COVID-19 Mortality in Australia: Deaths registered until 30 November 2023

• 20,755 of the 658,524 death registrations received by the ABS between March 2020 and November 2023 were of people who died from or with COVID-19. 
• The underlying cause of death for 16,472 (79.4%) of these people was COVID-19. 
• There were a further 4,283 people who died of other causes (e.g. cancer) but COVID-19 contributed to their death.  
• Chronic cardiac conditions were the most common pre-existing chronic condition for those who had COVID-19 certified as the underlying cause of death.
• 379 Aboriginal and Torres Strait Islander people died from or with COVID-19 since August 2021. 

The Coronavirus Disease 2019 (COVID-19) is a respiratory infection caused by a new coronavirus. On 11 March 2020 the World Health Organization (WHO) declared COVID-19 to be a pandemic.

Data published by the ABS in this article is collected through the civil registration system. COVID-19 mortality is identified via death certificates - if the certifying practitioner records COVID-19 on the death certificate, coding is undertaken and the death is classified as either "due to COVID-19" (the virus is considered to have caused the train of morbid conditions leading to death) or "died with COVID-19" (the virus contributed to death, but another disease or condition caused death). COVID-19 must be recorded on the death certificate for a death to be classified as being either "due to" or "with" COVID-19. 

Civil registration based data is not directly comparable with that released from disease surveillance systems which are designed to release information rapidly on both infections and mortality. 

The table below shows the number of registered deaths due to COVID-19 over the course of the pandemic by month of occurrence. 

The number of deaths occurring in October and November 2023 is not reflective of the true total and will increase as additional death registrations are received by the ABS. Other time periods may also change if the death registration process has been delayed. 

Deaths due to COVID-19 have increased slightly in October and November 2023 after lows in August and September. For every month in 2023 deaths due to COVID-19 have been below the level of the comparable month in 2022. 

Cumulatively, the highest number of deaths have occurred during the Omicron wave.

• Males had a higher number of registered deaths (9,013) due to COVID-19 than females (7,459 deaths). In 2023 there have been 12.0% more male deaths than female deaths, with male deaths exceeding female deaths in all age groups other than those aged over 90 and those aged 30-39.
• For each year of the pandemic, the highest number of COVID-19 deaths occurred among those aged 80-89 years. In 2022 and 2023, the female age group with the highest number of COVID-19 deaths was those aged over 90 years.
• Males aged under 80 years had a higher number of deaths than females (3,199 compared with 1,833). In 2023 there have been 62.1% more male deaths than female deaths in this age group.

• As of 30 November 2023, the most registered deaths due to COVID-19 had occurred in New South Wales (5,829) and Victoria (5,508). These states also have the highest age standardised death rates (SDRs) since the pandemic began, at 13.2 and 15.9 deaths per 100,000 population (rate for total pandemic period) respectively.
• In 2023, the highest SDRs were in NSW (12.3) and Tasmania (12.1). Queensland (9.8) and Western Australia (10.3) recorded the lowest SDRs.

COVID-19 was the underlying cause of death for 16,472 registered deaths that have been received by the ABS occurring up to 30 November 2023. The WHO defines the underlying cause of death as the disease or condition that initiated the train of morbid events leading to death. Diseases and conditions reported on the MCCD that are not the underlying cause of death are referred to as associated causes. Associated causes can be either: 

Conditions listed in the causal sequence (the chain of events leading to death). These are conditions that were caused by COVID-19 and its complications; or

Pre-existing chronic conditions, often listed in Part II of the MCCD as ‘other conditions relevant to the death’. These are conditions that a person had before they contracted COVID-19.

The proportion of deaths where COVID-19 was the only condition recorded on the medical certificate has declined since the pandemic began to 3.1% of deaths in 2023, from 11.3% in 2020. The proportion of deaths with both causal sequence conditions and pre-existing chronic conditions has increased from around 40% in 2020 to nearly 60% in 2023.

COVID-19 is a respiratory illness that weakens the immune system causing inflammation. This commonly leads to poor respiratory outcomes such as viral pneumonia and secondary infection. Other manifestations such as acute kidney injury and cardiac complications have also been reported but these are less common. 

In 2023, 69.2% of COVID-19 deaths had a causal sequence specified, similar to 2022 (71.0% of deaths).

• Acute respiratory diseases were the most commonly certified diseases listed as a consequence of COVID-19.
• Pneumonia was present as a consequence of COVID-19 in over 50% of deaths where a causal sequence was certified by a doctor each year.
• The proportion of deaths with other infections (e.g. sepsis) recorded has increased from 11.3% of deaths with an acute condition in 2022 to 13.3% in 2023.

People with pre-existing chronic conditions have greater risk of developing severe illness from COVID-19. While pre-existing chronic conditions do not cause COVID-19, they increase the risk of COVID-19 complications and therefore increase the risk of death. 

The proportion of deaths from COVID-19 which had a chronic condition recorded has increased from a low of 65.1% in 2021 to 85.1% in 2023. Of these deaths:

• Chronic cardiac conditions including coronary atherosclerosis, cardiomyopathies and atrial fibrillation were the most commonly certified co-morbidities each year since 2021, occurring on around 40% of all COVID-19 deaths with a chronic condition.
• Dementia including Alzheimer's disease was certified as a pre-existing condition in 28.3% of deaths due to COVID-19 with a chronic condition mentioned in 2023, slightly down from 30.2% in 2022.
• Chronic respiratory conditions were certified as a pre-existing condition in 18.2% of the deaths with a chronic condition mentioned in 2023, which has been very stable since 2021.
• Cancer was a pre-existing condition in 18.4% of COVID-19 deaths with a chronic condition in 2023, up from 17.4% in 2022. Blood and lymph cancers (e.g. leukaemia) were the most commonly certified cancer type among those deaths. 
• Diabetes, a condition that weakens the immune system, was certified as a pre-existing condition in 15.2% of deaths with a chronic condition mentioned. This proportion has fallen from 23.9% in 2021 to 13.0% in 2023.
• The type of comorbidities most commonly present in Australian deaths due to COVID-19 are consistent with those reported internationally.

• Over 60% of those who died from COVID-19 in 2023 were born in Australia. This has risen from around 30% in 2021 and around 55% in 2022. 
• Around 30% of the people who died from COVID-19 in 2023 who were born overseas were born in the United Kingdom or Ireland. This proportion was just over 6% in 2021 and around 20% in 2022.
• Around 3% of the people who died from COVID-19 in 2023 who were born overseas were born in the Middle East, down from 23% in 2021 and 6% in 2022.

• Those who died of COVID-19 with a country of birth of overseas, had an age-standardised death rate 1.4 times higher than that of people who were born in Australia (15.4 deaths per 100,000 people compared to 11.2 deaths). This mortality rate has varied considerably during the course of the pandemic. In 2020, the age standardised death rate was 2.1 times higher for those who are were overseas born, increasing to 3.9 times higher in 2021 before falling to 1.3 times higher in 2022. In 2023 the age standardised death rate for those born overseas (11.9) was lower than that of those born in Australia (12.6). 
• The range of age standardised death rates by country of birth was much wider in 2021 and 2022 than in 2023. In 2021 the highest rate was for those born in the Middle East (47.7) and the lowest rate was for those born in the United Kingdom and Ireland (1.6). In 2022 the highest rate remained for those born in the Middle East (60.3) and the lowest rate was for those born in Sub-Saharan Africa (21.4). In 2023 the highest rate was for those born in Eastern Europe (15.5) and the lowest rate was for those born in the Americas (7.1).
• Since the pandemic began, those with a country of birth in the Middle East had the highest age-standardised death rate at 31.9 deaths per 100,000 people, and those with a country of birth in Sub-Saharan Africa had the lowest age-standardised death rate at 9.2 per 100,000 people.

Socio-economic indexes rank areas in Australia according to relative socio-economic advantage and disadvantage.

• Throughout the pandemic, deaths have been higher in more disadvantaged areas and lower in less disadvantaged areas. The extent of this has varied during the pandemic.
• In 2021, the number of people who died due to COVID-19 was 6 times higher for in those in quintile 1 (most disadvantaged) than those in quintile 5 (least disadvantaged). This ratio declined to 2.8 times higher in 2022, and has fallen further to 2.4 times higher in 2023. 

For death registrations received by the ABS up to 30 November 2023, there were 4,283 people who died with COVID-19 rather than directly from the virus itself. In this article, these deaths are referred to as COVID-19 related deaths.

A COVID-19 related death is one where there is a disease or injury pathway to death that is not directly caused by the virus. For example, a person may have late stage cancer that has metastasised extensively causing organ damage leading to death. This person may also have contracted COVID-19. While the virus or its complications may have negatively impacted health in an immuno-compromised person, the virus itself did not cause the terminal event leading to death (e.g. organ failure caused by metastases). In this example, the underlying cause of death would be recorded as cancer and COVID-19 would be considered an associated cause of death.

Most recorded COVID-19 related deaths (4,210 deaths, 98.3%) occurred during the Omicron waves. There were 9 COVID-19 related deaths (0.2%) recorded during wave 1 and 2 of the pandemic in Australia, and 64 deaths (1.5%) during the Delta wave. The number of COVID-19 related deaths is expected to increase as additional registrations are received by the ABS. 

COVID-19 related deaths have been lower throughout 2023 than 2022.

As of 30 November 2023, the most registered COVID-19 related deaths had occurred in New South Wales (1,570) and Queensland (958). The highest age standardised death rates have been in the Northern Territory (8.2 deaths per 100,000 people per year) and Tasmania (6.2) while the lowest rates have been in Victoria (2.0) and South Australia (2.7).

In 2023, the highest SDRs were in Tasmania (6.6) and the ACT (5.7). Victoria (1.6) recorded the lowest SDR.

Considering the deaths from and with COVID-19 together, the states with the highest age standardised death rates since the pandemic began were the Northern Territory (20.1), Victoria (17.9) and NSW (16.8). The state with the lowest rate was Western Australia (11.2). In 2023 the highest rates were in Tasmania (18.7), the ACT (17.1) and NSW (16.5) while the lowest rate has been in Victoria (13.1).

Of the 4,283 people who died with COVID-19, cancers were the most common underlying cause of death. Blood and lymph cancers (e.g. leukaemia) were the most commonly certified cancer type among those deaths. Circulatory system diseases were the second most common underlying cause of death in COVID-19 related deaths. Ischaemic heart diseases were the most common cause of circulatory system disease for those who died with COVID-19. All of these results still hold in 2023.

Aboriginal and Torres Strait Islander peoples are at heightened risk of more severe outcomes from COVID-19. There are several reasons for this, including higher rates of socioeconomic disadvantage, higher rates of chronic diseases and limited access to culturally safe health care.

This article presents information on Aboriginal and Torres Strait Islander people who have died ‘from’ COVID-19 (where it directly caused conditions leading to death) or ‘with’ COVID-19 (where it was a contributing factor but did not directly cause death). For most of the analysis deaths ‘from’ and ‘with’ COVID-19 are presented together due to small numbers of deaths.

There were 379 COVID-19 associated deaths of Aboriginal and Torres Strait Islander people between August 2021 and November 2023 across all jurisdictions in Australia. There were no recorded deaths due to COVID-19 of Aboriginal and Torres Strait Islander people in 2020 through to July 2021.

There have been deaths recorded in all jurisdictions of Aboriginal and Torres Strait Islander people. However, the rest of this analysis focusses on deaths registered in New South Wales, Queensland, Western Australia, South Australia and the Northern Territory only. Only these five states and territories have evidence of a sufficient level of Indigenous identification and high enough numbers of Aboriginal and Torres Strait Islander deaths to support mortality analysis.

Throughout 2023 there have been fewer deaths of Aboriginal and Torres Strait Islander people than in the same month in 2022. The largest number of deaths occurred in February 2022 (39 deaths), followed by 28 deaths in August 2022. In 2023, the highest number of deaths has occurred in January (18 deaths).

There were 346 Aboriginal and Torres Strait Islander people who had COVID-19 certified as a cause of death across the five jurisdictions. Of these people:

• 226 died due to COVID-19. This is where the virus caused complications that led directly to death. A further 120 people died “with COVID-19”. This is where another disease caused the terminal complication causing death but COVID-19 was a contributing factor.
• The age-standardised death rates for deaths from COVID-19 and deaths with COVID-19 are similar for Aboriginal and Torres Strait Islander males and females. 
• Of those who died from or with COVID-19, a higher proportion of Aboriginal and Torres Strait Islander people died with COVID-19 as a contributing factor compared with non-Indigenous people (34.7% compared with 24.2%).
• The mortality rate from COVID-19 is 1.7 times higher in Aboriginal and Torres Strait Islander people compared to non-Indigenous people.
• For Aboriginal and Torres Strait Islander females, the rate of mortality with COVID-19 is 2.7 times higher than that of non-Indigenous females.

• The highest age-specific death rate for Aboriginal and Torres Strait Islander people is in those aged 75 years and over. 
• Aboriginal and Torres Strait Islander females aged 75 years and over had higher age-specific death rates than males.
• The rate of mortality in Aboriginal and Torres Strait Islander people aged 45-54 and 55-64 years of age is around 4 times higher than non-Indigenous people of the same age. 

Additional causes of death certified on the Medical Certificate of Cause of Death provides more information on mortality from COVID-19. Examining conditions in the causal sequence can provide insights into how a disease progresses and leads to death. Examining pre-existing chronic conditions provides an understanding of risk factors that might contribute to death from a particular disease. Both can inform health prevention and intervention policies.

Aboriginal and Torres Strait Islander people have a high prevalence of chronic diseases such as diabetes, renal disease, and cardiovascular disease with an earlier onset of these conditions. Chronic disease is a leading contributor to the burden of disease among Aboriginal and Torres Strait Islander peoples.

For the Aboriginal and Torres Strait Islander people who died from COVID-19:

• Just over 60% developed pneumonia as a consequence of COVID-19. 
• Chronic cardiac conditions were the most common pre-existing condition present in 38.7% of deaths.
• Diabetes, chronic respiratory conditions and chronic kidney diseases were present in around 23-34% of deaths with a chronic condition recorded. 
• A higher proportion of Aboriginal and Torres Strait Islander people had diabetes, chronic kidney disease, chronic respiratory diseases, hypertension and obesity listed as pre-existing chronic conditions compared to non-Indigenous people.

SEIFA ranks areas in Australia according to relative socio-economic advantage and disadvantage. Nearly 50% of the Aboriginal and Torres Strait Islander population are in quintile 1 (most disadvantaged). The majority of deaths associated with COVID-19 deaths occurred among Aboriginal and Torres Strait Islander people in quintile 1 (most disadvantaged).

Those who live in regional areas can be susceptible to poorer health outcomes. Aboriginal and Torres Strait Islander peoples living in remote areas have a lower life expectancy and higher rates of chronic disease than people living in urban areas. The table below shows mortality rates by region for those who died from COVID-19. Age-standardised death rates are presented below to enable comparison between populations with different age structures for those living in different regions.

For Aboriginal and Torres Strait Islander people who died from or with COVID-19:

• The highest number of deaths for Aboriginal and Torres Strait Islander people occurred among those living in inner and outer regional areas.
• The highest age-standardised death rate for Aboriginal and Torres Strait Islander people was among those living in remote and very remote areas.
• The age-standardised death rate was higher for Aboriginal and Torres Strait Islander people across all remoteness areas compared to non-Indigenous people. The rate ratio was highest for those living in remote and very remote communities (3.9 times higher).