New publications on COVID, including data on excess deaths, a clinical update on long COVID, and recent developments in prevention through clean air measures, including ventilation, are reported below.
Alison Barrett writes:
COVID-19 appears to have been the ninth leading cause of death in Australia in 2023, causing 4,600 deaths last year – a significant decline from the 10,300 COVID deaths in 2022 when it was the third leading cause of death.
The 4,600 deaths were from COVID-19 and contributed to more than half (55 percent) of the excess deaths in 2023, according to a report by the Actuaries Institute Mortality Working Group.
The group’s report, ‘How COVID-19 has affected mortality in 2020 to 2023‘, estimates that 8,400 more deaths occurred in 2023 than would have been expected if the pandemic had not occurred.
Of the remaining excess deaths, the Working Group estimate that 1,500 (18 percent) were related to COVID-19, in that COVID-19 contributed to the death but wasn’t the sole cause, and 2,300 (27 percent) had no mention of COVID-19 on the death certificate.
The Working Group also reported this week that excess deaths in Australia more than halved in 2023 to five percent (95%CI 3-7%), down from 11 percent in 2022.
Karen Cutter, spokesperson for the Actuaries’ Working Group said in a statement that “while Australia’s excess mortality rate had dropped substantially, it remains significantly higher than the one to two percent excess observed in years of high flu deaths prior to the pandemic”.
“We think that COVID-19 is likely to cause some excess mortality for several years to come, either as a direct cause of death or a contributing factor to other causes such as heart disease,” she said.
Long COVID
However, the report does not take account of the impact of long COVID on excess mortality outcomes.
The most recent ‘COVID-19 Mortality’ data by the Australian Bureau of Statistics does not report on post-COVID or long COVID deaths. However, in data including deaths registered from the beginning of the pandemic until 31 July 2023, 196 deaths were due to long term effects of COVID-19 (for example, post COVID-19 condition, long COVID-19).
Meanwhile, Professor Trisha Greenhalgh, Nuffield Department of Primary Care Health Sciences in Oxford UK, and colleagues have published a new clinical update on long COVID in The Lancet, with a lay summary here.
Manifestations of long COVID are heterogeneous, multisystemic (the condition can affect any and all organ systems), and can change over time, they report.
The article outlines treatment and service approaches and stresses the importance of prevention.
“Long COVID currently has no definitive cure, so prevention is of the utmost importance. The best way to prevent long COVID is to prevent COVID-19 through well established public health measures such as paying attention to indoor air quality (eg, ventilation or filtration); wearing well fitting, high-filtration masks or respirators when appropriate; and supporting infectious individuals to quarantine. People with acute COVID-19 should ensure they rest.
“Vaccination is also crucial. Given that reinfection is emerging as a substantial contributor to persistent long COVID, ensuring that health-care settings, especially long COVID clinics, are COVID-safe (eg, enforcing mask requirements among clinic staff, air quality measures, and testing protocols) is important.”
The article stresses the importance of further research into the multiple interacting biological mechanisms in the pathogenesis of long COVID to inform clinical mananagement and “combat what has been described as the ‘mass disabling event’ of long COVID”.
Excess deaths
The Actuaries Institute Mortality Working Group reports that the majority of excess deaths in 2023 occurred in people 65 years or older. Females experienced higher excess deaths than males in all age groups except the 65–74-year-old group.
The report shows that in 2023, Tasmania experienced the highest proportion of excess mortality (11 percent excess mortality rate), the next highest was in Victoria (seven percent).
The Working Group also analysed excess mortality of 40 countries from 2020 to 2023.
“Despite high excess mortality in 2022 and 2023, Australian excess mortality over the four years (five percent) is among the lowest of the [40] countries included,” they write.
The weighted average excess mortality of the 40 countries over the four-year period was 11 percent.
In comparisons of note, the United States experienced 10 percent excess mortality, Canada six percent, Aotearoa/New Zealand 0.4 percent and the United Kingdom 9.6 percent.
Mexico (20.8 percent) and Ecuador (27 percent) experienced the highest excess mortality over the four years – excess mortality was very high in Latin America with an average of 18 percent for the region.
“The international comparisons also revealed that overall excess mortality across the period was largely driven by experience in the first two years of the pandemic,” the Working Group said. “Countries that suffered high loss of life in the first two years generally had worse outcomes over the whole four years.”
However, they urge caution in making comparisons between countries due to varying data collection, reporting and calculation methods.
The Working Group point out that while it is difficult to ascertain conclusively, available evidence indicates that COVID-19 vaccines are “highly unlikely” to be a cause of excess mortality.
Of the 27,200 estimated excess deaths across 2020-2023, approximately 17,000 have been identified as deaths from COVID-19, whereas fewer than 20 deaths have been identified as caused by COVID-19 vaccination in Australia in the same timeframe.
In the latest COVID-19 vaccine safety report by the Therapeutic Goods Administration – noting this was in November 2023 – 14 deaths have been linked to COVID-19 vaccination the beginning of the vaccine rollout. The TGA said “there have been no new vaccine-related deaths identified since 2022”. Almost 69 million doses of COVID-19 vaccines had been given in Australia up until November 2023.
The Working Group suggest the most likely causes for non-COVID-19 related excess deaths include, but are not limited to, delays accessing routine and emergency healthcare, resulting in missed opportunities to diagnose or treat non-COVID-19 diseases; or the impact of COVID-19 on mortality risk for heart disease, stroke, diabetes and dementia.
The impact of other potential causes for excess mortality in 2020-2023, including undiagnosed COVID-19, mental health or alcohol-induced and road deaths, is not yet understood.
Understanding the likely causes, whether direct or indirectly related to COVID-19, of non-COVID-19 excess mortality is crucial, the Working Group say.
It is also important to understand variations in excess mortality between populations and reasons why some may be disproportionately impacted.
The Australian Bureau of Statistics mortality data, on which the Mortality Working Group base their calculations, is broken down by cause of death (doctor-certified and coroner-referred), age and gender, and state/territory.
A recent report by Croakey on the Senate Inquiry into Excess Mortality highlighted the need to improve data collection and publication on excess mortality among Aboriginal and Torres Strait Islander people and rural and remote populations.
The Australian Bureau of Statistics said in its submission to the inquiry that as we move further away from the beginning of the pandemic, new ways of considering excess deaths are required.
For example, estimates of expected mortality will need to include COVID-19 in the baseline when calculating excess mortality, according to the ABS.
Read the full report, including a detailed explanation of the approach taken to measure excess deaths (pages 14-16), here.
Clean air
Below are links to recent developments and news on clean air and ventilation, from Victoria to global perspectives.
Science: Lessons from the COVID-19 pandemic for ventilation and indoor air quality
It’s worth reading the article in full; key points include:
- As the SARS-CoV-2 virus spread rapidly around the world, experts called for recognition of airborne transmission as the predominant mode of infection transmission and for relevant measures to be adopted to control it.
- However, it took far too long for airborne transmission of the SARS-CoV-2 virus to be accepted. At the beginning of the pandemic, many public health authorities rejected existing knowledge and reverted to old hygienic dogmas, which led to misguided control measures aimed at cleaning surfaces instead of ventilation, filtration, face-masking, and deactivation of airborne virus.
- This highlights the need for multidisciplinary knowledge and expertise to contribute to public health decision-making.
- With frequent outbreaks in elder care facilities and school classrooms, it was a fatal mistake to largely neglect the recommendations of scientists and engineers regarding minimum standards for ventilation and indoor air quality.
- The article also highlights the importance of mechanical ventilation, stating: We cannot rely solely on natural ventilation in buildings that are not designed to provide sufficient and effective air supply under all meteorological conditions.
- Regulation of indoor air quality performance standards is recommended, including ventilation and monitoring of indoor air pollution as part of compliance with the standards.
- It is becoming evident that scientific and technological bases for mandating indoor air quality exist and that the main barriers are political and differ from country to country.
ABC: Victoria’s new ‘clean air’ project could help end the COVID pandemic and boost productivity
Burnet Institute: Transformative $9.87m project to improve indoor air quality in Victoria
Dr Jerome Adams, commenting below, is a former United States Surgeon General.
See Croakey’s archive of articles on COVID-19.
