Abstract
Excess mortality is the difference between expected and observed mortality in a given period and has emerged as a leading measure of the COVID-19 pandemic's mortality impact. Spatially and temporally granular estimates of excess mortality are needed to understand which areas have been most impacted by the pandemic, evaluate exacerbating factors, and inform response efforts. We estimated all-cause excess mortality for the United States from March 2020 through February 2022 by county and month using a Bayesian hierarchical model trained on data from 2015 to 2019. An estimated 1,179,024 excess deaths occurred during the first 2 years of the pandemic (first: 634,830; second: 544,194). Overall, excess mortality decreased in large metropolitan counties but increased in nonmetropolitan counties. Despite the initial concentration of mortality in large metropolitan Northeastern counties, nonmetropolitan Southern counties had the highest cumulative relative excess mortality by July 2021. These results highlight the need for investments in rural health as the pandemic's rural impact grows.