the lowest numbers and rates of death among all categories. All regions experienced an increase of
22-24% in resident deaths during the pandemic compared to the PPP.

Table 2.4 – Statewide Average Annual Counts of Virginia Resident Deaths by Place of
Death

Summary
This table summarizes the average annual number of deaths before (PPP) and during the pandemic
(CPP) by place of death as defined by the CDC National Center for Health Statistics (NCHS) in death
certificates (Centers for Disease Control and Prevention National Center for Health Statistics.,
2022). Rates are not calculated for this table because of population denominator challenges. This
table also includes the numerical difference in deaths between the two periods, the percent change,
and the proportion of total.

Page 21
 Table 2.4 – Statewide Average Annual Counts of Virginia Resident Deaths by Place of Death

COVID-19
Pre-Pandemic
Pandemic
Period (PPP) Change from
Period (CPP)
(2015-2019) PPP to CPP
(2020-2021)
Place of Death Five Years
Two Years
Average Average Difference in
Proportion of
Annual # of Annual # of Average Annual % Change
Total
Deaths Deaths # of Deaths
Private
Residence/ 22,515.2 29,286.5 6,771.3 30.1% 44.4%
Home
Hospital
21,132.8 27,329.5 6,196.7 29.3% 40.7%
Inpatient
Nursing Home/
Long-Term 13,170.2 13,857.5 687.3 5.2% 4.5%
Care Facility
Other 4,235.8 5,953.5 1,717.7 40.6% 11.3%
Emergency
Room 3,981.0 4,171.5 190.5 4.8% 1.2%
Outpatient
Hospice Facility 2,424.6 2,152.5 -272.1 -11.2% -1.8%
Dead on arrival
(DOA) at 285.8 217.5 -68.3 -23.9% -0.4%
Hospital
Unknown/
54.6 74.0 19.4 35.5% 0.1%
Unreported

Total 67,800.0 83,042.5 15,242.5 22.5% 100.0%

What this table means

One third of all deaths in Virginia in both periods occurred at a private residence/home, followed very
closely by almost another one third of all deaths, in both periods, occurring at an inpatient hospital
facility in the state. These two places (private residence/home and inpatient hospital facility) also
experienced the largest influxes of deaths during the pandemic with over 13,500 additional deaths
occurring at home during the two year period (average of over 6,700 each year) and inpatient
hospitals facilities experiencing an additional 12,000 deaths over the two years (average of over
6,000 each year). Interestingly, the average number of people who died in hospice facilities actually
decreased slightly (-11.2%) during the pandemic when compared to the PPP.

Page 22
Table 2.5 – Statewide Annual Death Counts of Virginia Residents by Year of Death and
Grouped Causes of Death
Summary
This table provides annual mortality counts by the leading causes of death, including homicide,
among residents of Virginia by year of death.

Table 2.5 – Statewide Annual Death Counts of Virginia Residents by Year of Death and Grouped
Causes of Death

COVID-19 Pandemic
Pre-Pandemic Period (PPP)
Period (CPP)
(2015-2019)
Leading Causes of Death* (2020-2021)
Five Years
Two Years
2015 2016 2017 2018 2019 2020 2021

Heart Disease 13,864 13,779 14,832 14,526 15,061 15,570 16,228

Cancer 14,736 14,667 15,037 15,142 15,046 15,476 15,381

COVID-19 0 0 0 0 0 5,754 8,582

Unintentional Injury
3,339 3,507 3,886 3,800 3,997
(Accident) 4,529 5,142

Stroke 3,334 3,415 3,549 3,771 3,823 4,082 3,977

Chronic Lower Respiratory
3,335 3,177 3,359 3,467 3,665 3,442 3,140
Diseases

Alzheimer's Disease 2,228 2,387 2,548 2,594 2,632 2,862 2,544

Diabetes 2,021 2,028 1,966 2,281 2,352 2,576 2,614

Nephritis, Nephrotic
1,442 1,509 1,617 1,563 1,662 1,647 1,598
Syndrome, and Nephrosis

Liver Disease 921 855 972 944 1,038 1,215 1,137

Suicide 1,100 1,132 1,158 1,198 1,137 1,167 1,163

Parkinson's Disease 631 736 835 878 894 1,064 1,112

Influenza and Pneumonia 1,368 1,110 1,242 1,279 1,103 1,174 913

Sepsis 1,161 1,186 1,242 1,121 1,086 988 1,042

Hypertension and Renal
675 678 682 788 817 872 923
Diseases

Homicide 372 434 451 419 435 520 580

Other Causes (Various) 14,040 15,659 15,101 15,584 15,594 17,429 19,642

All Deaths 64,567 66,259 68,477 69,355 70,342 80,367 85,718

* The leading causes of death listed are not inclusive of all deaths. Deaths of varying causes with small annual totals are
omitted from the breakdown among the leading causes, but are included in the overall total.

Page 23
What this table means
Generally, this table simply provides counts of deaths by cause of death and year. This does not take
into account population changes or growth that naturally increase annual mortality numbers. From
2015-2018, the leading cause of death among Virginia residents based on counts was cancer. In
2019, heart disease overtook cancer (by a very small margin), and, by number, became the leading
cause of death in the state through 2021. From 2015-2019, unintentional injuries (accidents) were
the third leading cause of death in Virginia. In 2020, the pandemic began and COVID-19 deaths
overtook unintentional injuries (accidents) and became the third leading cause of death in Virginia
(2020 and 2021).

Table Limitations
This table is simply based on counts of death. Age-adjusted rates of death, which take into account
population totals and age differences among categories, may affect the rankings among grouped
causes of death. Generally, age-adjusted mortality rates, which are available in Table 2.6, are
preferable over straight counts of death by cause.

Table 2.6 – Statewide Age-Adjusted Rates of Virginia Resident Deaths by Year of Death
and Grouped Causes of Death

Summary
Similar to Table 2.5, this table examines the leading causes of death by year of death, but instead
calculates age-adjusted rates to standardize for age variations among different categories of
leading causes of death.

Page 24
 Table 2.6 – Statewide Age-Adjusted Rates of Virginia Resident Deaths by Year of Death and
Grouped Causes of Death

COVID-19
Pre-Pandemic Period (PPP) Pandemic Period
(2015-2019) (CPP)
Leading Causes of Death* Five Years (2020-2021)
Two Years
2015 2016 2017 2018 2019 2020 2021
Heart Disease 151.8 147.0 154.2 147.1 149.1 150.9 157.5
Cancer 157.2 152.4 152.3 149.3 144.9 146.4 145.3
COVID-19 0.0 0.0 0.0 0.0 0.0 55.7 82.8
Unintentional Injury
(Accident) 38.5 40.1 43.6 42.2 43.8 50.1 56.7
Stroke 37.4 37.2 37.4 38.8 38.3 39.8 38.9
Chronic Lower
Respiratory Diseases 36.7 34.1 34.9 34.8 35.8 32.7 29.8
Alzheimer's Disease 25.3 26.5 27.6 27.1 26.9 28.7 25.4
Diabetes 21.6 21.3 20.1 22.8 22.8 24.6 24.9
Nephritis, Nephrotic
Syndrome, and Nephrosis 15.8 16.3 16.9 15.9 16.4 16.0 15.4
Liver Disease 9.4 8.8 9.7 9.3 10.1 11.7 11.2
Suicide 12.5 12.9 13.1 13.5 12.8 13.1 13.0
Parkinson's Disease 7.3 8.3 9.1 9.2 9.1 10.5 11.0
Influenza and Pneumonia 15.1 12.0 13.1 13.0 11.0 11.5 8.9
Sepsis 12.7 12.6 13.0 11.3 10.6 9.5 9.9
Hypertension and Renal
Diseases 7.4 7.3 7.1 8.0 8.1 8.5 9.0
Homicide 4.5 5.3 5.3 5.0 5.3 6.2 6.9
Other Causes (Various) 157.2 171.1 161.0 162.3 158.5 174.6 195.3
All Deaths 710.5 713.1 718.3 709.5 703.5 790.5 841.8

* The leading causes of death listed are not inclusive of all deaths. Deaths of varying causes with small annual
totals are omitted from the breakdown among the leading causes, but are included in the overall total ('All
Deaths')

Page 25
What this table means
Age-adjusted rates are impacted by varying age distributions among the categories, which is
evident in the calculations for this table. These rates slightly affected the rankings in cause of death
when compared to the straight counts in Table 2.5. Overall, many annual age-adjusted rates of all
leading causes of death have generally increased each year, with the exception of cancer, chronic
lower respiratory disease, influenza and pneumonia, and sepsis. Since 2015, cancer was the leading
cause of death in Virginia based on age-adjusted rates, but heart disease overtook cancer in 2017
as the leading cause, but then again dropped to second in 2018. In 2019-2021, heart disease again
overtook cancer and was the leading cause of death in Virginia based on rates. Interestingly,
although cancer mortality rates consistently remain in the first or second ranked leading causes of
death in Virginia, the rates have slowly been decreasing since 2010. As shown in Table 2.5,
unintentional injuries (accidents) were the third leading cause of death in Virginia from 2015-2019,
but were bumped to fourth when the pandemic began and COVID-19 became the third leading cause
of death in the state (2020-2021).

Table Limitations
This table compares leading grouped causes of deaths by the underlying (primary) cause of death,
which are exclusive categories. Contributing causes of death are not included in these statistics.

Tables 2.7a, 2.7b, and 2.7c – Statewide Person Years, Death Counts, and Age-Adjusted
Death Rates by at Least One COVID-19 Vaccination Received by Age Group

Summary
These tables contain person-years (Table 2.7a), death counts (Table 2.7b), and mortality rates of
Virginia residents (Table 2.7c) who received at least one dose of the COVID-19 vaccine during 2021
compared to the rest of the Virginia population.

Person-years, a CDC unit of measure for calculating incidence rates, is used instead of population
totals to adjust for how much the population that received at least one dose of COVID-19 changed
in 2021. Since vaccine roll-out began in late 2020, it meant that most people had not had their first
dose for the full duration of 2021. Using person-years, someone first vaccinated in April 2021 would
count for 0.75 person-years in the vaccinated category, whereas someone first vaccinated in July
2021 would count for 0.5 years in the vaccinated category. This allows for the length of time each
person had been vaccinated for to be directly incorporated into the denominator when calculating
death rates.

In addition, the data are age-adjusted and broken out by age groups because people of a higher age
are more at risk of dying after they are infected with COVID-19 (Yek C, Warner S, Wiltz JL, et al.,
2022).

Page 26
 Table 2.7.a Person Years by Vaccine Status and Age Group, 2021

People With
Virginia Unvaccinated
Age Group At Least One
Population (Difference)
Dose
0-14 125,303 1,548,688 1,423,385
15-24 437,880 1,117,118 679,238
25-34 485,214 1,195,477 710,263
35-44 533,065 1,127,091 594,026
45-54 566,671 1,084,314 517,643
55-64 647,745 1,116,831 469,086
65-74 565,861 827,566 261,705
75-84 289,987 416,842 126,855
85+ 98,917 156,636 57,719
Total 3,750,643 8,590,563 4,839,920

Table 2.7.b Total Death Counts by Vaccine Status and Age in 2021

People With At Virginia Unvaccinated

Age Group
Least One Dose Population (Difference)

0-14 7 795 788

15-24 135 956 821
25-34 234 1,897 1,663
35-44 507 2,818 2,311
45-54 1,196 4,978 3,782
55-64 3,604 11,708 8,104
65-74 7,180 17,912 10,732
75-84 9,774 21,232 11,458
85+ 10,700 23,420 12,720
Total 33,337 85,716 52,379

Page 27
 Table 2.7.c Age-Adjusted Death Rates by Vaccine Status in 2021

People With
Virginia Unvaccinated
Age Group At Least One
Population (Difference)
Dose
0-14 1.2 11.0 11.9
15-24 4.3 11.9 16.8
25-34 6.5 21.5 31.7
35-44 15.5 40.7 63.3
45-54 28.5 61.9 98.5
55-64 48.5 91.5 150.7
65-74 83.8 142.9 270.8
75-84 151.1 228.4 405.0
85+ 167.8 231.9 341.8
Total 507.2 841.6 1,390.5

What these tables mean

Through the deterministic and probabilistic record linkage process for both 2021 death certificates
and 2021 vaccination records, 33,337 deaths were identified in 2021 among people in Virginia who
had received at least one dose of a COVID-19 vaccine and 52,379 deaths among people who did not
receive a COVID-19 vaccine. As expected, rates were higher for older ages whether a person
received at least one dose or not. More notably, however, the death rates among people who
received at least one dose were much lower than death rates among unvaccinated people or Virginia
residents. The greatest disparity between the death rates of people who received at least one dose
and unvaccinated people was observed for the age group 25-34 years old; in this age group,
unvaccinated people had a death rate (31.7) that was 4.9 times the death rate of people who
received at least one dose (6.5). For most age groups, the death rate among unvaccinated people
was two to four times higher than that of vaccinated people.

Table Limitations
Unvaccinated person-years may be overestimated because it assumes the unvaccinated population
equals the difference between Virginia's population estimates and people with at least one dose of
the COVID-19 vaccine. It is known that many people residing in Virginia received a vaccination
across state lines, from the federal government, or outside of the United States, so their records are
not reported in a format compatible with this analysis. These individuals are not likely counted
among people with at least one dose during 2021 unless they received another dose in Virginia. The
relationship between COVID-19 vaccination and death is not a simple relationship and many other
factors contribute, including income, education, and rurality, which were not included in this analysis.

Page 28
Proposed Tables on Death Rates by Vaccine Manufacturer, Cause of Death, and Chronic
Disease
In response to the request for an analysis on COVID-19 vaccinations and excess mortality, a
substantial amount of time and effort was spent by VDH staff attempting to compile the proposed
data tables. However, multiple complications arose with the analysis and in the end, resulted in the
inability to fulfill the request. Specifically, death rates associated with vaccination are not meaningful
unless compared to a similar unvaccinated group of people (of same ages, races, sex, etc.) for a
similar time period. These control group data for Virginia are not readily available. Specific
challenges include:

1) Public chronic conditions datasets used substantially different methods from this analysis.
For example, inferential methods for population denominators that would rely on BRFSS data
were outside the scope of this analysis and age groups were often not compatible.
2) Chronic conditions reporting on death certificates is limited and often incomplete due to non-
reporting of chronic conditions that did not contribute to the death.
3) The definition of chronic conditions differ between death certificates and multiple public
health datasets.
4) The vaccinated population continuously changed over the course of 2021. To determine the
vaccinated and unvaccinated populations at points in time with disaggregation by type of
vaccine, cause of death, and chronic disease would require methods that were outside the
scope of this analysis.
5) Unavailable or exceedingly complex denominators for rate calculations, resulting in
significant problems with data interpretation and reliability.

Page 29
Discussion
Excess deaths and mortality statistics were used in this analysis to identify areas of potential
research and to detect any abnormalities in patterns of death. These are the key results and
recommendations for future research:

COVID-19 drove excess mortality in Virginia, but mortality for other causes of
death was also higher than expected. The top five leading causes of death contributed
to 70.4% of all excess deaths observed between the two time periods. COVID-19 contributed
47.0% of all excess deaths.

Disparities in all-cause mortality were observed during the pandemic period that
also existed before the pandemic. The southwest health planning region had the highest
mortality rates in the state during both time periods (864.1 and 1,026.2, respectively). Across
race and ethnicity groups death counts and rates were higher during CPP. Additionally, Black
residents of Virginia had the highest rate of death during the pandemic (1,026.0 deaths per
100,000 persons) followed by White residents (814.9). The Asian or Pacific Islander
population had the lowest mortality rate both before the pandemic and during the CCP in
Virginia. Although, comparing the rate differences among the two periods by the
demographic groups, Asian or Pacific Islander (1.6) and Hispanic populations (1.4) had the
highest rates of change between the two periods.

Death rates among people who received at least one dose of COVID-19 vaccine
were much lower than death rates among Virginia residents and people who did
not have any recorded dose of COVID-19 vaccine. The all-cause standardized death
rate in 2021 was 2.7 times higher for Virginia residents with no recorded dose (1,390.5) than
for people who received at least one dose (507.2). The greatest disparity between the death
rates of people who received at least one dose and people who did not was observed for the
age group 25-34 years old; in this age group, people with no recorded dose had a death rate
(31.7) that was 4.9 times the death rate of people who received at least one dose (6.5). For
most age groups, the death rate among unvaccinated people was two to four times higher
than that of vaccinated people. Given the known limitations of estimating the unvaccinated
population, further research could be beneficial to verify the disparity observed here.

Page 30
Works Cited
Anderson, R. N., & Rosenberg, H. M. (1998, October 7). Age Standardization of Death Rates:
Implementation of the Year 2000 Standard. Centers for Disease Control and Prevention,
National Center for Health Statistics. Retrieved September 1, 2022, from
https://www.cdc.gov/nchs/data/nvsr/nvsr47/nvs47_03.pdf

Centers for Disease Control and Prevention National Center for Health Statistics. (2021, December
22). NVSS - Public Use Data File Documentation. Centers for Disease Control and Prevention.
Retrieved September 23, 2022, from
https://www.cdc.gov/nchs/nvss/mortality_public_use_data.htm

Excess Deaths Associated with COVID-19. (2022). In

https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm. Centers for Disease
Control and Prevention.

Leading Causes of Death. (2022, September 6). In https://www.cdc.gov/nchs/fastats/leading-causes-

of-death.htm. Centers for Disease Control and Prevention, National Center for Health
Statistics.

NCHS - Age-adjusted Death Rates for Selected Major Causes of Death. (2022, March 30). [Dataset].
Centers for Disease Control and Prevention, National Center for Health Statistics.
https://data.cdc.gov/NCHS/NCHS-Age-adjusted-Death-Rates-for-Selected-Major-C/6rkc-
nb2q

Safety of COVID-19 Vaccines. (2022, September 19). In https://www.cdc.gov/coronavirus/2019-

ncov/vaccines/safety/safety-of-
vaccines.html#:~:text=COVID%2D19%20vaccines%20are%20safe,Years%20and%20older
%2C%20if%20eligible. Centers for Disease Control and Prevention, National Center for
Immunization and Respiratory Diseases, Division of Viral Diseases.

U.S. Census Populations with Bridged Race Categories. (2019, June). In

https://www.cdc.gov/nchs/nvss/bridged_race.htm. Centers for Disease Control and
Prevention, National Center for Health Statistics.

Virginia COVID-19 Cases & Testing Dashboards. (2022). [Dataset]. Virginia Department of Health.
https://www.vdh.virginia.gov/coronavirus/see-the-numbers/covid-19-in-virginia/covid-19-
in-virginia-demographics/

Yek C, Warner S, Wiltz JL, et al. Risk Factors for Severe COVID-19 Outcomes Among Persons
Aged ≥18 Years Who Completed a Primary COVID-19 Vaccination Series — 465 Health Care
Facilities, United States, December 2020–October 2021. MMWR Morb Mortal Wkly Rep
2022;71:19–25.

Page 31