1 December 2020
Death from Covid-19 is estimated to be around 40% more likely in men compared to women but despite this, the total mortality impact of the pandemic so far, measured by excess deaths, has been much more evenly split.
Public Health England data for the year up to 6th November find around 45% of excess deaths, deaths above the five year average, to have been in women. These seemingly higher rates of non-COVID-19 excess deaths in women have important implications, both for how the population was affected by the first wave and looking to mortality over the winter and beyond.
While differences in certifying death from Covid-19 early in the pandemic, such as many requiring a positive Covid-19 test for example, may have impacted the sex differences, certifying procedures have become much more standardised since. In the year to date, deaths with Covid-19 on the death certificate are higher in men in almost every age group, 11,400 in men vs 7,800 in women in the 75-84 year old bracket for example. In the over 85s however, the reverse is true, with 15% more deaths involving Covid-19 in women (13,200) compared to men (11,300). On average, women in England have 3.6 years longer life expectancy, but this alone does not explain the seemingly larger indirect impact of the pandemic on women.
Indirect mortality impacts of COVID-19
In the first 10 weeks of the pandemic, health systems had to focus on Covid-19 to the detriment of other acute and non-urgent care. Many have been concerned about the indirect impacts of the pandemic on mortality and fear these impacts may outlast the pandemic itself. The healthcare system had to change its behaviour; alongside the short term impacts on chronic disease care, pressures on an already stretched service has seen wait times increase and 300,000 fewer people seeing a cancer specialist from April to September this year compared to prior years. The behaviours of people have changed too; care home residents have been unable to physically see and interact with families for long periods and there are fears that health seeking behaviour has changed with individuals fearful of catching Covid-19 in healthcare settings whilst also wanting to ‘protect the NHS.’ There are also mixed findings on behavioural risk factors with some groups seeing less smoking, alcohol and sedentary behaviour, while others have seen this increase. The full impact of all this will become apparent in the coming months and years and the extent will depend on how much these new behaviours of the health system and individuals) become engrained.
Rising mortality in the community
Data from the Office for National Statistics has identified a worrying trend. Since the first wave of the pandemic we have continued to see excess deaths in the community (such as private homes) throughout the summer and autumn. In fact, during this time there were more non-Covid-19 excess deaths in the community than deaths from Covid-19 in all settings combined. Up to September there were 25,000 (31%) excess deaths in the community. Many of the leading cause of excess deaths in the community are from conditions that have greater chance of survival from if treatment is timely and in the most appropriate setting.
Over the past decade we have seen a divergence in the leading killer in men and women. While heart disease remains the leading killer in men, dementia is now the leading killer in women. People with heart disease have a greater reliance on hospital care, while those suffering from Dementia and Alzheimer’s will receive more care in the community. The difference in excess death figures between these two conditions speaks volumes about the disparity of the impact on care pathways during the pandemic. In 2020 to date, there were similar increases in men and women, but this was not the case in care homes. While there were just above 300 excess deaths (7.9% increase) in men in care homes, the figure was more than 16 times this in women – 5,000 excess deaths representing an increase of 27%.
When community care is stretched, women lose out
The displacement of a portion of deaths from hospital to the community has had very different impacts on overall mortality in 2020 so far. In men, there has been a modest 2.3% increase in deaths due to Ischaemic heart disease across all settings comprising a 26% increase in the community, largely offset by a 22% decrease in hospital deaths. Women have experienced a much larger 22% increase in deaths due to Dementia and Alzheimer’s comprising substantial increases of 75% and 32% in the community and care homes respectively, partially offset by a 40% reduction in hospital deaths. Lung cancer deaths, the leading cause of cancer death in the community, are 29% and 40% up in men and women respectively in the community this year suggestive of substantial impacts on chronic disease care pathways of the pandemic, felt as hard in women.
Weekly ONS death data suggests that community excess deaths have continued over recent weeks and at a largely equal rate among men and women.
As we look to the winter, when we can expect health and social care resources to be stretched further than ever before, politicians and health leaders are desperate to mitigate the indirect impacts of the pandemic worsening. If they fail, it is likely to be felt hardest by women.