Covid-19 directly and indirectly the cause of excess deaths in Singapore in 2021, say experts

Excess deaths refer to a higher than expected number of deaths. - The Straits Times/ANN

SINGAPORE, April 1 (The Straits Times/ANN): Singapore saw excess deaths last year, which experts said reflected not just Covid-19 fatalities but also how the pandemic might have indirectly caused some people to receive medical help later due to the crisis.

Excess deaths refer to a higher than expected number of deaths.

In Singapore, the number of deaths each year usually goes up by a few hundred, in line with both an ageing and growing population. But last year, it went up by 2,220.

On March 24, the Ministry of Health (MOH) released figures that showed that the age-standardised death rate in Singapore rose to 557 per 100,000 persons last year, up from 519 per 100,000 in 2020.

The rate had been decreasing steadily from 563 per 100,000 in 2017, to 548 in 2018 and 525 in 2019.

The age-standardised rate takes into account the age of the population to give a more meaningful comparison than the actual number of deaths.

MOH said the increase was not unexpected given how the pandemic has been a health crisis which has killed many millions of people in the world.

It added that Singapore, however, has recorded "one of the lowest rates of excess deaths in the Covid-19 pandemic from international comparisons so far".

The ministry said the total excess deaths due to Covid-19 will require further analysis and breakdown of the numbers, after the Omicron wave subsides.

Excess death numbers are not readily available. But looking at the number of deaths caused directly by Covid-19, it is clear that many countries would be suffering from excess deaths caused by the pandemic.

In the United States, the coronavirus has killed about 3,000 per million population. It was just over 1,000 in Malaysia and about the same in Hong Kong. For Singapore, the number is 214 per million population.

In terms of the number of total deaths, data from the Immigration and Checkpoints Authority show an increase from about 18,500 deaths a year in 2012 to 22,000 in 2020. The biggest year-on-year increase was in 2017, which saw 888 more deaths, and the lowest was 2016 with an increase of 155 deaths.

But last year, 24,220 people died, including about 800 from Covid-19. This was 2,220 more people than in 2020. The breakdown on the causes for death last year is not yet available.

In 2020, the first year of the pandemic, the increase over 2019 was 554, including the 29 people who died of Covid-19.

As at March 30 this year, Singapore has had a total of 1,268 Covid-19 deaths.

Experts interviewed suggested some possible contributory causes for the big jump in deaths last year.

Those who died directly from Covid-19 had contributed to the numbers.

In addition, those whose chronic conditions worsened as a result of a Covid-19 infection could also have died.

Delayed treatment of other diseases due to the postponement of non-urgent procedures, including surgery for cancer, during much of the past two years could have also resulted in ailments becoming more severe and, in some cases, becoming fatal, they said.

Professor Ooi Eng Eong of the Duke-NUS Medical School, an expert in emerging infectious diseases, said that while Covid-19 measures have helped to reduce the burden of some respiratory viral diseases, they have also posed challenges to the management of other diseases.

"Anecdotally, I have heard of surgery, even cancer biopsies, being delayed due toCovid-19 measures in the hospital," he said. "To me, the health of our population is more than just reducing the number of Covid-19 cases," he added.

Associate Professor Jeremy Lim, director of the Leadership Institute for Global Health Transformation at the NUS Saw Swee Hock School of Public Health, said many deaths may be multi-factorial.

He gave the example of social isolation leading to depression, which in turn could have resulted in a diabetes patient not taking medicine as prescribed, accelerating complications.

Prod Lim added: "It shows Covid-19 has had a real impact, whether directly, or indirectly through delayed diagnosis for other diseases, late treatment because of insufficient capacity in public hospitals. Resources deployed to Covid-19 were diverted from other essential functions and this caused longer waiting times."

Earlier this month, Singapore's director of medical services, Associate Professor Kenneth Mak, referred to these delayed treatments as "a debt that we have incurred over the past few months that must now be repaid" when he spoke of hospitals returning their focus now to non-Covid-19 patients.

But in terms of infectious diseases, including respiratory problems, Covid-19 safe distancing measures resulted in a major drop in the number of such patients.

At a recent Straits Times webinar, Professor Leo Yee Sin, executive director of the National Centre for Infectious Diseases, noted that the reduction in social interactions had led to a significant drop in many acute infectious conditions. "Things like influenza basically was rock bottom in Singapore," she said

Professor Dale Fisher of the National University Hospital, who was also on the webinar panel, said flu, acute respiratory illnesses, hand, foot and mouth disease, and gastrointestinal illnesses also saw drops. "Once you stopped people interacting, you stopped infectious diseases."

There was a noticeable decline in the number of people who died from lung and respiratory diseases in 2020, the first year of the pandemic: 4,610 against 4,952 in 2019. But deaths from cancer, heart diseases and stroke all went up that year. Heart related deaths in particular went up by 12 per cent and accounted for one in four deaths. - The Straits Times/ANN