Perspective

Observations on COVID-19 impact to mid-term mortality [Infographic]

March 10, 2022| By Eva Odenkirchen and Nicolas Zimmer | Life | English

COVID-19 has now been with us for two years. It has hit the global life insurance industry hard. Although we can’t predict the ultimate course of pandemic, we expect the virus to impact global mortality in the near future. In the accompanying infographic, we compile observations and propose a framework to consider the most likely impact on medium-term mortality at the end of an "acute" pandemic phase.

There are reasons for optimism and pessimism around COVID-19’s direct and indirect effects on near- and mid-term mortality. Mounting evidence exists for deteriorated health status (missed screenings and medical interventions), which would suggest mortality deterioration. An endemic COVID-19 may continue to generate excess deaths particularly in unvaccinated. Previous pandemics offer scant evidence but suggest glimmers of enhanced mortality improvements – reasons for those improvements may be due to improved hygiene/health maintenance and some element of survival of the fittest. However, the causes of death as well as medicine were different then. Both Long COVID and mental health deterioration during the pandemic may be relevant themes for disability blocks but we do not find evidence to suggest mortality deterioration globally.

Below you can find a wealth of information on the impact of COVID-19 on mid-term mortality, concisely summarised in an infographic. Also, don't miss to take a look at our extensive literature review, which contains links to many interesting articles and publications. If you have any questions about the research, please do not hesitate to contact us.

 

A huge thank you also goes to Beata Puls, Sarah Hogekamp and Dr. David Zimmermann-Kollenda for their contribution to this project.

For further reflection:

All of the following web sources were last accessed on 3 March 2022.

Endemic excess

Continued effects to mortality from COVID-19 itself are likely to remain, though as the pandemic transforms to endemic may well take the shape of initial continued shocks as witnessed in the post-Spanish flu 1920s, for instance.  It is also possible that endemic COVID-19 will bring yet more virulent strains to a public with their guard down. However, Omicron has been less severe than the prior dominant strains, and there is a plausible scenario of the fatality rate (IFR) decreasing due to mutations, background exposure and sustained vaccine efficacy, with it eventually fading into the background of uncertainty. We explore scenario-based calibrations of regional seasonal excess mortality: COVID-19 may also take a more seasonal form, similar to flu in temperate climates, with seasonal mortality more pronounced (see endnote 2).

An excellent overview of virus history:
https://journals.sagepub.com/doi/full/10.1177/0169796X211047221
https://www.ijidonline.com/article/S1201-9712(20)30511-7/pdf

1 Plot created by Gen Re. Data sources:


2 We derive seasonal mortality by comparing all-cause mortality in a given winter season against all-cause mortality in the preceding autumn and subsequent spring season and create an index ("Seasonal Mortality Index") across countries. https://www.genre.com/knowledge/publications/ri21-6-en.html

3 Plot created by Gen Re. Data source: https://github.com/dkobak/excess-mortality

4 Plot created by Gen Re. Data source: https://github.com/TheEconomist/covid-19-the-economist-global-excess-deaths-model

Delayed treatment

A plethora of evidence suggests health maintenance extends life expectancy. Conversely, delayed treatment may not only affect near-term mortality (e.g., from a missed cancer screening) but perhaps cause sustained compromised health status (e.g., delayed treatment initiation and improper handling of chronic conditions leading to irreversible complications). The disruptions from the COVID-19 pandemic may result from either actual missed treatments due to either reduced access to hospitals or fear of care settings, or from reduced contact with medical professionals and more sustained loss of habit in getting check-ups, etc. In theory, the more progressive the disease, the more impact a missed appointment may have. Our biggest concern is that a change in diagnosis and treatment initiation of several common diseases has a negative impact on the long-term prognosis, resulting in increased medical costs and mortality.

5 Plot created by Gen Re. Data source: https://data.worldbank.org/indicator/SH.MED.BEDS.ZS, © 1970-2017 by World Health Organization, supplemented by country data. Data is made available under a Creative Commons Attribution 4.0 International License.

6 National Vital Statistics Reports, Volume 70, Number 8

7 Carnall Farrar, "Disruption and Recovery of CVD from COVID-19", https://www.carnallfarrar.com/media/1664/210308-recovering-cvd-from-covid.pdf

8 de Mestral, Charles, et al. "A Population-Based Analysis of Diabetes-Related Care Measures, Foot Complications, and Amputation During the COVID-19 Pandemic in Ontario, Canada." JAMA network open 5.1 (2022): e2142354-e2142354

9 Currie, Craig J., et al. "The impact of treatment noncompliance on mortality in people with type 2 diabetes." Diabetes care 35.6 (2012): 1279-1284

10 Source: https://www.aerzteblatt.de/treffer?mode=s&wo=1041&typ=1&nid=130989&s=alkohol

11 Mafi JN, Craff M, Vangala S, et al. "Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic", 2019-2021. JAMA. 2022;327(3):237–247. https://jamanetwork.com/journals/jama/fullarticle/2788140

12 J. Klauber et al. (Hrsg.), Krankenhaus-Report 2021, https://doi.org/10.1007/978-3-662-62708-2_16

13 Chao Liu, Jiaxing You, Weifen Zhu, Yixin Chen, Shengyun Li, Yuefeng Zhu, Shujuan Ji, Ying Wang, Hongye Li, Lin Li, Shunwu Fan; "The COVID-19 Outbreak Negatively Affects the Delivery of Care for Patients With Diabetic Foot Ulcers". Diabetes Care 1 October 2020; 43 (10): e125–e126. https://doi.org/10.2337/dc20-1581

14 Campo G., Fortuna D., Berti E., De Palma R., Pasquale G.D., Galvani M., Navazio A., (...), AMI-Co investigators; "In- and out-of-hospital mortality for myocardial infarction during the first wave of the COVID-19 pandemic in Emilia-Romagna, Italy: A population-based observational study "; (2021) The Lancet Regional Health - Europe,  3 , art. no. 100055; doi: https://doi.org/10.1016/j.lanepe.2021.100055

15 Plot created by Gen Re. Data source: Global Health Estimates 2019: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2019. Geneva, World Health Organization; 2020

16 Plot created by Gen Re. Data source: National Disease Registration Service (Part of NHS Digital), https://www.cancerdata.nhs.uk/covid-19/rcrd

17 Hanna T P, King W D, Thibodeau S, Jalink M, Paulin G A, Harvey-Jones E et al. "Mortality due to cancer treatment delay: systematic review and meta-analysis" BMJ 2020; 371 :m4087 doi: https://doi.org/10.1136/bmj.m4087

COVID-19 may have accelerated deaths that were imminent, which means that we have not been observing only excess deaths. At the same time, deaths where COVID-19 was mentioned on the death certificate may have a natural cause like heart or lung disease. These were accompanied by a COVID-19 infection but not caused by COVID-19.  We estimate the portion of deaths from COVID-19 that would have transpired without the pandemic over the next few years by looking at prevalence rates and excess mortality of dominant co-morbidities.

18 Stephanie L. Harrison, Elnara Fazio-Eynullayeva, Deirdre A. Lane, Paula Underhill, Gregory Y. H. Lip; Comorbidities associated with mortality in 31,461 adults with COVID-19 in the United States: A federated electronic medical record analysis, Published: September 10, 2020, https://doi.org/10.1371/journal.pmed.1003321

Healthier behaviors, medical progress

Observations of mortality levels pre- and post-Spanish flu may point to a slight remaining excess in the winter in the few years thereafter, and favourable mortality in the non-winter months. Better hygiene, continued mask wearing and germaphobia are cited as lasting and being indoctrinated19 after pandemics including in the 1920s, perhaps dampening post-pandemic disease outbreak. Online doctors, more effective triaging, new antiviral treatments, the rapid advancement in mRNA technologies offer hope not just for infection diseases20 but importantly cancer21, and for better vaccine guideline adherence for other immunizations/vaccines.

19 https://www.bloomberg.com/news/features/2020-05-26/how-our-behavior-will-change-after-the-pandemic

20 https://www.economist.com/the-world-ahead/2021/11/08/what-to-expect-in-year-three-of-the-pandemic

21 https://www.aamc.org/news-insights/mrna-technology-promises-revolutionize-future-vaccines-and-treatments-cancer-infectious-diseases

Long COVID is real, but mid- and long-term impacts of COVID-19 infection remain to be seen. There are many studies that have assessed at least a near-term impact on the changes in health status.

Nice and understandable summary on potential causes of Long COVID: https://www.sciencedirect.com/science/article/pii/S1871402121001193

Multicountry systematic review of studies reporting Long COVID symptoms: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2784918

Detailed UK study about perceived symptoms and clinical changes in health after COVID-19 hospitalization: https://www.sciencedirect.com/science/article/pii/S2213260021003830

Recently published analysis on mortality after hospital discharge for COVID-19 vs. matched general population controls and influenza controls: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003871

Even though mental health deterioration is palpable and can also lead to deteriorated physical health, poor nutrition, substance abuse and lifestyle factors, generally we are optimistic that the pandemic's effects on mental health are circumstantial, and furthermore that the stress imposed is not a significant driver of mortality deterioration.

22 Taylor S, Paluszek MM, Rachor GS, McKay D, Asmundson GJG "Substance use and abuse, COVID-19-related distress, and disregard for social distancing: A network analysis"; Addict Behav. 2021 Mar;114:106754. doi: https://doi.org/10.1016/j.addbeh.2020.106754. Epub 2020 Dec 3. PMID: 33310690; PMCID: PMC8164919

Further Endnotes

23 Economic downturn: https://www.bis.org/publ/bisbull35.pdf

24 Lower traffic fatalities / Flexible working arrangements: https://www.bis.org/publ/bisbull35.pdf

25 Technology /medicine spurt: https://www.aamc.org/news-insights/mrna-technology-promises-revolutionize-future-vaccines-and-treatments-cancer-infectious-diseases

26 "What if"-Scenario 4: https://www.darwintreeoflife.org/

 

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