Long COVID is showing up in Colorado death data, even as COVID-19 deaths drop sharply

A close-up image of an array of buttons and a lanyard on a person's orange knit shirt. The lanyard is red with "VISITOR" on it. Both buttons are in support of long COVID treatment.
Frank Augstein/AP Photo
COVID campaigners and families of those who died during the pandemic wear badges in support of children with long COVID as they protest in London, Monday, Dec. 11, 2023.

COVID-19 is no longer in the top 10 reasons why Coloradans die, according to the state’s annual death data, but the virus still casts a shadow over the numbers. 

Long COVID is starting to be listed as a "significant contributing factor" in the deaths of some Coloradans, according to the Colorado Department of Public Health and Environment.

Since January 2023, there have been 52 deaths among Colorado residents in which long COVID was recorded as playing a role.

“It doesn't surprise me. It's definitely something that we should pay attention to because long COVID exists,” said Dr. Dana Dabelea, an epidemiology professor at Colorado's School of Public Health, where she’s associate dean for research. 

Last year, the state recorded 38 deaths in which long COVID was a significant contributing factor, with 14 in 2024 so far. It has not yet been recorded as the "underlying cause of death," according to the state health department.

Long COVID is defined by the federal Centers for Disease Control and Prevention as a chronic condition that occurs after an infection and with a wide range of symptoms lasting at least three months. 

“It's not surprising because if you look at the epidemiology of long COVID, the group that seems to suffer a great deal from it in terms of the more virulent qualities of long COVID tend to be people who had serious COVID to start with,” said Dr. John Swartzberg, a professor and expert in infectious diseases, at UC Berkeley. He said the largest group with serious COVID cases were the elderly.

Long COVID also has a cascade of other impacts, like often making it hard to exercise. “So I'm not surprised at all that long COVID is contributing to mortality rates,” he said.

CDPHE started tracking long COVID in death data, after a study in December 2022 described the use of death certificate text to identify the condition in the National Vital Statistics System.  

How the death data gets gathered

The state’s numbers are based on data collected through routine registration of death certificates, according to the state health department. That includes information about cause of death as provided by medical certifiers. Physicians, coroners or medical examiners may make the official determination.  

Cause of death information reported on death certificates is then submitted to the CDC/National Center for Health Statistics. Employees there code them to underlying cause of death codes and contributing factors, which allows for the systematic analysis of the data across the country and over time, including the latest results.

Here are three takeaways from this year’s data, which was recently released by the state. It also provides data online via the Colorado Health Information Dataset, going back more than two decades.

The mortality rate is still higher than before the pandemic

The age-adjusted mortality rate for 2023, for all causes of death, was 682 per 100,000 people. That’s higher than the rate before COVID, in 2019, which was 636 per 100,000.  

Both the age-adjusted death rate and the total numbers of deaths shot up the first two years of the pandemic, before starting to decline after COVID-19 vaccines became widely available and protection, prevention and treatment improved. The total number of deaths climbed from about 39,300 deaths in 2019 to around 48,300 deaths in 2021, with the rate spiking from 636 per 100,000 in 2019 to 773 per 100,000 two years later, according to the state’s data.

Across the myriad causes of death, there’s a combination of causes that remained higher, the same or decreased.  

Other steady increases between this time period include drug overdose, other injury causes (which include falls, motor vehicle accident, and homicide), chronic liver diseases and cirrhosis, certain heart diseases (including hypertensive disorders and stroke), chronic kidney diseases, nutritional deficiencies, and certain cancers.

Overall cancer rates were consistent with 2019, according to the health department data. 

The top 10 causes of death for Coloradans in 2023 were cancer, heart disease, accidents, chronic lower respiratory diseases, cerebrovascular diseases, Alzheimer’s disease, suicide, chronic livers disease and cirrhosis, diabetes mellitus, and other diseases of the respiratory system.

Not on that top-10 list: COVID-19.  It dropped to 12th with 626 deaths. It was the third leading cause of death among Colorado residents in 2021 and 2020, according to health department data. In 2022, the virus claimed more than 2,200 lives in the state, the fifth most that year.

A lot has changed since the dire early months and years of the pandemic, Swartzberg said.

“Vaccines work, personal protection works. We've got a less virulent variant with omicron and all of its sub variants than alpha and delta, for example,” he said. 

“There's tremendous background immunity from people who've been infected before,” Swartzberg said. “Ninety-six percent of the American population has some degree of immunity from vaccines or previous infection or both. So, yeah, it's a very different game than it was before.”

The impact of drug overdoses

One of the most notable trends over the last decade is the sharp rise in overdose deaths.

Drug overdose deaths in Colorado rose to 1,865 in 2023 from 1,799 the year before and nearly eclipsing the record set in 2021 of 1,881. The number was 683 more than a decade ago in 2010.

The biggest driver of those overdoses is fentanyl, a powerful synthetic opioid. It claimed almost 1,100 Colorado lives last year. Methamphetamine and cocaine overdose deaths also increased; many of those deaths were due to the presence of other drugs, often fentanyl, detected in someone’s system. Overdoses due to a combination of drugs have risen steadily since Colorado began tracking them in 2016.

The overall overdose death figure is nearly triple the number in 2010. That same year, the state recorded fewer than 40 deaths due to fentanyl — so the number of fentanyl deaths is more than 25 times what it was more than a decade ago.

Life expectancy rebounded, after a historic drop when the pandemic hit

In terms of life expectancy, there was continued improvement from 2022 to 2023. Overall life expectancy increased among Colorado residents, female and male. 

That was true for a number of demographic groups including among the White non-Hispanic, Black/African American non-Hispanic, Asian non-Hispanic, those who were listed as two or more races, and Hispanic (inclusive of all races) populations.  

Declines were seen in the Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native, non-Hispanic, populations. Due to the relatively small populations in these categories, the potential errors and variations of life expectancy estimates are larger, and these differences are not statistically significant, according to the state health department.

Life expectancy rose for all Coloradans to 79.9 in 2023, up more than a year from 2020 but not back to the figure recorded the year before the pandemic (80.9). After a big drop at the start of the pandemic, life expectancy for Hispanic and Black Coloradans climbed back up by about three years, comparing 2020 and 2023 (to 79.1 and 75.7 respectively), but still below that of white and Asian Coloradans (80.7 and 87 respectively).

Life expectancy had dropped in Colorado for two straight pandemic years, 2020 and 2021. It was the kind of decline not seen in decades.

The average life expectancy for Colorado residents fell to 78 years in 2021. That's slightly lower than 2020, the first year of the pandemic, when it was 78.4 years, but the slide represented a persistent and significant drop of nearly three years compared to 2019.

“The last time life expectancy dropped like this was in 1943, which was the most fatal year of World War II, for the nation,” Dr. Eric France, then the state’s chief medical officer, told CPR in 2022. Key drivers for the decline were COVID-19 and overdose deaths.

The drop in life expectancy the first year of the pandemic was most startling among communities of color. Hispanic and Black residents died in such relatively higher numbers in 2020 that both groups’ life expectancy fell by about four years. The drop among white people in Colorado was 1.4 years.

These numbers are also illustrative of the substantial health inequities still found in Colorado, said Dr. Tamaan Osbourne-Roberts, a family medicine doctor who serves a diverse population at Daybreak Health in Denver.

Particularly striking, he said via email, was the sudden and substantial drop in life expectancy amongst Black and Hispanic Coloradans relative to other demographic groups, as well as the current low life expectancy for Black Coloradans, despite a substantial rebound in more recent years.  

“While Colorado ranks consistently in the top ten U.S. states for total life expectancy amongst several surveys completed in 2023, if Black Coloradans represented a state, they would rank consistently amongst the bottom ten of U.S. states for the same measure,” said Osbourne-Roberts.

He said the trends in these demographic groups and others, is “indicative of a range of inequities they face in healthcare, public health infrastructure, and the social and political determinants of health.”

Colorado should be happy to be past the pandemic, he said, “But we have a long way to go in building a health system that truly serves all Coloradans equitably.”

The big picture

For epidemiology professor Dabelea, the state’s health seen through the lens of its death data presents good and bad news.

“Good news is we are seeing these declines in deaths from chronic diseases, at least as of today or last year,” she said. And deaths from COVID-19 are down sharply. 

But the troubling information comes especially in the deaths from overdoses, including ‘those that were accidental and unintentional. 

“I think that's the bad news, and maybe things are improving a little bit, but Colorado is listed as the state with the second highest rates of unintentional overdoses in teens and adolescents in the country,” she said. “So that's worrisome.”