Longitudinal trends in 30-day mortality attributable to SARS-CoV-2 among vaccinated and unvaccinated US Veteran patients

Abstract: Surveillance is a cornerstone of public health practice. Accurate monitoring of deaths and hospitalizations caused by coronavirus disease 2019 (COVID-19) is important for informing public policy responses. During the early phases of the pandemic, prior to the availability of medical countermeasures, death within a window period following a positive microbiologic test for SARS-CoV-2 had high predictive value as a surveillance tool for measuring COVID-19–attributable deaths. However, following increasing access to testing including for asymptomatic patients, acquisition of widespread immunity in the population and advances in medical therapeutic options, the attribution of a death due to COVID-19 has become more complex. Thus, we examined trends in the percentage of deaths attributable to COVID-19 in both vaccinated and unvaccinated patients with a documented positive SARS-CoV-2 test in a multicenter, retrospective cohort. We applied an electronic measurement tool, previously developed using a chart reviewed sample of cases from a national cohort using Veterans’ Affairs (VA) data and validated on manually adjudicated cases at Tufts Medical Center, to classify deaths as attributable to or not attributable to COVID-19. The cohort consisted of 10,778 veterans who died within 30 days of a positive SARS-CoV-2 test during the study period. This included 6,081 vaccinated veterans and 4,697 unvaccinated veterans. Unvaccinated veterans who died were younger: median age, 74.3 vs 77.6 years in vaccinated veterans (P < .001). In summary, over the course of the pandemic, COVID-19 severity, as measured by hospitalizations and deaths within 30 days of a positive test, have decreased as population immunity has increased and therapeutics have been developed. Mortality attributable to COVID-19 in patients who recently tested positive for SARS-CoV-2 has also decreased in both vaccinated and unvaccinated populations, and to a similar extent. Simple metrics for determining death attribution can be applied to improve the speed and accuracy of public health surveillance metrics.

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