Socio-demographic inequalities and excess non-COVID-19 mortality during the COVID-19 pandemic: a data-driven analysis of 1 069 174 death certificates in Mexico

Abstract

Background In 2020, Mexico experienced one of the highest rates of excess mortality globally. However, the extent of non-COVID deaths on excess mortality, its regional distribution and the association between socio-demographic inequalities have not been characterized. Methods We conducted a retrospective municipal and individual-level study using 1 069 174 death certificates to analyse COVID-19 and non-COVID-19 deaths classified by ICD-10 codes. Excess mortality was estimated as the increase in cause-specific mortality in 2020 compared with the average of 2015–2019, disaggregated by primary cause of death, death setting (in-hospital and out-of-hospital) and geographical location. Correlates of individual and municipal non-COVID-19 mortality were assessed using mixed effects logistic regression and negative binomial regression models, respectively. Results We identified a 51% higher mortality rate (276.11 deaths per 100 000 inhabitants) compared with the 2015–2019 average period, largely attributable to COVID-19. Non-COVID-19 causes comprised one-fifth of excess deaths, with acute myocardial infarction and type 2 diabetes as the two leading non-COVID-19 causes of excess mortality. COVID-19 deaths occurred primarily in-hospital, whereas excess non-COVID-19 deaths occurred in out-of-hospital settings. Municipal-level predictors of non-COVID-19 excess mortality included levels of social security coverage, higher rates of COVID-19 hospitalization and social marginalization. At the individual level, lower educational attainment, blue-collar employment and lack of medical care assistance prior to death were associated with non-COVID-19 deaths. Conclusion Non-COVID-19 causes of death, largely chronic cardiometabolic conditions, comprised up to one-fifth of excess deaths in Mexico during 2020. Non-COVID-19 excess deaths occurred disproportionately out-of-hospital and were associated with both individual- and municipal-level socio-demographic inequalities.

Differences Between Reported COVID-19 Deaths and Estimated Excess Deaths in Counties Across the United States, March 2020 to February 2022

“…More unrecognized COVID-19 deaths may have occurred in these areas as a result of limited COVID-19 testing and a greater share of deaths occuring outside of hospital settings, both of which complicate valid cause-of-death assignment. 8,14,39 Another potential contributing factor is the greater reliance on coroners in these regions, who are typically elected and often hold other positions within the county such as sheriff-coroners. 40 Medical training required for coroners is limited and highly variable across states, 41 whereas medical examiners are physicians with extensive training in forensic pathology and death investigation.…”

Late Mortality After COVID-19 Infection Among US Veterans vs Risk-Matched Comparators

“…The large number of deaths attributable to COVID-19 have been noted on death certificate tabulations and comparisons with historical rates of death . Prior studies have generally adjusted for demographic information, and some have adjusted for a range of more nuanced measures such as socioeconomic status, insurance coverage, comorbid conditions, and long-term care .…”

A high density of ultra-processed food, alcohol & tobacco retail stores, and social inequalities are associated with higher mortality rates of non-communicable diseases in Mexican adults: 2005 to 2021

“…The expected MR per 100,000 inhabitants was calculated using the predicted deaths from the negative binomial regression model and was subsequently age-standardized according to Mexico’s 2015 age structure. Additionally, recognizing the impact of excess mortality during the COVID-19 pandemic [ 27 ], we conducted a separate model to analyze municipal-level factors from 2005 to 2019. All analyses and maps were developed with Stata 17 (College Station, TX).…”