PROJECT SUMMARY/ABSTRACT Coronavirus disease-2019 (COVID-19) is an international public health emergency caused by the respiratory droplet transmission of the coronavirus-2 (SARS CoV-2) virus. The United States has emerged as an epicenter of the pandemic, with distinctive regional patterning. To date, COVID- 19 mortality has largely been monitored using death certificates that contain reference to COVID- 19. However, prior analyses of excess mortality reveal that between 12% to 25% of excess deaths in 2020 were not directly assigned to COVID-19. The percent of deaths not assigned to COVID- 19 is also known to vary significantly by state and by county-level sociodemographic factors. However, it remains unknown to what extent excess mortality and excess mortality not assigned to COVID-19 differs by region and across the urban-rural continuum. The proposed Supplement will build upon and expand on current work on geographic inequalities in mortality by integrating a focus on COVID-19. Our preliminary work on excess mortality associated with COVID-19 has shown that mortality from COVID-19 and excess mortality not assigned to COVID-19 varies substantially across subsets of U.S. counties defined by their sociodemographic and health characteristics and along the urban-rural continuum. This preliminary work has also raised questions about the quality of the coding of causes of death across states and counties. The proposed supplement will enable us to expand our analyses to excess mortality and directly assigned COVID-19 mortality by geography and race/ethnicity. There is considerable evidence that excess mortality and COVID-19 mortality varies by race/ethnicity but little is known how the impact of the pandemic on the various U.S. racial/ethnic subgroups varies by geography. We will also investigate the potential impact of cause of death coding differentials on estimates of geographic inequalities in excess mortality and mortality directly assigned to COVID-19. Concerns about the quality of cause-of-death coding were also raised by the new report of the National Academy of Sciences, Engineering and Medicine, High and Rising Mortality Rates among Working-age Adults.

PROJECT NARRATIVE The widening geographic inequalities and persistent racial and ethnic disparities in U.S. mortality is a cause for concern. The COVID-19 pandemic has reinforced and exacerbated these existing geographic and racial/ethnic inequalities. This proposed supplement will help quantify the excess mortality caused by the pandemic and its impact on divergence in US mortality by geography and race/ethnicity.