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dcyphr | Deaths from Covid-19: Who are the forgotten victims?

Abstract:

This paper examined current population-based mortality rates, compared them with the expected rate of mortality based on data for the past 3 years, and compared any excess in deaths with the number of deaths attributed to COVID-19. 

Data came from government sources in England, Wales, the Netherlands, Scotland, and New York State. 

We found there was an increase in observed, compared with expected, mortality in Scotland (+27%), England and Wales (+35%), the Netherlands (+60%) and New York state (+26%). Of these deaths, only 43% in Scotland and England and Wales, 49% in the Netherlands and 30% in New York state were attributed to COVID-19 leaving a number of excess deaths not attributed to COVID-19. These excess deaths may be due to non-COVID-19 causes, or may be undiagnosed COVID-19. 

Introduction:

The huge influx of COVID-19 patients has led to hospitals cancelling elective in-patient procedures and outpatient activity. Even non COVID-19 emergency department activity has declined. As a result, there is concern that deaths from non-COVID-19 causes could increase, due to reduced routine care. To assess whether or not this is the case, we examined recent observed population-based mortality rates, compared with expected rates, and compared any excess in deaths with the number of deaths attributed to Covid-19. We have analysed these data for 4 countries which have provided such data on a routine basis for at least 5 years. 

Methods:

The number of excess deaths was defined as the difference between the observed number of deaths and the number of deaths expected according to the observed number from 2015-2019. The number of deaths related to Covid-19 was then deducted from the excess deaths to calculate the number of non-Covid-19 defined excess deaths. All the data was drawn from Scotland, England & Wales, the Netherlands, and New York State, USA. As this analysis utilized publicly available national statistics, no ethical approval was required. 

Results:

Scotland: There were 604 excess deaths in Scotland in the period 23 March to 5 April 2020 compared to the same period in 2015-2019 (an increase of 27%). Of these excess deaths only 344 (57%) were recorded as related to Covid-19. 

England and Wales: In England and Wales there were 7093 excess deaths in the period 21 March to 3 Apri 2020, a 35% increase from the prior 5-year average. Of these excess deaths, 4014 (57%)were Covid-19-related.

The Netherlands: the number of deaths increased from an expected 5953 (based on the prior 5-year average) to 9523 (60% increase) over the period 23 March to 5 April 2020. Of the 3,570 excess deaths, 1814 (51%) were related to Covid-19.

In the New York state the number of deaths increased from an expected 34835 (based on the prior average from 2015-2018)to 43962 (26% increase) over the period 26 January to 11 April 2020. Of the 9127 excess deaths, 6402 (70%) were related to Covid-19. 


Discussion:

The increase in mortality is not wholly explained by deaths attributed to Covid-19. Indeed, only between 51 and 60% of the excess in deaths can be explained by official Covid-19 reports. The two most likely explanations for the discrepancy between the overall excess of deaths and the extra deaths explained by Covid-19 are either there are additional deaths caused (or contributed to) by Covid-19, but not recognized as such,or that there is an increase in deaths from non-Covid-19 causes, potentially resulting from diminished routine diagnosis and treatment of other conditions. We believe that both are likely. There are also anecdotal reports of people choosing to stay home and not go to a hospital to be diagnosed for fear of dying alone without their loved ones, which could contribute to this discrepancy. 

Clearly it will take time to fully explain the trends we have described and, especially, to quantify the exact causes of the excess of non-Covid-19 deaths. Even then it may be difficult to accurately determine whether Covid-19 caused or contributed to death. In patients requiring mechanical ventilation for Covid-19 induced respiratory failure it may be appropriate to attribute cause of death to Covid-19 but other patients may have the cause attributed to Covid-19 while dying from worsening heart failure or unidentified pulmonary thromboembolism. If it is correct that the Covid-19 pandemic has had a detrimental effect on medical care more generally, other “downstream” consequences are likely.

Our analysis has several limitations. We relied on publicly available data that are collected and collated in a fast-moving pandemic and may be subject to revision. The coding and therefore definition of a Covid-19 related death may be influenced by local regulations and guidelines on certifying the cause of death in each country. In addition, a lack of testing in each country may mean that patients were dying from Covid-19 but were not coded as such. 

Final Summary:

In summary, a substantial proportion of excess deaths observed during the current COVID-19 pandemic are not attributed to COVID-19. This may indicate an increase in non-COVID-19 deaths due to changes in routine health care delivery during this pandemic. People should be reminded that it is still appropriate to seek medical attention for other serious life-threatening illnesses during this period.