Intended for healthcare professionals

Letters Covid-19: excess all cause mortality

Covid-19: excess all cause mortality in domiciliary care

BMJ 2020; 370 doi: (Published 13 July 2020) Cite this as: BMJ 2020;370:m2751
  1. Judith R Glynn, professor of infectious disease epidemiology1,
  2. Katherine Fielding, professor in medical statistics and epidemiology1,
  3. Tom Shakespeare, professor of disability research2,
  4. Oona Campbell, professor of epidemiology and reproductive health1
  1. 1Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
  2. 2Department of Clinical Research, London School of Hygiene and Tropical Medicine
  1. judith.glynn{at}

Piccininni and colleagues show the importance of using excess all cause mortality to measure the impact of covid-19.1 This approach has drawn attention to the shocking rates of covid-19 related deaths in care homes. But domiciliary care remains neglected.

In England from 10 April to 8 May, deaths of recipients of domiciliary care were 2.7 times the three year average for that period.2 From 10 April to 1 May (latest available data), deaths of care home residents were 2.8 times or 3.2 times that of the same period in 2019 (using different data sources).2 Subtracting these deaths from those in the total population,3 we estimate that deaths in all non-care home residents in England were 1.7 or 1.8 times the usual for this period.

So the rise in deaths among those receiving domiciliary care is similar to that among care home residents, yet it is scarcely mentioned. The number of people receiving domiciliary care in the UK was nearly 900 000 in 2014-15.4 Recipients of domiciliary care are at higher risk of getting covid-19 because of their age and underlying health problems and because of the way care is provided. Care workers might visit multiple clients daily,4 and clients might receive care from multiple care workers.

The domiciliary care workforce is slightly larger than that for adult residential care.5 A quarter are 55 years or older and 23% are from black, Asian, or minority ethnic (BAME) groups.5 Care workers cannot maintain “social distancing” from the vulnerable clients they are helping, putting themselves at risk. About 9400 agencies provide domiciliary care, and other care workers are contracted individually, making access to personal protective equipment (PPE) or testing challenging. For both men and women in England and Wales, the age adjusted mortality rate of covid-19 in social care workers is twice that of healthcare workers.6

To protect those providing and receiving domiciliary care, the importance of this sector needs to be recognised. Although guidelines for PPE are available,78910 shortages are well documented. PPE supply and regular infection testing are needed to reduce transmission to the most vulnerable people, to the care workers, and to the wider community.


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