Mortality Related to Chronic Obstructive Pulmonary Disease during the COVID-19 Pandemic: An Analysis of Multiple Causes of Death through Different Epidemic Waves in Veneto, Italy

Abstract

Mortality related to chronic obstructive pulmonary disease (COPD) during the COVID-19 pandemic is possibly underestimated by sparse available data. The study aimed to assess the impact of the pandemic on COPD-related mortality by means of time series analyses of causes of death data. We analyzed the death certificates of residents in Veneto (Italy) aged ≥40 years from 2008 to 2020. The age-standardized rates were computed for COPD as the underlying cause of death (UCOD) and as any mention in death certificates (multiple cause of death—MCOD). The annual percent change (APC) in the rates was estimated for the pre-pandemic period. Excess COPD-related mortality in 2020 was estimated by means of Seasonal Autoregressive Integrated Moving Average models. Overall, COPD was mentioned in 7.2% (43,780) of all deaths. From 2008 to 2019, the APC for COPD-related mortality was −4.9% (95% CI −5.5%, −4.2%) in men and −3.1% in women (95% CI −3.8%, −2.5%). In 2020 compared to the 2018–2019 average, the number of deaths from COPD (UCOD) declined by 8%, while COPD-related deaths (MCOD) increased by 14% (95% CI 10–18%), with peaks corresponding to the COVID-19 epidemic waves. Time series analyses confirmed that in 2020, COPD-related mortality increased by 16%. Patients with COPD experienced significant excess mortality during the first year of the pandemic. The decline in COPD mortality as the UCOD is explained by COVID-19 acting as a competing cause, highlighting how an MCOD approach is needed.

Comparison of Azvudine and Nirmatrelvir/Ritonavir and Combined Use in Patients with COVID-19

“…Furthermore, comorbidities, such as hypertension, diabetes, coronary heart disease, hepatitis, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD) are all factors associated with poor prognosis in COVID-19. [18][19][20][21][22][23][24] Systemic steroids play an important role in the treatment of patients with COVID-19, particularly in those with severe COVID-19 pneumonia, as they help prevent disease complications and improve clinical outcomes. 25 Empiric antibiotic use in patients with COVID-19 does not prevent disease progression, reduce mortality, or shorten hospital stays; 26,27 however, the use of antibiotics may be necessary for patients with bacterial infections.…”

COPD-Related Mortality before and after Mass COVID-19 Vaccination in Northern Italy

“…Underreporting, however, is unlikely to have changed significantly across the study period; therefore, estimates of variations through subsequent epidemic waves were unlikely to be affected by this issue. Moreover, the MCOD approach at least addresses one of the mechanisms of underestimation, e.g., selection of a different UCOD, and it is more suitable for assessing time trends [ 8 ]. Only MCOD-based analyses can uncover the full burden of COPD-related deaths during the pandemic: in Veneto, analyses limited to the UCOD did not reveal any excess in mortality from COPD during 2020 [ 8 ].…”

“…Moreover, the MCOD approach at least addresses one of the mechanisms of underestimation, e.g., selection of a different UCOD, and it is more suitable for assessing time trends [ 8 ]. Only MCOD-based analyses can uncover the full burden of COPD-related deaths during the pandemic: in Veneto, analyses limited to the UCOD did not reveal any excess in mortality from COPD during 2020 [ 8 ]. Reports from Spain confirmed such a discrepancy: compared to the 2018–2019 average, in 2020, the number of deaths attributed to COPD as the UCOD declined by 10.5%, whereas using the MCOD approach, a 7.3% increase could be observed [ 9 ].…”

“…Data for the first trimester of 2022 are provisional, with an estimated coverage of about 97–98%, and were only used to confirm the trends observed at the end of 2021. Selection criteria were the same as adopted in previous studies on COPD-related mortality in Veneto, both in the pre-pandemic period and during the first year of the pandemic [ 8 , 11 ]. The yearly and monthly number of deaths and age-standardized mortality rates with 95% confidence intervals (direct standardization, 2013 European reference population) were computed for any mention of COPD in death certificates (MCOD).…”

“…According to analyses limited to the UCOD, in 2020, a decrease in mortality from COPD was reported from countries severely affected by the pandemic, such as the US [ 6 ], Spain [ 5 ], and Scotland and Wales [ 7 ]. By contrast, based on MCOD analyses, a 14% increase in the number of COPD-related deaths was registered in 2020 compared to the 2018–2019 average in the Veneto region (Northeastern Italy, 4.9 million inhabitants) [ 8 ]; similar analyses carried out in Spain reported a 7.3% increase [ 9 ]. According to these latter observations, the long-term declining trend in COPD mortality observed in Europe over recent decades, at least in the male gender [ 10 , 11 ], was abruptly interrupted in 2020.…”