Demographic changes in COVID-19 mortality during the pandemic: Analysis of trends in disparities among workers using California’s Mortality Surveillance System

Background There is limited information on the extent and patterns of disparities in COVID-19 mortality throughout the pandemic. We aimed to examine trends in disparities by demographics over variants among Californian workers using a social determinants of health lens. Methods Using death certificates, we identified all COVID-19 deaths that occurred between January 2020 and May 2022 among workers aged 18–64 years in California. We derived estimates for at-risk worker populations using the Current Population Survey. The waves of COVID-19 mortality were March 2020-June 2020 (wave 1), July 2020-November 2020 (wave 2), December 2020-May 2021 (wave 3), June 2021-January 2022 (wave 4), and February 2022-May 2022 (wave 5). Poisson regression models with robust standard errors were used to determine wave-specific mortality rate ratios (MRRs). We examined the change in MRR across waves by including an interaction term between each demographic characteristic and wave period in different models. Results Among the 24.1 million working age CA population included in the study, there were 26,068 COVID-19 deaths in the period between January 2020 and May 2022. Compared with their respective reference groups, workers who were 50–64 years old, male, Native Hawaiian, Latino, or African American, foreign-born; individuals who had lower education; and unmarried were disproportionately affected by COVID-19 mortality. While disparities by sex, race and foreign-born status narrowed in later waves, disparities by age, education level and marital status did not change substantially across waves. Conclusion The existence of disparities across all waves of the pandemic, even in an era of widespread vaccine coverage, could indicate remaining gaps in prevention and differential vulnerability. Addressing the underlying social, structural, and occupational factors that contribute to these disparities is critical for achieving health equity.