Rurality as a Risk Factor for Excess Mortality in Nebraska During the COVID-19 Pandemic

Introduction/ObjectivesThe COVID-19 pandemic increased mortality across the United States, but its burden was uneven across communities. Rural populations may be vulnerable because of differences in age structure, health care access, preventive behaviors, and vaccination uptake. This study examined the association between rurality and excess mortality during the COVID-19 pandemic in Nebraska.MethodsThis ecological study used Nebraska death certificate data from 2015 through May 2023, COVID-19 laboratory, hospitalization, and vaccination data, and American Community Survey sociodemographic data. Monthly deaths from 2015 through 2019 were used to forecast expected deaths by zip code tabulation area from January 1, 2020, through May 31, 2023, using seasonal autoregressive integrated moving average models. Excess mortality was calculated as observed minus expected deaths. Secondary regression analysis using Poisson regression assessed associations between rurality and excess mortality, with inclusion of demographic, socioeconomic, COVID-19 infection, hospitalization, and vaccination measures as covariates.ResultsNebraska had 63,333 observed deaths and 57,865 expected deaths, corresponding to 5,468 excess deaths. Rurality was the strongest associated factor for excess mortality across pandemic phases, with the strongest association during the pre-vaccine phase. Vaccination was generally associated with reduced excess mortality.ConclusionsRurality was an important risk factor for excess mortality in Nebraska. Findings support targeted rural surveillance, outreach, primary care engagement, and emergency preparedness.