Excess All-Cause Mortality During the COVID-19 Epidemic in Canada June 2021 An RSC Policy Briefing Excess All-Cause Mortality During the COVID-19 Epidemic in Canada i Excess All-Cause Mortality During the COVID-19 Epidemic in Canada An RSC Policy Briefing Authors Tara J. Moriarty University of Toronto Anna E. Boczula University of Toronto Eemaan Kaur Thind Independent Public Health Professional Nora Loreto Independent Journalist Janet E. McElhaney Health Sciences North Research Institute Peer Review Monitor Tom Marrie, FRSC Dalhousie University Peer Reviewers David Fisman University of Toronto David Naylor University of Toronto Ashleigh Tuite University of Toronto Suggested citation for Policy Briefing Report Moriarty, T., Boczula, A.E., Thind, E.K., Loreto, N., McElhaney, J.E. Excess All-Cause Mortality During the COVID-19 Epidemic in Canada. Royal Society of Canada. 2021 Cover Art Walter Jule, By All Things Advancing, a clock for two kinds of time (1993) Etching, lithograph on gampi sukiawase, 40 x 36 cm The title was inspired by the writings of Zen master Dogen who said, “Everything is a kind of time.” In the prints I explore the combination of “additive” and “reductive” techniques. The drawn elements and photo images of wrinkled paper are “reductive” having been etched into a copper plate while the small luminescent “orb” has been “added” through offset lithography. I was attempting to create a visual metaphor for the universal law of cause and effect; being and non-being. Land Acknowledgement The headquarters of the Royal Society of Canada is located in Ottawa, the traditional and unceded territory of the Algonquin Nation. The opinions expressed in this report are those of the authors and do not necessarily represent those of the Royal Society of Canada. 1 Background on the Policy Briefing Report Process Established by the President of the Royal Society of Canada in April 2020, the RSC Task Force on COVID-19 was mandated to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of Working Groups to rapidly develop Policy Briefings, with the objective of supporting policy makers with evidence to inform their decisions. About the Authors Tara J. Moriarty (Chair), Faculties of Dentistry and Medicine (Laboratory Medicine and Pathobiology, University of Toronto Anna E. Boczula, Faculties of Dentistry and Medicine (Laboratory Medicine and Pathobiology, University of Toronto Eemaan Kaur Thind, Independent public health professional Janet E. McElhaney, Northern Ontario School of Medicine, Health Sciences North Research Institute Nora Loreto, Independent journalist Notes from the Working Group Due to limited availability of death reporting as of the time of writing, this report does not directly address or make specific recommendations for preventing excess deaths during the COVID-19 epidemic among specific occupational groups, people experiencing homelessness and incarceration, Black, Indigenous and people of colour who do not live with clinical frailty or in high priority neighbourhoods. Acknowledgements The authors acknowledge the suffering and deaths of all people living and working in Canada who passed away during the COVID-19 epidemic and their loved ones. The authors also thank Carolyn Abraham, David Naylor and Laura Rosella for critical editorial contributions to the development of this report. An RSC Policy Briefing 2 Table of Contents Abbreviations and Definitions ................................................................................................4 Executive Summary ................................................................................................................6 Introduction .........................................................................................................................10 The COVID-19 epidemic in Canada ......................................................................................10 Canadian monitoring of the COVID-19 epidemic .................................................................11 Who has been at greatest risk of exposure to SARS-CoV-2 in Canada? ...............................12 Who has been at greatest risk of dying of COVID-19 in Canada?........................................12 The irregular landscape of Canadian COVID-19 death reporting .........................................14 The importance and challenges of estimating excess all-cause mortality during the COVID-19 pandemic ............................................................................................................15 Anomalies in Canada’s COVID-19 death numbers ...............................................................17 Study outline and methods ..................................................................................................18 Data sources ........................................................................................................................18 Results .................................................................................................................................20 Comparison of excess all-cause mortality in Canada, peer countries and Canadian regions .................................................................................................................................20 Reported COVID-19 fatalities as a proportion of excess all-cause mortality in Canada, peer countries and Canadian regions ..................................................................................21 Reported COVID-19 fatalities in long-term care as a proportion of excess all-cause mortality in Canada, peer countries and Canadian regions ..................................................22 Impact of the toxic drug epidemic on Canadian excess all-cause mortality during COVID-19 .............................................................................................................................23 Timing of toxic drug-adjusted excess all-cause mortality in Canada compared to reported COVID-19 deaths and cases ..................................................................................23 Toxic drug-adjusted excess all-cause mortality compared to COVID-19 deaths predicted from SARS-CoV-2 seroprevalence ........................................................................25 Contributions of specific non-COVID-19 specific causes of death to toxic drug-adjusted excess all-cause mortality ....................................................................................................26 Toxic drug-adjusted excess mortality during the second wave ............................................27 Estimated toxic drug-adjusted excess all-cause mortality in working age adults, and people living in and outside long-term care to November 28, 2020 ............................29 Guesses about COVID-19 deaths after November 28, 2020 ...............................................30 A recalibrated view of COVID-19 epidemic deaths across Canadian regions ......................31 Discussion ............................................................................................................................31 Conclusion ...........................................................................................................................34 Figures, Tables, and Legends ...............................................................................................35 Appendix 1: Comparison of reported and test positivity-adjusted COVID-19 cases with excess all-cause mortality .............................................................................................42 Appendix 2: Comparison of excess deaths with reported COVID-19 deaths and COVID-19 deaths predicted from SARS-Cov-2 seroprevalence ...........................................45 Appendix 3: Comparison of cumulative estimated toxic-drug adjusted excess deaths to reported COVID-19 deaths over time in Canadian regions, February 1-November 28, 2020 ...........................................................................................48 References ...........................................................................................................................49 Excess All-Cause Mortality During the COVID-19 Epidemic in Canada 3 Abbreviations and Definitions Abbreviations CDC: United States Centers for Disease Control and Prevention CFR: Case fatality rate CI: Confidence interval LTC: Long-term care OECD: The Organisation for Economic Co-operation and Development Definitions Clinical frailty: People living with frailty have a greater vulnerability to developing increased dependency and/or mortality upon exposure to physiological and psychological stressors, due to an accumulation of deficits across multiple domains, including physical fitness and illness, ability to function independently and need for and access to psychosocial supports. These accumulated deficits can be graded on the Clinical Frailty Scale (Church et al., 2020). 95% Confidence interval (CI): Let us say you wish to know the average blood pressure of adults in Canada. You cannot measure everyone’s blood pressure in the country, so you measure the blood pressure of a particular number of individuals (‘sample statistic’) and calculate their average blood pressure. Now you can use a ‘Confidence Interval’ (CI) to quantify your certainty that your ‘sample statistic’ has captured the average blood pressure of Canadian adults within a certain margin of error. A 95% CI would signify that you are 95% sure