All excess deaths in Singapore linked to recent COVID infection: Study

No pattern of excess deaths has been found among people without a recent COVID-19 infection in Singapore, the country’s health authority has stated.
 
A report on excess mortality published this week by Singapore’s Ministry of Health details a higher than usual number of deaths in the country from 2020 to June 2022.
 
The research puts the number of excess deaths from the beginning of 2020 to June 2022 as 2490 – taking into account the ageing of the population – with an official COVID-19 death toll of 1403.
 
Authors suggest the gap between the figures is due to the impact on those with underlying illnesses, saying further research indicated no variation to expected patterns among those not recently infected.
 
‘The remainder can be explained by patients who passed away from other illnesses within 90 days after being infected with COVID-19,’ the report reads.
 
‘In other words, COVID-19 aggravated existing illnesses, resulting in further mortalities.
 
‘In a secondary analysis of persons without recent infection, no additional excess deaths were found.’
 
No details of the methods used for the secondary analysis are included within the report and newsGP has sent an inquiry to the Ministry of Health requesting further detail. No response was received.
 
Karen Cutter, a long-standing actuary who helps mortality analysis for the Actuary Institute’s COVID-19 Mortality Working Group, describes the report as ‘very interesting’ but believes more detail is needed.
 
‘It’s a very striking finding with very little backing,’ Ms Cutter told newsGP.
 
‘I don’t think we can make some blanket statements that this why we’re having excess deaths anywhere.’
 
Context of different health systems
The authors of the Singapore Ministry of Health study also acknowledge the unique circumstances in the country and say that while health systems in many places were overwhelmed, the country’s hospitals were ‘strained’ but ‘able to support patients with urgent medical needs’.
 
Health system pressures causing people to avoid seeking help and timely care could be having ‘low-to-moderate’ impact on excess deaths in Australia, as could delays in obtaining routine care, according to a recent Actuaries Institute analysis.
 
‘With all of these things, you need to take this specific context of the jurisdiction that you’re looking at into account,’ Ms Cutter said.
 
‘We hear a lot about the dire situation with the NHS in the UK.
 
‘Australia also has issues with healthcare delivery, but it sounds as though not to the same extent, whereas in the Singapore report, they said that they’ve looked at that and that it’s not a cause of excess mortality over there.’
 
The Singapore health report does raise the possibility of other factors at play, including so-called ‘mortality displacement’.
 
The phenomenon involves an initial increase in excess deaths in a pandemic or other significant event such as a heatwave, caused by the impact on those with pre-existing conditions, followed by a decrease in mortality.
 
However, the report hones in on the influence of the virus on other conditions.
 
‘In particular, COVID-19 has also been shown to increase the risks of developing medical conditions such as heart attacks and stroke and could have contributed to deaths from these conditions in persons with past infections,’ it reads.
 
Comparison with Australia
Like Australia, Singapore has had a low excess death rate for much of the pandemic and followed a similar pattern of suppression and tight border controls. It is also now beginning to ease many public health measures aimed at managing the spread of COVID-19, including a recent reduction in mask-wearing requirements.
 
Australia was one of the few countries in the world which registered fewer deaths in 2020 than expected, with excess mortality only rising more significantly this year. The Singaporean data does not break down its research annually so it is not clear whether what happened there mirrors the same trend.
 
The Actuary Institute’s most recent analysis indicates deaths from heart disease, cerebrovascular disease, diabetes and dementia have all been higher in Australia this year.
 
While the death rate due to ischaemic heart disease was higher during the study period in Singapore too, the authors state there is ‘no clear evidence’ for a rise in mortalities due to stroke.
 
They also highlighted the impact of vaccination, finding that 28% of deaths attributed to COVID-19 in the first half of 2022 were among patients who were not fully vaccinated, a disproportionate total when set against the 5% of the population not fully vaccinated by mid-March this year.
 
Around the world, the mortality rate has climbed significantly due to the pandemic, although many of the excess deaths are not being attributed directly to COVID-19.
 
A review of global mortality published in The Lancet in March suggested official figures were less than a third of the true total caused by the pandemic.
 
It found the number of reported COVID-19 deaths for 2020 and 2021 stood at around 5.94 million globally but estimated 18.2 million had died worldwide using analysis of excess mortality figures.
 
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