Abstract
BACKGROUND: Estimating the indirect mortality due to COVID-19 is of the utmost importance to develop adequate public health policy during future outbreaks. METHODS: From province-wide administrative datasets, we identified British Columbians who tested negative for COVID-19 during the first wave and never tested positive throughout 2020. We obtained a pre-pandemic (2018) cohort matched on age, sex, history of non-communicable disorders (NCDs), multimorbidity, and severity/acuity, and implemented a doubly robust estimation of the effect of the first pandemic wave on mortality. RESULTS: The adjusted odds ratio (AOR) of death was 3.2 times higher for a 2020 cohort who tested negative for COVID-19 (n = 123,133), compared to matched pre-pandemic controls. In both cohorts, a majority (72.5%) experienced at least one pre-existing NCD. Stratification by NCD shows an AOR of death ranges between 2-for people with substance use disorders- and 7-for people previously undiagnosed with NCDs (e.g., incident cases that went untreated). The largest subgroup was composed of people with mental disorders (47,413 people), with an AOR of death of 2.5. Though the COVID-19 direct mortality in the general population remained low (1.9 per 10,000), the excess mortality in this COVID-negative cohort was extremely high - 4,085 of the 123,133- which entails a minimum indirect excess mortality death rate of 6.5 per 10,000 in the general population. CONCLUSIONS: During the first pandemic year, mortality in COVID-negative adults was several times greater than before COVID-19, in people with matched NCD distribution and severity. Our findings suggest that low direct COVID-19 mortality was accompanied by less visible-but much higher- indirect mortality due to undiagnosed and/or untreated NCDs, highlighting the need to focus not only on mitigating the harms of new agents, but also of continuing service delivery for treatable conditions.