Variability in US COVID Mortality, Viral Evolution, and the Emergence of Acquired Social Immune Dysfunction

Background. The course of a pandemic depends on viral traits, available public health interventions, implementation, and individual behavior, all of which interact and vary over time and space. Understanding COVID-19 therefore requires considering these factors together. Methods. National mortality, state-level mortality per 100,000 population for four representative states, policy stringency, and vaccination coverage were assembled from publicly available sources for February 2020 through September 2022. Viral traits, mutation rates, and vaccine effectiveness were drawn from published systematic reviews and standardized relative to wild-type values. Results. Each state experienced a differe