Alcohol-Assisted Liver Disease Deaths Climbed During COVID-19


National data show mortality rates climbed 23% in 2020, primarily driven by increases among American Indian or Alaska Native people.

Alcohol-Assisted Liver Disease Deaths Climbed During COVID-19

Jagpreet Chhatwal, PhD

National rates of alcohol-assisted liver disease mortality increased by more than 23% from 2019 to 2020, according to new research.1

New data from a team of US investigators show that deaths due to alcohol-associated liver disease spiked during the COVID-19 pandemic, with all but 1 state reporting an increase in age-adjusted mortality from the condition. The issue seems to particularly impact American Indian or Alaska Native people, who are at a 6-fold increased risk of mortality compared to White people.

Led by Jagpreet Chhatwal, PhD, of the Institute for Technology Assessment at Massachusetts General Hospital and Harvard Medical School, investigators conducted an analysis of association between race and alcohol-associated liver disease mortality in US states during the COVID-19 pandemic. They noted the mean US life expectancy declining to 77.3 years in 2021—its lowest mark since 1996, and an average particularly brought down by significantly declining life expectancies among non-Hispanic American Indian or Alaska Native populations.

The third-leading cause of death for this group was chronic liver disease, after COVID-19 and unintentional injuries, investigators noted. The increase in such a disease is directly tied to increases in alcohol-associated liver disease.

“Rates of alcohol-associated liver disease increased by 43% from 2009 to 2015, accounting for over $5 billion in direct health care costs in 2015,” investigators wrote. “This problem was exacerbated by the COVID-19 pandemic, during which alcohol-associated liver disease deaths increased by 22.4%”

Chhatwal and colleagues used data from the 2019 – 2020 Centers for Disease Control and Prevention (CDC) WONDER Multiple Cause of Death database. They extracted age-adjusted mortality rates for alcohol-associated chronic liver disease per 100,000 people based on their US state and race, via the International Statistical Classification of Diseases and Related Health Problems.

Identified races for assessment included American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, and White.

The prevalence of alcohol-associated liver disease increased among Americans during the COVID-19 pandemic; the states with the greatest age-adjusted mortality rates for the disease corresponded to states with the greatest such rates for American Indian or Alaska Native populations.

The national mortality rate increased for alcohol-associated liver disease increased from 6.4 to 7.9 people per 100,000 (23.4% increase) from 2019 – 2020. State-level age-adjusted mortality rates for the condition increased in 49 of 50 states, with West Virginia being the lone state where annual rates decreased.

In 2019, highest age-adjusted mortality rate for alcohol-associated liver disease in a state was 95.3 per 100,000, in South Dakota. In 2020, the highest was in Wyoming—at 199.4 per 100,000. In each case, the mortality rate was greatest among the American Indian or Alaska Native populations.

Investigators additionally observed 68.5 deaths per 100,000 American Indian or Alaska Native people due to alcohol-associated liver disease in 2020; comparatively, just 11.7 deaths per 100,000 White people were observed—a 5.85-fold difference. Despite representing only 3.2% of the US population in 2020, American Indian or Alaska Native populations constituted 9.6% of all alcohol-associated liver disease deaths.

Chhatwal and colleagues noted that, though alcohol consumption is less likely among this adversely-affected population, they are observed to be more likely to drink excessively—a key component of alcohol-associated liver disease risk.

“However excessive drinking is not the only factor associated with ALD mortality,” they wrote. “Systemic failures, such as insufficient preventive care and underfunded resources, also contribute to high mortality for American Indian or Alaska Native individuals.”

Though the trial was limited by the heterogeneity of populations including American Indian or Alaska Native persons in the US, as well as risk of racial misclassification of people on death certificates, investigators concluded alcohol-associated liver disease represents “a significant burden on the US health care system” that may only worsen.

“American Indian or Alaska Native individuals are particularly vulnerable to alcohol-associated liver disease; thus, policy actions must be taken, including wide implementation of universal alcohol screening and provision of federal and state resources for alcohol-associated liver disease through the Indian Health Services and Urban Indian Organizations in both tribal and urban areas,” they wrote. “Such actions could help mitigate the growing alcohol-associated liver disease burden.”


Kulkarni NS, Wadhwa DK, Kanwal F, Chhatwal J. Alcohol-Associated Liver Disease Mortality Rates by Race Before and During the COVID-19 Pandemic in the US. JAMA Health Forum. 2023;4(4):e230527. doi:10.1001/jamahealthforum.2023.0527

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