Use of all cause mortality to quantify the consequences of covid-19 in Nembro, Lombardy: descriptive studyBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1835 (Published 14 May 2020) Cite this as: BMJ 2020;369:m1835
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COVID-19 and excess all-cause mortality in domiciliary care Re: Use of all cause mortality to quantify the consequences of covid-19 in Nembro, Lombardy: descriptive study
Piccininni et al demonstrate how measuring excess all-cause mortality can give a fuller picture of the impact of COVID-19 than relying on confirmed cases. Excess all-cause mortality has also been important in highlighting the shocking high rates of COVID-19-related deaths in care homes. Belatedly, in the United Kingdom the risks to care-home providers and to residents are being recognised, and help, including PPE (personal protective equipment), is becoming more widely available. But there is another large group - those receiving care in their own homes (domiciliary care or personal assistance) - that remains neglected.
Again using all-cause mortality, the Office for National Statistics (ONS) released figures collected by the Care Quality Commission (CQC) for England showing that during the period 10th April – 8th May, recipients of domiciliary care had 2.7-times more deaths than the average for the same period for the previous 3 years.
The report also gives all-cause mortality data for care home residents up to 1st May. For England, for the period from 10th April to 1st May, care-home residents had 2.8-times more deaths than in the same period in 2019 (using ONS data), or 3.2 times more deaths (using CQC data). Subtracting these deaths from those in the total population in England, we estimate that all non-care-home residents in England had 1.8-times more deaths (using ONS data) or 1.7-times more deaths (using CQC data) than usual for this period.
So the increase in the death toll among those receiving domiciliary care is much higher than the general population, and similar to that in care-home residents, yet this group is scarcely mentioned. Since those receiving domiciliary care are likely, on average, to be younger and fitter than those in care homes, these high rates are particularly worrying.
The true number of people receiving domiciliary care is difficult to know. In 2014/15 it was estimated at 874,000 for the UK (of which about one quarter were self-funded). Domiciliary care and personal assistance cover personal care (help with washing, dressing, eating and taking medication), long-term care needs, re-ablement services for leaving hospital, or crisis interventions to avoid hospital attendance. For the most disabled they can mean 24/7 support. Other support can include help with household tasks –‘mopping and shopping’ activities - but these are often paid for privately and not included in the statistics.
Domiciliary care is delivered by a large workforce, with an estimated 685,000 jobs in adult domiciliary care in England in 2018/19 – slightly higher than the number in adult residential care. Around half domiciliary care workers work less than full time, and half are on zero-hours contracts. The majority (84%) are female, a quarter are 55 years or older and 23% come from Black. Asian or minority ethnic (BAME) groups. Pay is low, with a high turnover of staff and many vacancies. About 9400 agencies providing domiciliary care are registered with the CQC. Other carers are paid for privately or contracted individually. This fragmentation makes it challenging to ensure access to PPE or testing.
Recipients of domiciliary care are likely to be at particular risk from COVID-19 because of their age (76% of adults receiving local authority-funded domiciliary care are aged 65 years or over) and underlying health problems, and because of the way care is provided. Those requiring care or assistance cannot self-isolate. Carers may visit multiple clients daily, often making brief visits, and clients may receive care from multiple carers or personal assistants. Carers who move from home to home are at high risk of both acquiring and passing on SARS-CoV-2 unless adequate protection is provided. It is often impossible for carers to maintain “social distancing” from the vulnerable clients they are helping.
The carers are at risk, as well as those receiving care. For both men and women in England and Wales the age-adjusted mortality rate from COVID-19 in social care workers is twice that of health care workers. The data are not presented separately for care home and domiciliary workers.
To protect those providing and receiving domiciliary care, the importance of this sector needs to be recognised. While guidelines for use of PPE are available,[6-9] shortages are well documented, and independent providers and those privately employed may find it particularly difficult to access. Regular testing should be readily available to carers and personal assistants, including those privately employed. This would reduce transmission to the most vulnerable, to those on the front line, and to the wider community.
1. Office for National Statistics. Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 1 May 2020 and registered up to 9 May 2020. (provisional). Updated 15 May 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri.... Accessed 16/5/20
2. Office for National Statistics. Deaths registered weekly in England and Wales, provisional. Release date 12 May 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri.... Accessed 16/5/20
3. Holmes J. UKHCA Summary. An overview of the domiciliary care market in the United Kingdom. https://www.ukhca.co.uk/pdfs/DomiciliaryCareMarketOverview2015.pdf, 2016. Accessed 16/5/20
4. Skills for Care. The state of the adult social care sector and workforce in England. https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workfo.... 2019. Accessed 16/5/20
5. Office for National Statistics. Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 20 April 2020. Release date 11 May 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/.... Accessed 16/5/20
6. Public Health England. Personal protective equipment (PPE) – resource for care workers delivering homecare (domiciliary care) during sustained COVID-19 transmission in England. Updated 30 April 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploa.... Accessed 16/5/20
7. Public Health Wales. PHW Advisory Note - Use of Personal Protective Equipment (PPE) in Social Care Settings (Care Homes and Domiciliary Care). https://phw.nhs.wales/topics/latest-information-on-novel-coronavirus-cov.... Accessed 16/5/20
8. Health Protection Scotland. COVID-19: Guidance for Domiciliary Care. Version 1.0. 4 May 2020 https://hpspubsrepo.blob.core.windows.net/hps-website/nss/3046/documents.... Accessed 16/5/20
9. Department of Health. COVID-19: Guidance for domiciliary care providers in Northern Ireland. Updated 12 May 2020. https://www.health-ni.gov.uk/sites/default/files/publications/health/COV.... Accessed 16/5/20
Competing interests: No competing interests
Re: Use of all cause mortality to quantify the consequences of covid-19 in Nembro, Lombardy: descriptive study
Shyan Goh has already addressed several important limitations of this report. I would add the following:
How did the authors select Nembro? How can they contradict concerns that they selected Nembro just because of an extremely high number of deaths?
The authors say nothing about whether or not a home for the aged or a nursing home exists in Nembro. Could it be that such an institution was newly built?
In this respect, it is also noteworthy to get information how home nursing of the aged was organised at Nembro. Could it be that a considerably number of the old-aged were in home nursing? Can the authors exclude that the geriatric nurses went away fearing an infection or were hindered by the lockdown to go to these homes? Resulting in death by thirst?
Competing interests: No competing interests
I thank Piccininni et al for their interesting descriptive study involving mortality rates in the town of Nembro, Lombardy, in northern Italy.
They attempt to quantify the impact of COVID-19 on all cause mortality due to concerns about underreporting COVID-19 related deaths due to the extent of the catastrophic human crisis of this infectious disease upon the accuracy of the recording and diagnosis of the cause of deaths during the pandemic period.
They concluded that the all cause mortality in a given region and time frame should be considered in addition to official confirmed COVID-19 related death data, for the full implications of this pandemic to be completely understood.
I would consider the following possible confounders that can affect the accuracy of the reported COVID-19 related death rates:
Misclassification of death due to lack of COVID-19 testing, testing errors or recording error. This is partially addressed by the authors
Delay or lack of healthcare services due to restriction in movement, time or services to provide acceptable standard of care to patients with serious medical conditions who would normally have survived if there is no pandemic. This is also discussed by the authors
As a result the authors expected the all cause mortality to capture those deaths not reported as COVID-19 related but which possibly were, or the situation of the pandemic was contributing to the death in an indirect way.
However I would suggest a few other confounders which may affect all cause mortality rates during the pandemic, from anecdotal Australian experience.
Workplace-related or industrial accident resulting in deaths may be increased or decreased. With increased distraction and reduced workforce, particularly skilled labourers/technicians, adverse incidents may increase as a result and contribute to more deaths. However it is more likely that occupational accidents are reduced as more industrial work is either reduced or totally suspended during movement restrictions or lockdown. Therefore the death rates from workplace accidents are most likely reduced.
Similarly overall road traffic volume are significantly reduced during lockdowns and as a result, traffic accidents involving vehicle driver/passengers as well as pedestrians are reduced. It is expected deaths from traffic accidents would also reduce in proportion, although fatal accidents involving single driver vehicles may not reduce as much (see below on mental health)
Domestic violence may increase during the lockdown period, movement restrictions and home confinement may have increase propensity to escalate to serious physical harm and fatal events.
Movement restrictions may result in social isolation despite the so-called increased connectivity through technology, which is inherently related to inequity and access to stable place of residence. Furthermore the same lockdown result in loss of employment and income, a significant proportion of which may be permanent long after the removal of restrictions. This will contribute to significant mental health distress in a portion of people and can end up with neglect or self harm resulting in death. It is possible that some unexplained single vehicle fatal accidents on quiet roads may be due to suicidal drivers.
Public health measures, particularly cardiovascular and cancer screenings may be disrupted during the immediate crisis and then some time as human resources (and funding) priority are given to more acute health services. As a result, premature deaths normally preventable by screening may increase over the next few years rather than limited to the pandemic period.
Due to these reasons, the descriptive study of Nembro, although of some academic and historical interest, really has limited applicability in 2 major ways.
As the town demographic data revealed, less than 30% of the population is under 30 years old (the proportion of which has halved in the last 50 years) with the age group 65+ years representing almost a quarter of the population (and 4 times the proportion 50 years before), at least 5% more than the EU average.
As a result, the social impact affects Nembro (and Italy in general) differently from other nations. An older population may be more reliant on social pension and superannuation income, the latter is especially sensitive to the economic crisis that resulted from the pandemic lockdown as well as the lack of consumer confidence long after. Similarly the workforce the majority under 65 years will be directly affected by employment security and income uncertainties. Both working and retired adults will face mental health concerns arising from the pandemic, although its impact upon the physical health and related mortality rates will take time to uncover over the next 5-10 years.
Similarly the direct impact upon the disruption of public health screening will take at least 5-10 years to become evident as the disparity from those who participated in (and benefited from) these preventive program pre-COVID-19 widens over time.
Thus this descriptive study would have limited immediate applicability outside Italy and the impact of COVID-19 upon all cause mortality would be far more and longer than defined by the study parameters.
Competing interests: No competing interests