This week saw the UK pass the tragic milestone of more than 100,000 deaths from covid-19, becoming the first country in Europe to do so. Throughout the pandemic there have been several different measures of deaths published regularly and used across the media. The daily update on the UK Government covid-19 dashboard represented deaths within 28 days of a positive test; the weekly update from the Office for National Statistics (ONS) and other national statistical bodies reports the number of deaths with covid-19 on the death certificate; and these same statistical bodies estimate excess deaths through the weekly death statistics.
Excess deaths from all-causes are seen as the most comprehensive measure to assess the full extent of the pandemic and to inform ongoing strategy. The mortality impacts of covid-19 can be broadly grouped into three; direct effects of the virus, indirect impacts of our response to tackle the virus, and the wider economic effects;
- direct effects—individuals contracting the virus and dying from the disease;
- indirect effects of either/both the health system pivoting to focus on covid-19 alongside individual behaviour change whereby one may alter health seeking behaviour and not seek medical attention for symptoms such as chest pain as early as they might ordinarily do so impacting chronic disease mortality rates;
- the wider social and economic conditions resulting from the pandemic are likely to have substantial impacts which will be felt unequally across communities and the nation over a longer time period—a similar rise in unemployment to that seen after the 2008 recession would be expected to lead to 900,000 more working age people with chronic medical conditions.
The ONS reports excess deaths on a weekly basis, using the past five-years of data to compare observed deaths in any given week. Our group at the School of Public Health, Imperial College London, used an ensemble of statistical models and historical mortality data by age group and sex while accounting for seasonality, ambient temperature, and where bank holidays fall to compare excess deaths from the first wave across 21 industrialised countries. We found that England and Wales, at nearly 60,000 excess deaths, had the highest excess death toll in Europe in men (second highest in women) with 37% more deaths than would have been expected during that period. We have already seen many more consecutive weeks of excess deaths in the second wave albeit generally at lower weekly levels of excess deaths compared to the first wave. By 31 December estimates suggested there were around 608,000 deaths in England & Wales in 2020, 77,000 above the 5-year average.
This week’s mortality data from the ONS, covering deaths in the week ending 15th January (week 2), reports 18,042 deaths across England and Wales. This was the 4th highest number of weekly deaths since the pandemic began with more than 7,000, around 40% of all deaths, mentioning covid-19 on the death certificate. This was 4,220 (excess) deaths above the 5-year average representing around 31% more deaths than would’ve been expected in this week ordinarily. The substantial rise in covid-19 infections at the end of 2020 had large regional variations with London and the South-East seeing the largest increases earliest. This is reflected in the differences in excess deaths in this week’s report too. London saw 84% more deaths than would have been expected, compared to just 2.5% in Yorkshire.
Deaths from covid-19 this week (approximately 7,000) were, as we have seen during most weeks in the second wave, far larger than the number of excess deaths (4,220). Aggregated together therefore, deaths not involving covid-19 are below the 5-year average, but that masks a complex picture. Public Health England (PHE) data sheds light on cause-specific trends. Perhaps unsurprisingly, deaths from other respiratory diseases such as (non covid-19) acute respiratory infections and chronic lower respiratory infections are 3,800 (19%) and 4,000 (17%) lower than the 5-year average since the pandemic began. In contrast however, we have seen excess deaths across cardiovascular diseases with approximately, 2,500 (6%), 1,400 (5%), and 1,900 (7%) more deaths in ischaemic heart disease, stroke, and other circulatory diseases respectively than the 5-year average. The largest relative increase in deaths has been seen in cirrhosis and other liver disease with 11% more deaths (700) since the pandemic began. These excess deaths among chronic diseases speak to the indirect mortality impacts of the pandemic that health systems will fear could continue for some time to come.
Finally, there is one trend that has often gone underreported despite persisting from the first wave, during the summer and continuing today. Each week, the ONS have reported approximately 1,000 more people dying in private homes than the 5-year average, now estimated (by PHE) at more than 34,000 excess deaths since the pandemic began. At 35% more deaths than would be expected, this is a far larger relative increase in deaths than seen in hospitals (13%) while deaths in hospices have declined 19% over this same period. Analysis by the ONS up to September found a “redistribution of deaths” away from the hospital into private homes for many leading (non-covid-19) causes including IHD, dementia, and common cancers. Such trends threaten to stall or even reverse the improvements in chronic disease mortality we have seen over past decades if they persist.
In the coming weeks there will unfortunately be many more lives lost to covid-19. The total mortality and morbidity impacts of the pandemic across populations however, are likely to to be seen for years to come.
Jonathan Pearson-Stuttard, Wellcome Trust Clinical Research Fellow, School of Public Health Imperial College London
Competing interests: JP-S is also vice-chair of the Royal Society for Public Health, Head of Health Analytics at Lane Clark & Peacock LLP and reports personal fees from Novo Nordisk A/S outside of this work.