Canadian Excess Deaths Report

Tara Moriarty wrote a compelling thread a couple weeks ago. I've never teared up from reading stats before.

For anyone who doesn't know her, Moriarty's an Associate Professor at the University of Toronto, and she and a small team of experts voluntarily create Covid stats each fortnight, posted at Canadian Covid-19 Hazard Index, and she also offers a Covid conversation place every Tuesday and Thursday nights. Below, this is all from Tara's thread. It's long, but I wanted to include it all. She beautifully captures what it feels like to keep looking at it all:

"The percentage excess mortality for Canada from 2020-2022 for SPECIFIC CAUSES OF DEATH is now up on our excess mortality tracker. Thanks to StatCan_eng for the data. I'll do a brief summary thread here. You can view/download the analysis on p. 21 of tracker. We calculate age-specific mortality rates for each cause of death from 2015-2022, then compare each of 2020, 2021 and 2022 to the 2015-2019 mean. Our page reports only on specific causes of death in 2020-2022 greater than the 2015-2019 mean +95%CI. The report also excludes some specific causes of death that account for less than 0.1% of total excess mortality over the 2020-2022 period. We're trying to focus on the biggest sources of excess mortality, although there are significant increases across age groups in deaths from diseases like syphilis and TB where the overall numbers of deaths are quite small (rightfully and thankfully). Finally, we can ONLY meaningfully interpret INCREASES in specific causes of death compared to 2015-2019. Why? Because of 89,248 excess deaths in Canada from 2020-2022, specific causes of death are still not available for 29% of excess deaths. It's more than 36% for 2022, 17% for 2020... Finally, excess mortality for all years is still nudging up, but is still increasing significantly for 2022 with each month of reporting from StatsCan. StatsCan carefully checks annual specific cause of death numbers they release. We have to wait till late 2024 for next issue. 

Over time, the specific causes of death where we see consistent, persistent increases in reported numbers over time are deaths reported as accidental poisonings (drug deaths) and COVID-19 deaths. There's an almost perfect inverse correlation between numbers of deaths with unknown cause and COVID-19 deaths reported to the CVS-D, so we anticipate most increases for the 2020-2022 period will likely be COVID.

Since reporting of toxic drug deaths is particularly slow (due to coroners' investigations in many provinces), it is certain that accidental poisoning death numbers will still increase. However, accidental poisonings account for less than 7% of overall excess mortality in Canada from 2020-2022, and substantially less in 2022, when there were many COVID deaths. So, we anticipate most future changes in numbers will come mainly from reporting of COVID deaths. By the way, for those who don't know, specific cause of death reporting uses ICD-10 codes. Deaths attributed to toxic drugs mainly fall under the Accidental Poisoning code. We also watch for untimely (excess deaths) under other reported codes related to suicide and other accidents. 

We've shared specific cause of death data in four age groups: 0-44 years, 45-64 years, 65-84 years and 85+ years. Why? Because these are the age groups used by StatsCan for all cause excess mortality reporting. And the reason we analyze specific cause of death is to try to understand causes of excess mortality during the twin COVID and toxic drug epidemics era and going forward. We have broken down some age groups like the 0-44 year age group into infants, preschool age, primary and secondary school ages and young adults. Since increases in mortality pre-teens are quite small and reporting is really incomplete, it's still not super robust to interpret. At some point I'll come back to this, but first we need to focus on the ages where the largest total excess deaths are occurring. I will return to younger age groups, I promise...just have to take things step by step. 

In tonight's thread I will focus only on the major trends for the entire Canadian population (ALL AGES) in the report table. There's a lot to unpack in every age group, but this will give you a decent overview. COVID-19 deaths reported to the CVS-D (Canadian Vital Statistics Death database) account for 57% of excess deaths from 2020-2022. This is substantially lower than peer countries like UK and USA (a topic for another day). When StatsCan reports excess mortality and grouped weekly specific cause of death data each month more COVID deaths slowly trickle in, dating back as far as 2020. Since reporting these deaths in a timely fashion is clearly not a provincial priority, and since there is no stick to enforce reporting, we may not know the true COVID death toll of 2020 for another five years. I'm exaggerating, but also have an uneasy feeling that I may be right.

So, from 2020-2022 COVID-19 deaths reported so far to the CVS-D account for 57% of the 89,248 excess deaths during this period. The next major cause of death was "Accidental poisoning and exposure to noxious substances [X40-X49]", accounting for 6.9% of total excess deaths. If you're looking at the table while I type, note that accidental poisoning falls under non-transport accidents, which falls under accidents. I show the parent and sub-group headings, when all are significantly elevated. Google Looker doesn't allow much table formatting BTW...The next major specific cause of excess mortality is "Falls", at 5.2% of total excess from 2020-2022. That's 4,593 untimely deaths attributed to falls during that period. Most in older age groups. This is almost certainly a "symptom" of staffing shortage in residential care, but also failure to recognize that falls are an important symptom of COVID in older people. I'll be coming back to neglect-related causes of death and possible misattribution of COVID deaths a bit later. 

First, though, I wanted to pause for a moment to reflect on the staggering number of excess deaths so far in 2020-2022 attributed to accidental poisoning (toxic drugs). 10,034 untimely (excess deaths) from 2020-2022. Almost everyone younger than 65. A 51% increase in deaths from accidental poisoning for the 2020-2022 period compared to 2015-2019. That's the national average. The numbers are SO much higher in the BC and Prairie provinces. And probably also in Newfoundland and Labrador, based on what we're seeing monthly. Like COVID, the soaring excess mortality attributable to toxic drugs continues relentlessly, while we dither (or ignore) the problems. We are a country that can now countenance 30,000 untimely deaths a year due to drugs and COVID without a flicker in our collective composure. Seeing this, and the existential struggle of harm reduction and street advocates to get the toxic drug supply onto the policy radar, and the endless moralistic debates about how to address the problem by people who don't live it....Seeing this and our professional and social failure to protect the most at-risk from COVID....Seeing both of these, I doubt we can address climate change. Or Truth and Reconciliation and landback. Or the systematic marginalization of racialized and low income people. 

I'll keep describing Canada's specific cause of death data....as I go along, you'll see why I am so angry. Not disheartened or discouraged. Profoundly angry about the deaths behind the numbers. Repulsed by what they say about our "nice" self-congratulatory parochial fucking country. Had to plug in my laptop. Doesn't look like I'll be writing a to-the-point data thread. I am so angry. 

 Did you know that there are 48,000 deaths a year in Canada attributable to smoking? Between COVID and toxic drugs we're now seeing 30,000 excess (untimely) deaths a year (actually, at least 45,000 untimely deaths in 2022, but no one seems to be blinking an eye at that). It looks like 2023 excess deaths may be ~15-20% lower than 2022, if we're lucky, so 36K. Life expectancy in 2022 dropped for the third year in a row. We have wiped out 20-30 years of hard-won research and lifespan gains, depending on the province. Our leaders are behaving like Nero fiddling while Rome burned. 

OK--I was going to keep ranting, but actually, I don't want to anymore. This is a time for constant, relentless activism. We're accepting nearly as many annual deaths as deaths from smoking. On TOP of smoking deaths, actually. Society very slowly changed around smoking, seat belts, water sanitation. We just need to keep working and advocating. And advocating for the value of everyone's lives...the people killed by toxic drugs and COVID and TB (yes, that's increasing significantly). The untimely cutting short of lives of people whose deaths were attributed to falls, malnutrition, complications of medical care. 

I don't know where I'm going with this thread, actually. I feel suddenly so deeply sad, like all of this effort is futile. I know it's not futile. I just whiplashed from anger to grief. I'm nothing if not good at getting up in the morning and trying again--don't worry! I won't crash and burn (and can't, in any case). But, perhaps now that I've digressed badly I'll just finish the thread of the numbers, which is what everyone actually needs and wants.

Here's a summary: Total excess (untimely) deaths in Canada from 2020-2022: 89,248 Number (percent of total excess deaths) attributed to specific causes:  
1) Covid 50,548 (56.6%)
2) Accidental poisoning and exposure to noxious substances 6,194 (6.9%)
3) Falls 4,593 (5.2%)
4) Dementia 2,598 (2.9%). And yes, these figures are age-adjusted. That increase in deaths attributed to dementia is almost entirely from 2,115 excess deaths attributed to dementia 2022. That's not everyone getting dementia--or at least that's unlikely. What's most likely is that this is a reporting issue where the deaths of people dying of Covid or falls or neglect in residential care are attributed to the most common underlying diagnosis in these settings. Dementia, pneumonia, falls, aspiration pneumonia, malnutrition, unidentified infections, kidney infections.Also, by the way, when I talk about malnutrition, we don't have the specific codes for types of malnutrition, but in Canada it's unlikely these deaths were the type of malnutrition seen in famines. It's more likely unexplained weight loss, or failure to gain weight/grow (kids). Back to the list:
5) Chronic liver disease and cirrhosis 2,598 (2.8%). That breaks down into 1,295 attributed to alcoholic liver disease, and 1,217 all other chronic liver diseases. Numbers in categories don't always add up precisely BTW, since each is calculated separately.
6) Kidney diseases (nephritis, nephrotic syndrome and nephrosis) 1,736 (2.0%), the large majority of which were deaths attributed to renal failure (1,652)
7) Heart diseases. I should actually have listed these as #2 after COVID and before poisoning deaths, because among the cardiovascular disease sub-groups there were collectively 5,306 excess deaths (6% total 2020-2022 excess deaths) Not myocarditis, not heart attacks really, or not many, relatively. Deaths attributed to hypertensions, strokes, ischemic (blood flow) diseases, atherosclerosis.
8) Parkinson's disease: 1,276 untimely deaths (1.4% of total excess mortality)
9) Pancreatic cancer: 1,276 (1.4%) 
10) Pneumonitis due to solids and liquids (that's the aspiration pneumonia I was discussing above): 1,033 (1.2%)
11) Unspecified infectious diseases: 864 (1%)
12) Diabetes: 765 (0.8%) I won't continue this list past diabetes, since deaths attributed to other diseases each accounted for fewer than 1% of excess deaths from 2020-2022. I would note, however, that if you look at our table, diabetes is a more substantial, and significant contributor to deaths in younger age groups. There weren't large significant increases in deaths attributed to diabetes among people 65 and older (most excess deaths). 

Finally, since there's still so much outstanding cause of death reporting for 2022, and we're nearly in 2024, we've also been looking at which specific cause of death increased most in 2022 compared to the average for 2020-2021. This may help us better see early warning signals, assuming 2022 trends have continued into 2023, and will continue beyond. Importantly, the numbers I'm about to list reflect changes in the proportion of total deaths attributed to specific causes. These changes can reflect shifts in how certain deaths were reported, or underlying events affecting survival (e.g. COVID infections, healthcare overload). The column to look at for these numbers is on the far right of the table on p.21 of the report. Here are the highlights, for all ages. I'll focus here on trends that we saw in most age groups.

1) The biggest change in 2022 from the average for 20-21 was a 9.6-fold increase in excess deaths attributed to unspecified dementia (not Alzheimer's, not vascular). Overall, there was a 7.5-fold increase in deaths attributed to dementia. That is almost certainly a reporting shift.
2) The next biggest change in 2022 from 20-21 was a 7.9-fold increase in excess deaths attributed to complications of medical and surgical care. A complicated topic, but basically people dying from medical and surgical care who would normally have survived. The absolute numbers are small (101 in 2022 vs avg of 12 for 2020-2021), but this is likely concerning, since it's rare for deaths to be attributed to this cause. This could be hospital overloading/understaffing, hospital COVID outbreaks....we don't know, based on these data. We just know there was a big change in 2022. 

I will take this opportunity to say that there are many, many reasons why it's crucial NOT to avoid healthcare and hospitals because of poor control of Covid in many healthcare settings. You can die avoiding healthcare too. And yes, no one should be in this position.

The next biggest changes in 2022 compared to 20-21 are, in order:
3) Hernia (entirely preventable deaths with timely medical care): 3.7-fold increase
4) Other and unspecified infectious diseases: 2.9-fold increase
5) Other acute ischemic heart diseases: 2.6-fold increase
6) Malnutrition (2.0-fold increase)
7) Pneumonitis due to solids and liquids (1.8-fold increase)
8) Brain tumours (1.7-fold increase)
9) Atherosclerotic cardiovascular disease, so described (1.6-fold increase)
10) Prostate hyperplasia (1.5-fold increase)
11) Other (non alcoholic) chronic liver disease and cirrhosis (1.5-fold increase)
12) Vascular dementia (1.4-fold increase)
13) Unspecified cancers (1.3-fold increase)
14) Falls (1.3-fold increase)
15) Other diseases of arteries, arterioles and capillaries (1.2-fold increase)
16) Unspecified non-transport accidents (1.2-fold increase)
17) Renal failure (1.2-fold increase) 

 I'll stop there. 

There are several in the 10% increase range (1.1-fold), but you can look them up.What you may have noticed is how many of these increases are in not very specific categories--atherosclerosis, so called, is much less specific than determining that someone died of a specific cardiovascular condition that atherosclerosis contributes to. Some, like brain tumours and hernias, likely reflect delayed access to surgery. But a LOT of these are generic conditions that could be on the charts of the majority of people living in residential care settings. The lack of specificity of the causes also suggests death in a less acute care environment. Anyway, at this point I'm just rambling out loud, and although I tend to do that on Twitter (I should really develop a diary habit), I'm also just hand-waving and taking about my initial impressions of these data. They require substantial thought, and input from others. And I am not a physician, so even though I know a lot about the underlying statistics, it doesn't replace clinical understanding (both officially spoken and unspoken) of attribution of cause of death. From what I understand, it is also quite non-standardized in Canada. Thanks for your patience. 

Even though I often write long threads, I actually do try to get to the point as quickly as I can, while providing context people need to understand. Tonight I'm tired and sad and scattered. Working on these numbers over the last few days got to me. Take care of yourself and those around you, even if you don't know them. You matter. Your life matters. It matters to me. It matters to others. You and your life are valuable."

*****

BASICS REMINDER (from me): Most Covid transmission is from people who look and feel completely healthy. Exhaling unmasked can send Covid across a room in minutes, where it hangs in the air for hours like cigarette smoke. Vaccines help reduce severity of cases, but can't eliminate transmission and wane in effectiveness within months because Covid mutates so fast (because of all the spread!). It takes seconds to inhale Covid where it gets into cells all over the body, able to hibernate and affect the brain, heart, and other organs. N95s trap Covid using inertial impaction, diffusion, interception, and electrostatic attraction. They really work!! Covid's the #3 killer in Canada, and we don't know how many people it has disabled. Avoid being one of them. There is no treatment, only prevention. Be wise with N95s!