key: cord-0939782-u5rrvjlt authors: Trias-Llimos, S.; Riffe, T.; Bilal, U. title: Monitoring life expectancy levels during the COVID-19 pandemic: Example of the unequal impact in Spanish regions date: 2020-06-05 journal: nan DOI: 10.1101/2020.06.03.20120972 sha: 6c9baf728a44aaab717ae387c7b8173836ce566f doc_id: 939782 cord_uid: u5rrvjlt Background: The COVID-19 pandemic is causing substantial increases in mortality worldwide. To provide an interpretable summary of the impact on mortality of the COVID-19 pandemic we estimate weekly and annual life expectancies at birth in Spain and its regions. Methods: We used daily death count data from the Spanish Daily Mortality Surveillance System, MoMo, and death counts from 2018, and population on 1 July, 2019 by region (CCAA), age groups, and sex from the Spanish National Statistics Institute. We estimated weekly and annual (2019 and 2020*, the shifted annual calendar period up to 10 May 2020) life expectancies at birth as well as their differences over a short period of time. Results: Weekly life expectancies at birth in Spain were lower in weeks 11-20, 2020 compared to the same weeks in 2019. This drop in weekly life expectancy was especially strong in weeks 13 and 14 (March 23rd to April 5th), with national declines ranging between 6.1 and 7.6 years and maximum regional weekly declines of up to 15 years in Madrid. Annual life expectancy differences between 2019 and 2020* also reflected an overall drop in annual life expectancy of 0.8 years for both men and women. These drops ranged between 0 years in several regions (e.g. Canary and Balearic Islands) to 2.7 years among men in Madrid. Conclusions: Weekly and annual life expectancy are easy to interpret measures for understanding the heterogeneity of mortality patterns across Spanish regions. Weekly life expectancy is a valuable indicator of the immediate intensity of health impacts from the pandemic. This sensitive indicator is also useful for understanding disparities and communicating the gravity of the situation because differences are expressed in intuitive year units. 3 The COVID-19 pandemic is causing substantial increases in mortality in several populations worldwide. According to WHO, by June 1 st , 2020 over 370,000 confirmed COVID-19 deaths occurred worldwide (1) . Spain has been one of the most affected countries with more than 27,000 deaths with laboratory confirmation of COVID-19 (1) . Nonetheless, both the official number of COVID-19 cases and deaths, and the results from a recent seroprevalence study reveal important differences across Spanish regions (2, 3) . Beyond the official death toll statistics, the COVID-19 pandemic has been associated with net increases in mortality in several populations (4) , which could owe to a combination of factors. The COVID-19 pandemic used an unprecedented amount of health service resources, including intensive care unit beds, and strong preventive health measures in hospitals. This has put health systems in struggling and challenging situations (5) , and thus potentially leading to increases in morbidity and mortality indirectly related to COVID-19. For example, some excess mortality could result from healthcare avoidance, from a delay in treatment, or from insufficient care for other urgent conditions resulting from a reduced capacity to treat other medical emergencies. Other kinds of mortality may be temporarily reduced, such as deaths from acute respiratory conditions related to air pollution, or traffic accidents, but those mortality reductions may be outweighed by excesses. While total excess mortality and total number of COVID-19 deaths provide some measure of the impact of the pandemic within populations, their interpretation is not always straightforward, and comparisons between populations can be challenging. Few studies assessing the impact of the pandemic on mortality have reported life expectancy estimates. Life expectancy is a summary index of mortality that is easy to interpret, but that is also subject to common misunderstandings. The most literal understanding of life expectancy is All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint as the expected average length of life that would follow in the long run if a given set of mortality conditions were held fixed. The most common misunderstanding is to treat it as a forecasted expectancy. In monitoring mortality patterns in non-crisis times, annual life expectancy is a standard indicator because it accounts for differences in age-specific mortality, and it is expressed in intuitive year units, making it easy to grasp and compare across populations and over time. The current pandemic, with fast mortality increases in specific weeks, makes it useful to shorten the calendar reference period of mortality rates in order to measure life expectancy changes. When calculated over short time intervals in this way, life expectancy should be understood as an annualized summary index of mortality. This index is much more volatile than standard period life expectancy calculated over a year, and it should be reported alongside traditional calendar-year life expectancy measures, possibly with shifting calendar reference windows. A few studies that have documented life expectancy declines have found notable declines in annual life expectancy in highly affected Spanish and Italian regions, Madrid and Bergamo (6, 7) , and declines in weekly life expectancy in Sweden (8) . The objective of this study is to estimate the impact of the COVID-19 pandemic by estimating both weekly and annual life expectancies in Spain and its 17 regions. We estimated life expectancy at birth by sex in Spain and its 17 regions (comunidades autónomas) in two time frames: i) weekly life expectancy at birth from week 1 in 2019 until the most recently available weekly data (week 20, May 11-17); and ii) annual life expectancy for both 2019 and the shifted annual reference period up to May 17 th , 2020 (referred as 2020*). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint Due to small population sizes, we excluded the Spanish cities of Ceuta and Melilla on mainland Africa from the analyses. Data sources included daily age-(<65, 65-75, 75+) and sex-specific death counts data from the Spanish Sistema de vigilancia de la mortalidad diaria (Daily Mortality Surveillance System, MoMo, updated May 28 th ) covering ~93% of the population (9) . We also used sex-and agespecific We conducted our analysis in five steps. First, we grouped daily death counts into weeks. Second, we redistributed the MoMo death counts from broad age groups (<65, 65-75, and 75+) into 5-year age groups using 2018 death counts from the INE as a proportional standard. Third, we estimated age-specific death rates for each population group using the 2019 mid-year population as the denominator for annual estimates, and the population divided by (365/7) as denominator for weekly estimates. Fourth, both weekly and annual life expectancies were estimated using conventional life table techniques, and 95% confidence intervals were estimated based on the 2.5 and 97.5th percentiles of 1,000 random binomial deviates (12, 13) . Finally, we derived the expected variation in annual life expectancy between 2019 and 2020* by subtracting life expectancy at birth in 2019 from life expectancy at birth in 2020*. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint To assess the robustness of our estimates we visually inspected the associations between the annual life expectancy variation and the IgG anti SARS-Cov2 prevalence by region and sex. In Spain, weekly life expectancies at birth for weeks 11-20 2020 were lower than those from the same weeks in 2019 (Figure 1 , and Appendix I Figure S1 ). This drop in weekly life expectancy was especially strong in weeks 13 and 14 (23 March to 5 April), with national declines ranging (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. Figure S4 ) are comparable with a previous study for Sweden (8) , in line with the higher impact of COVID-19 in Spain compared to Sweden (1). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint There are plausible reasons to think that mortality in the remainder of 2020 may further increase compared to 2019. The epidemic is not yet over at the time of this writing, and some regions are still experiencing excess mortality. Additionally, we could not rule out a potential second wave of COVID-19 in Spain, and if it happens it may affect regions differently than the first wave. Furthermore, the effects of delayed care of chronic conditions, cumulative anxiety, alcohol consumption, and other factors during the pandemic may contribute to elevated mortality in the coming months. However, mortality may also decrease in the coming months due to the mortality selection of frail individuals which usually occurs after severe flu episodes. That is, the COVID-19 pandemic has been more fatal among elderly individuals with pre-existing health conditions (14, 15) as well as individuals residing in nursing homes (15, 16) . Therefore, it is plausible that some individuals who would have been expected to die in the remaining part of the year have already died, which could lead to mortality reductions in the second half of 2020. Other populations seem to be as affected or more affected by COVID-19 than Spain. For instance, the UK is at the time of writing the country with the highest relative excess mortality (17) , and important geographical inequalities exist as well, with London leading the negative All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint ranking of relative excess mortality (18) . Indeed, metropolitan areas tend to be more affected than other regions within a country, not only in Spain or the UK, but also in Italy, where Lombardy was by far the most affected region (19) . Other highly affected metropolitan areas include New York city, where the excess mortality was three-fold higher during seven weeks (20) . Other populations, for example Brazil, are somewhat behind European countries in the pandemic, but rapidly experiencing a dramatic death toll increase. If the age distribution of Our analyses are based on detailed daily death counts data covering 93% of the population. We recognize that this could result in slightly overestimated life expectancies levels, especially for the four regions with real coverage <80% (Aragon, Cantabria, Castile and Leon, and La Rioja). Therefore, life expectancies per se need to be interpreted cautiously. However, the undercoverage of the data used is unlikely to substantially affect our main outcome, the differences between life expectancies (see Appendix II for details and for sensitivity analyses exploring the impacts of undercoverage). The weekly life expectancy estimates presented in this study summarize the intensity of mortality increases (8) . Weekly life expectancy is a sensitive, intuitive, and comparable translation of age-standardized excess mortality. Weekly-estimated life expectancies can be compared with standard annual life expectancies and with similar estimates from this or other mortality shocks, but one must be careful not to overinterpret this index as a forecast. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint shows a 2.7 year drop. This is not a provisional estimate of the 2020 life expectancy impact, which would require a forecast of mortality through the end of the calendar year. In conclusion, the impact of COVID-19 pandemic has been severe and highly heterogeneous in Spain. Weekly and annual updated life expectancy are valuable indicators of the health impacts of the pandemic in populations, and thus should be continuously monitored. Such monitoring efforts should be sustained by up-to-date information on all-cause mortality disaggregated by age and sex, which should be released by public health agencies and governments worldwide (21, 22) , requiring an increase of the coverage of electronic vital event reporting and seek to reduce other sources of reporting lags. The study was conceived by STL, and designed by STL, TR and UB. STL ran the analyses with input from TR and UB. STL drafted the manuscript and all authors participated in critical revision of the manuscript for important intellectual content. TR and UB supervised the study. All authors approved the final manuscript and were responsible for the decision to submit for publication. Figure 1. Weekly life expectancy at birth (with 95% confidence intervals) in Spain and three selected regions (Andalusia, Catalonia and Madrid)* by sex * Weekly life expectancies at birth for Spain and its 17 regions can be found in Figure S1 . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint Figure 2 . Annual life expectancy at birth in 2019, 2020* and differences between periods for Spain and its 17 regions by sex * Annual life expectancy at birth in 2020* was estimated using death counts from the shifted annual reference period up to 18 May 2020. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint * Annual life expectancy at birth in 2020* was estimated using data from the one year window that closes out May 17, 2020. **CM stands for Castille-La Mancha. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint Appendix I Figure S1 . Weekly life expectancy at birth (with 95% confidence intervals) in Spain and its 17 regions by sex All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. 16 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint Figure S3 . Annual life expectancy at ages 50 and 65 and 75 in 2019, 2020* and differences between periods for Spain and its 17 regions by sex All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint Figure S4 . Weekly life expectancy at age 50 (with 95% confidence intervals) in Spain and its 17 regions by sex All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint The Spanish daily mortality data that we have used has an overall coverage of ~93% of the population. We have done several sensitivity analyses to assess the robustness of our results: (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint In conclusion, we aimed at estimating differences in life expectancies during the COVID-19 pandemic. Due to data limitations life expectancy levels may be overestimates, especially for Aragón, Cantabria, Castille and Leon, and la Rioja, and should be interpreted carefully. However, the undercoverage of the data used is unlikely to substantially affect our main outcome, the differences between life expectancies. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint Figure 5 . Differences in life expectancy at birth between our original estimates and the sensitivity analyses where death counts are corrected for the real coverage of MoMo All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120972 doi: medRxiv preprint WHO. Coronavirus disease 2019 (COVID-19) Situation Report -133 Primera ronda Estudio Nacional de Sero-Epidemiología de la Infección por SARS-COV-2 en España. Informe preliminar 13 de mayo de Enfermedad por el coronavirus (COVID-19) Tracking covid-19 excess deaths across countries The resilience of the Spanish health system against the COVID-19 pandemic Impact of the COVID-19 pandemic on life expectancy in Madrid (Spain) News from the front: Excess mortality and life expectancy in two major epicentres of the COVID-19 pandemic in Italy. medRxiv Excess mortality from COVID-19. 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