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. 2021 May 19:373:n1137.
doi: 10.1136/bmj.n1137.

Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries

Nazrul Islam  1   2 , Vladimir M Shkolnikov  3   4 , Rolando J Acosta  5 , Ilya Klimkin  4 , Ichiro Kawachi  6 , Rafael A Irizarry  5   7 , Gianfranco Alicandro  8 , Kamlesh Khunti  9   10 , Tom Yates  9   11 , Dmitri A Jdanov  3   4 , Martin White  2 , Sarah Lewington  12   13 , Ben Lacey  12
Affiliations

Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries

Nazrul Islam et al. BMJ. .

Abstract

Objective: To estimate the direct and indirect effects of the covid-19 pandemic on mortality in 2020 in 29 high income countries with reliable and complete age and sex disaggregated mortality data.

Design: Time series study of high income countries.

Setting: Austria, Belgium, Czech Republic, Denmark, England and Wales, Estonia, Finland, France, Germany, Greece, Hungary, Israel, Italy, Latvia, Lithuania, the Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Scotland, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, and United States.

Participants: Mortality data from the Short-term Mortality Fluctuations data series of the Human Mortality Database for 2016-20, harmonised and disaggregated by age and sex.

Interventions: Covid-19 pandemic and associated policy measures.

Main outcome measures: Weekly excess deaths (observed deaths versus expected deaths predicted by model) in 2020, by sex and age (0-14, 15-64, 65-74, 75-84, and ≥85 years), estimated using an over-dispersed Poisson regression model that accounts for temporal trends and seasonal variability in mortality.

Results: An estimated 979 000 (95% confidence interval 954 000 to 1 001 000) excess deaths occurred in 2020 in the 29 high income countries analysed. All countries had excess deaths in 2020, except New Zealand, Norway, and Denmark. The five countries with the highest absolute number of excess deaths were the US (458 000, 454 000 to 461 000), Italy (89 100, 87 500 to 90 700), England and Wales (85 400, 83 900 to 86 800), Spain (84 100, 82 800 to 85 300), and Poland (60 100, 58 800 to 61 300). New Zealand had lower overall mortality than expected (-2500, -2900 to -2100). In many countries, the estimated number of excess deaths substantially exceeded the number of reported deaths from covid-19. The highest excess death rates (per 100 000) in men were in Lithuania (285, 259 to 311), Poland (191, 184 to 197), Spain (179, 174 to 184), Hungary (174, 161 to 188), and Italy (168, 163 to 173); the highest rates in women were in Lithuania (210, 185 to 234), Spain (180, 175 to 185), Hungary (169, 156 to 182), Slovenia (158, 132 to 184), and Belgium (151, 141 to 162). Little evidence was found of subsequent compensatory reductions following excess mortality.

Conclusion: Approximately one million excess deaths occurred in 2020 in these 29 high income countries. Age standardised excess death rates were higher in men than women in almost all countries. Excess deaths substantially exceeded reported deaths from covid-19 in many countries, indicating that determining the full impact of the pandemic on mortality requires assessment of excess deaths. Many countries had lower deaths than expected in children <15 years. Sex inequality in mortality widened further in most countries in 2020.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no specific funding was received for this study; the BMJ open access fee was supported by research funding from the US Centers for Disease Control and Prevention Foundation (with support from Amgen); SL reports grants from the MRC and research funding from the US Centers for Disease Control and Prevention Foundation (with support from Amgen); MW reports research funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, MRC, NIHR, and Wellcome Trust unrelated to this study; NI, SL, and VMS are members of the WHO-UN DESA Technical Advisory Group on covid-19 mortality assessment; KK is a member of the UK Scientific Advisory Group for Emergency (SAGE) and Independent SAGE; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Monthly excess deaths (per 100 000) in 29 high income countries in 2020, all ages, by sex. Excess deaths in 2020 were calculated as difference in observed deaths and expected deaths predicted using over-dispersed Poisson model that accounts for temporal trends and seasonal and natural variability. Estimated excess deaths for each week of 2020 were aggregated into months. Data: Short-term Mortality Fluctuations data series of Human Mortality Database
Fig 2
Fig 2
Weekly percentage deviation from expected deaths in 29 countries in 2020, all ages, by sex. Weekly percentage deviation of observed deaths versus expected deaths predicted using over-dispersed Poisson model that accounts for temporal trends and seasonal and natural variability. Percentage changes from mean during study period were modelled using smooth function of time. Data: Short-term Mortality Fluctuations data series of Human Mortality Database
Fig 3
Fig 3
Excess death rates in 29 high income countries in 2020, by sex and age. Excess death rate (per 100 000) in 2020 was calculated as difference in observed deaths and expected deaths predicted using over-dispersed Poisson model that accounts for temporal trends and seasonal and natural variability. Age standardised within each age group. Data: Short-term Mortality Fluctuations data series of Human Mortality Database
Fig 4
Fig 4
Crude and age standardised excess death rates in 29 high income countries in 2020, by sex. Excess death rate (per 100 000) in 2020 was calculated as difference in observed deaths and expected deaths predicted using over-dispersed Poisson model that accounts for temporal trends and seasonal and natural variability. Age standardised, where indicated, to 2013 European standard population. Bottom panel: estimates above horizontal line at zero indicate higher excess death rate in men. Data: Short-term Mortality Fluctuations data series of Human Mortality Database
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Comment in

  • Measuring the impact of covid-19.
    Clarke JM, Majeed A, Beaney T. Clarke JM, et al. BMJ. 2021 May 19;373:n1239. doi: 10.1136/bmj.n1239. BMJ. 2021. PMID: 34011499 No abstract available.

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