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05 October 2021 | Policy Analysis
Trends and disparities in mortality and excess mortality due to COVID-19 and beyond
1.4. Health status
Population health in Slovenia has improved considerably over the last decades. Before the COVID-19 pandemic, which started in 2020, life expectancy at birth had been rising, from 73.6 years in 1993 to 81.6 years in 2019 (Eurostat, 2021l) (Table1.3) and had surpassed the EU28 average (81.3 years in 2019). However, available estimates for life expectancy at birth for 2020 (available at the time of writing, July 2021) show that due to higher than usual death rates associated with COVID-19 during 2020, life expectancy in Slovenia had decreased by one year to its 2013 level, and now stands at 80.6 years. As with other indicators (Box1.1), there are significant gender gaps in life expectancy; average life expectancy for men was 77.8 years in 2020, while it was 83.4 years for women.
Table1.3 | Box1.1 |
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Mortality by age and sex groups shows similar patterns to the EU averages. Both infant and maternal mortality have declined over the last two and a half decades.
The burden of noncommunicable diseases is high. Circulatory diseases, followed by cancers, are the most common causes of death, accounting for 40% and 33% of mortality, respectively, in 2018. Other noncommunicable diseases cause 13% of further deaths (NIJZ, 2018). Looking at more specific diseases, stroke and ischaemic heart disease were the leading causes of mortality in 2018 (about 10% of all deaths each), followed by lung cancer (6%) (OECD/EOHSP, 2021).
The main cancer site among men in 2018 was prostate cancer (161.1 new cases per 100 000 population – 78.6 standardized incidence rate), followed by skin cancers, excluding melanoma (147.5 new cases per 100 000 population – 69.6 standardized incidence rate); cancer of the colon, rectum and anus (80.5 – 39.3); and cancer of lung, trachea, and bronchus (71.4 – 33.3). The most common type of cancer was breast cancer among women (134.2 new cases per 100 000 – 71.6 standardized incidence rate), followed by skin cancers, excluding melanoma (146.5 – 57.7); cancer of lung, trachea, and bronchus (50.6 – 22.7); and cancer of the colon, rectum, and anus (54.3 – 21.4). Notably, though the incidence of female breast cancer grew 1.63% on average annually between 2002 and 2018, the standardized death rate decreased from 30.6 to 14.7 deaths per 100 000 population (Zadnik & Žagar, 2020).
In 2020, COVID-19 accounted for about 11.8% of total deaths in Slovenia. Most deaths (83%) were among those over 75 years of age. The mortality rate from COVID-19 up to the end of June 2021 was about 45% higher in Slovenia than the average across EU countries (about 2267 per million population compared with about 1660). Moreover, data on excess mortality suggest that the direct and indirect death toll related to the pandemic in Slovenia is likely to be higher. Overall, excess mortality from March to December 2020 was around 3900 deaths – about 30% higher than total reported COVID-19 deaths (2891) (OECD/EOHSP, 2021).
Apart from COVID-19, communicable diseases are not a significant cause of morbidity or mortality. Immunization coverage is higher than the EU average. The incidence of vaccine-preventable diseases, such as measles and mumps, is decreasing, though there have been small measles outbreaks (in 2014, 2015, 2019) due to people with incomplete vaccinations travelling to other countries in which there occasionally are outbreaks of measles. There is also growing vaccine hesitancy, especially in the context of COVID-19; around 30% of the adult population in July 2021 opposed getting the vaccine (ranging, by age groups, between 27.5% and 31.2%; PANDA survey (NIJZ, 2021d)). In a 2019 Eurobarometer survey, while 83% of respondents believe vaccines are rigorously tested before authorization, 60% think that vaccines can often produce serious side-effects (European Commission, 2019b).
External causes (injuries and poisoning) account for 7.3% of deaths and are the leading cause of death for those aged between 1 and 45 years. This rate exceeds the European average.
Additionally, a large share of deaths is connected to behavioural factors (Fig1.2); for example, dietary risks (16% of all deaths), tobacco smoking (15%) and alcohol consumption (5%). Overweight and obesity rates are higher than in many EU countries and increasingly are a public health concern, particularly for teenagers (Inchley et al., 2020; OECD/EOHSP, 2021) (see section 7.5).
Fig1.2
Despite decreases in deaths caused by liver diseases, Slovenia has one of the highest mortality rates from diseases caused by alcohol abuse in Europe. In 2016, 17.9 deaths per 100 000 population were caused by liver disease, which is down from 30 per 100 000 population in 2011 (Eurostat, 2021l), but still higher than the EU average of 14.5 per 100 000. Though average alcohol consumption decreased from 13.4 litres per capita in 1995 to 11.0 litres in 2019 (NIJZ, 2020b), on a par with the EU average (WHO, 2020), there are substantial gender and age inequalities with more men (29%) more likely to report heavy episodic alcohol use than women (10%) (OECD/EOHSP, 2021).
The percentage of adults in Slovenia who smoke daily has fallen since the early 2000s. At 17.4% of the adult population between 15 and 64 years in 2019, it is below the EU27 (European Union Member States 2020 and after) average (19.5%). There is a gender and socioeconomic dimension, with more men and people with lower educational attainment likely to be daily smokers (Box1.1). Smoking in children and teens has decreased but remains high: 16% of 15-year-olds are smokers (which is the lowest recorded percentage in 16 years) and 2.6% of all youngsters start smoking before the age of 13 (Inchley et al., 2020; OECD/EOHSP, 2021), significantly down from 17% in 2014.
Meanwhile, over one third of adults reported a chronic condition in 2019, a proportion equal to the EU average. People with higher incomes are more likely to report better health, and fewer women perceive themselves to be in good health compared with men (Eurostat, 2021b; OECD/EOHSP, 2021).
See Box1.1 for more information on the gender and socioeconomic dimension of health status.
Since 2020 and the COVID-19 pandemic and its high fatality rates, mortality and excess mortality has received a lot of attention across countries. In retrospect, we can now say that mortality due to COVID-19 was extremely high in the second wave of the epidemic, which hit Slovenia in autumn of 2020. The first wave had low incidence and mortality rates, so the impact of the epidemic in spring 2020 was minimal. It is estimated that around 3900 people died due to and with COVID-19 in 2020 overall, mainly in autumn 2020. That is almost 20% of the average absolute mortality in a year. Excess mortality in November 2020 reached between 66% and100% above average levels (1). The curves for mortality for COVID-19 and excess mortality were quite close to each other, indicating that most excess mortality was probably due to COVID-19. The situation repeated to a much lesser degree late in 2021, when excess mortality exceeded the pre-COVID-19 levels by a maximum of 50% and where the impact of COVID-19 was still significant but not to the same degree as in 2020.
The Euromomo webpage analysing excess mortality in Europe shows a significant excess mortality for Slovenia in 2020 with the maximum z-value of 14.43 (2). Fatality rates for COVID-19 were higher in all age groups for males. Additionally, over 75% of the excess deaths in 2020 occurred in persons above the age of 75 (1). Such burden on the elderly was particularly felt in the nursing homes across the country, where staff shortages, partly from before and partly as a result of absences due to COVID-19, required additional staff to be transferred in from primary care. For the most part, patients from nursing homes with severe course of COVID-19 were moved to hospitals, thus significantly saturating the overall hospital capacity for critically ill patients in most regional hospitals. Lessons from this situation in 2020 were then used as a guidance in the autumn of 2021, when hospital capacity never reached critical level, even though it became relatively saturated by the end of the year.
All these developments caused a net drop in life expectancy for both genders in 2020 of 1 year, namely from 81.6 years in 2019 to 80.6 years in 2020 (3). In 2021, there are signs of life expectancy picking up again to 80.9 years.
Authors
References
- COVID-19 data for Slovenia: https://covid-19.sledilnik.org/en/stats
- EU Webpage on excess mortality: https://www.euromomo.eu/graphs-and-maps/#z-scores-by-country
- Eurostat data for 2020: https://ec.europa.eu/eurostat/databrowser/view/tps00205/default/table?lang=en