The Continuing Impact Of Covid-19 On Health And Inequalities
25th August 2022
This item is from The Health Foundation.
A year on from our COVID-19 impact inquiry.
Key points
A year on from publication of the Health Foundation's impact inquiry, inequalities in COVID-19 mortality persist with mortality rates 3 to 4 times higher in the most deprived areas. However, the overall number of COVID-19 deaths is now significantly lower than it was during the first year of the pandemic.
The vaccination programme has been key to reducing COVID-19 mortality rates, but for some groups uptake is still low, especially for people living in poorer areas and people from some minority ethnic groups.
The significant deterioration in mental health during the first year of the pandemic has been reversing but has not entirely returned to pre-pandemic levels. Data suggest that anxiety remains heightened, especially among women. People are likely to be less resilient to cope with the stress associated with financial strain in the growing cost-of-living crisis.
A large rise in unemployment was avoided, largely due to government support through the furlough scheme. However, long-term health conditions are keeping a significant number of people out of work, representing an ongoing challenge for government and the economy, as well as for individuals.
There has been a failure to act on education gaps due to lost learning time in the pandemic. These are between children from richer and poorer backgrounds and compared with previous cohorts. A cohort of ‘left-behind' children face significant risks to their long-term health and living standards, as well as causing a long-term economic cost to the country.
Introduction
In July 2021 we published our COVID-19 impact inquiry, providing an initial assessment of how the pandemic affected health and health inequalities during its first year. The report found that poor health and existing inequalities had left parts of the UK more vulnerable to the virus and had influenced its devastating impact. It also found that the pandemic has highlighted stark differences in the health of the working age population - with those younger than 65 in the poorest 10% of areas in England almost four times more likely to die from COVID-19 than those in the richest. The inquiry report concluded that the recovery needs to prioritise creating opportunities for good health - a vital asset needed to 'level up' and support the economy.
At the time of writing the report in May 2021, around a quarter of the population had experienced at least one COVID-19 infection, and just over half of UK adults had been vaccinated twice. We highlighted the effect of the pandemic on health and inequalities, but also explored how policy helped to mitigate some of these, while pointing to future risks to health.
A year on, 90% more than 90% of the UK population have had at least one COVID-19 infection, and 74% of adults had received three vaccinations by April 2022. The terms of reference for the statutory public inquiry have now been set. This inquiry will play a crucial role in understanding how the UK can prevent another human, social and economic disaster on the scale of that caused by COVID-19. The size and complexity of the task cannot be underestimated.
Here, we revisit the conclusions of our COVID-19 impact inquiry to consider the further direct impact of COVID-19 on health outcomes and the broader implications for health and the wider determinants. We also discuss the extent to which previously highlighted risks to health have been addressed and the implications for the country of ‘living with COVID-19'.
Direct effects on health
COVID-19 mortality
COVID-19 remains a significant cause of death in the UK in this latest phase of the pandemic: in the first 6 months of 2022, 13,500 people died due to COVID-19 (4.9% of all deaths) and 20,300 people's deaths where COVID-19 was mentioned on the death certificate but may not be the main cause (7.3% of all deaths). This is considerably lower than in 2020 and 2021, when the population had lower levels of immunity through vaccination and to a lesser extent infection. For comparison, a typical flu year in the UK has averaged around 28,000 deaths since 2000.
For most of the pandemic, excess mortality has been a better measure of the impact of COVID-19, due to the absence of community testing in early 2020. Excess mortality indicates how many people have died relative to expectations, typically by comparing to historical averages. Figure 1 shows how the UK (highlighted red) has fared compared to other OECD countries in excess deaths per 100,000 people since March 2020.
As of June 2022, the UK had experienced a cumulative 204 excess deaths per 100,000. In March 2022, when there are comparable data for most countries, the UK ranked 15th out of 33 available OECD countries for the highest cumulative excess mortality. Among OECD countries, the UK fared poorly by the end of 2020, ranking 4th out of 33 for excess deaths in this period. A delayed lockdown in winter 2020 contributed to a significant rise in excess deaths. There has been considerable improvement since then, due to the vaccine rollout and relatively high uptake, with the UK ranking 11th out of 33 countries with available data in the OECD in June 2022 in vaccinations administered per person.
One of the consequences of the pandemic has been a sharp fall in period life expectancy in 2020. However, it is important to note that this does not mean that COVID-19 will lead to significantly shortened life spans in future. Period life expectancyPeriod life expectancy: the number of years that someone born at a given point can be expected to live, if current age-specific mortality rates did not change for the rest of their life. is calculated based on current age-specific mortality rates applying over the lifetime. Assuming that the higher mortality rates of 2020 and 2021 are temporary, then period life expectancy can also be expected to return to pre-COVID-19 levels. The future challenge then becomes how to reverse the pre-pandemic trend of stalled improvements in life expectancy.
Inequalities in COVID-19 mortality by deprivation
The absolute number of COVID-19 deaths has reduced, but there is still a significant gap in the risk of dying from COVID-19 between people from the most and least deprived areas. Since July 2021, both age-standardised mortality rates and the absolute number of COVID-19 deaths have been consistently higher in the most deprived areas (Figure 2).
Age-standardised COVID-19 mortality rates have generally been around three or four times higher (in a given month) in the most deprived areas than in the least deprived. Between July and December 2021 there were 2,300 COVID-19 deaths in the most deprived areas of England, 2.5 times more than the 900 in the least deprived areas.
Inequalities have also remained among people from different ethnic backgrounds, although the latest data are only available up to February 2022. In the Omicron variant wave, Bangladeshi and Pakistani men and women have had mortality rates between two and three times higher than white British men and women, while mortality rates for black Caribbean men and women of mixed ethnicity are also higher than for white British men and women respectively.
Our impact inquiry showed the key factors associated with these patterns of deaths, including increased risk of exposure to the virus and pre-existing poor health. Risk of exposure may no longer be a key factor at this stage in the pandemic: the FT estimated that in April around 90% of the UK population had been infected with COVID-19, and the MRC Biostatistics Unit estimates there have been around 67 million COVID-19 infections as of July 2022, with the vast majority (around 52 million) occurring in the past 12 months. However, underlying health remains a key factor. People aged 50-69 years living in the 10% most-deprived areas are twice as likely to have two or more long-term conditions than those in the 10% least-deprived areas.
The vaccination programme
The reduction in COVID-19 mortality rates and excess mortality has in large part been driven by the vaccination programme, which has offered between three and five jabs to all UK adults and two jabs to 5-15-year-olds. As Figure 3 shows, the UK initially had a very speedy rollout of vaccines in 2021 although this is now equivalent to or slightly below other western European countries with around 220 COVID-19 vaccinations per 100 of population.
Despite the high overall level of vaccination there are inequalities in coverage, particularly when it comes to booster jabs. Figure 4 compares the age-standardised vaccination rate between different groups. The three or more vaccination rate is 20 percentage points higher in the least deprived areas than in the most deprived areas (81% to 61%). Those whose first language is not English are also less likely to have been vaccinated or have received a booster. People from most minority ethnic groups are less likely than white British groups to have received three shots, with around 40% of African Caribbean adults not having received any COVID-19 vaccination accounting for age. The UKHSA monitoring reports show the continued effectiveness of COVID-19 vaccination against hospitalisation and mortality, particularly for boosters.
COVID-19 illness
Long COVID
Long COVID refers to persistent symptoms lasting months after initial infection. One study drawing on the experiences of people with long COVID found a list of over 200 symptoms, but the most common symptoms were fatigue brought on by physical or mental activity, memory and cognitive problems.
Measuring how many people experience long COVID is difficult. The best-known data source in the UK is the ONS survey on self-reported long COVID. The survey tracks the number of people self-reporting 12 common long COVID symptoms continuously over a period of at least 4 to 12 weeks, which gives an estimate of around 2% of people in the UK experiencing long COVID at least 12 weeks after infection in July 2022. The ONS has also investigated methods such as experiencing any COVID-19 symptom at least 12 weeks after infection and self-reported long COVID, which provided prevalence estimates of 5% and 12% in September 2021. In the case of any one symptom, 3.5% of the control group who had not had COVID-19 also reported having these symptoms, indicating they can be common in the population generally. Other studies that include control groups tend to find lower incidences of long COVID.
While the ONS survey may be an overestimate of long COVID prevalence, it does reveal interesting trends and inequalities. The first is that the vaccination programme appears to have reduced the risk of a given infection leading to long COVID - something that appears in academic studies (eg Ayoubkhani et al 2022) - but also clear from observational data. In March 2021, the ONS survey suggested around 930,000 people in England had long COVID. By June 2022, this number was 1.6 million. Based on the MRC Biostatistics estimates, by March 2021 there had been 13 million COVID-19 infections, and 62 million COVID-19 infections by June 2022. Comparing the two very approximately suggests the first 13 million infections led to 930,000 cases (around 1 in 14), while the next 49 million infections led to around 700,000 instances of long COVID (around 1 in 70). This is not to downplay the severity of long COVID when it arises, with a large proportion reporting severe limitations on day-to-day activities. Nearly three-quarters (72%) of people on the ONS measure of long COVID report limitation in their day-to-day activities, posing a large health burden.
The incidence of long COVID on this measure is also unequal. Figure 5 shows that self-reported long COVID incidence is higher for those in more deprived areas, people of white ethnicity, those aged 35-69 years, and in particular, those whose pre-existing health was limited by conditions. Those with pre-existing health conditions have also seen the largest absolute increase in long COVID prevalence between March 2021 and June 2022.
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