Original research

Saskia Mostert ‍ ‍ ,1,2 Marcel Hoogland,3 Minke Huibers,2 Gertjan Kaspers1,2

To cite: Mostert S, Hoogland M,
Huibers M, et al. Excess
mortality across countries in
the Western World since the
COVID-­19 pandemic: ‘Our
World in Data’ estimates ofJanuary 2020 to December
2022. BMJ Public Health2024;2:e000282. doi:10.1136/
bmjph-2023-000282

ABSTRACTIntroduction Excess mortality during the COVID-­19
pandemic has been substantial. Insight into excess death
rates in years following WHO’s pandemic declarationis crucial for government leaders and policymakers toevaluate their health crisis policies. This study explores
excess mortality in the Western World from 2020 until
2022.
Methods All-­cause mortality reports were abstracted
for countries using the ‘Our World in Data’ database.
Excess mortality is assessed as a deviation between the► Additional supplemental
material is published online only. reported number of deaths in a country during a certain
week or month in 2020 until 2022 and the expected
To view, please visit the journal
online (https://​doi.​org/​10.​1136/​ number of deaths in a country for that period under normal
bmjph-​2023-​000282).
conditions. For the baseline of expected deaths, Karlinsky
and Kobak’s estimate model was used. This model uses
historical death data in a country from 2015 until 2019 andReceived 9 June 2023
accounts for seasonal variation and year-­to-­year trends in
Accepted 20 March 2024
mortality.
Results The total number of excess deaths in 47
countries of the Western World was 3 098 456 from 1
January 2020 until 31 December 2022. Excess mortality
was documented in 41 countries (87%) in 2020, 42
countries (89%) in 2021 and 43 countries (91%) in 2022.
In 2020, the year of the COVID-­19 pandemic onset andimplementation of containment measures, records present
1 033 122 excess deaths (P-­score 11.4%). In 2021, theyear in which both containment measures and COVID-­19
vaccines were used to address virus spread and infection,
the highest number of excess deaths was reported:
1 256 942 excess deaths (P-­score 13.8%). In 2022, when
© Author(s) (or theirmost containment measures were lifted and COVID-­19
employer(s)) 2024. Re-­use
vaccines were continued, preliminary data present 808 392
permitted under CC BY.
Published by BMJ.
excess deaths (P-­score 8.8%).
1
Conclusions Excess mortality has remained high in thePediatric Oncology, Emma
Children's Hospital, Amsterdam Western World for three consecutive years, despite the
UMC, Vrije Universiteit,
implementation of containment measures and COVID-­19
Amsterdam, The Netherlands
vaccines. This raises serious concerns. Government
2
Pediatric Oncology, Princess
leaders and policymakers need to thoroughly investigate
Máxima Center for Pediatricunderlying causes of persistent excess mortality.
Oncology, Utrecht, The
Netherlands
3
Independent researcher,
Amsterdam, The Netherlands

Correspondence to
Dr Saskia Mostert;​s.​mostert@​amsterdamumc.​nl

INTRODUCTION
Excess mortality is internationally recognised as an accurate measure for monitoring

WHAT IS ALREADY KNOWN ON THIS TOPIC⇒ Excess mortality during the COVID-­19 pandemic has

been substantial. Insight into excess death rates
in years following WHO’s pandemic declaration is
crucial for government leaders and policymakers toevaluate their health crisis policies.

WHAT THIS STUDY ADDS
⇒ Excess mortality has remained high in the WesternWorld for three consecutive years, despite the implementation of containment measures and COVID-­19
vaccines. This raises serious concerns.

HOW THIS STUDY MIGHT AFFECT RESEARCH,
PRACTICE OR POLICY⇒ Government leaders and policymakers need to thor-

oughly investigate the underlying causes of persistent excess mortality.

and comparing health crisis policies acrossgeographic regions.1–4 Excess mortality
concerns the number of deaths from allcauses during a humanitarian emergency,such as the COVID-­19 pandemic, above theexpected number of deaths under normal
circumstances.5–7 Since the outbreak of the
COVID-­19 pandemic, excess mortality thus
includes not only deaths from SARS-­CoV-­2
infection but also deaths related to the indirect effects of the health strategies to address
the virus spread and infection.1–4 The burdenof the COVID-­19 pandemic on disease anddeath has been investigated from its beginning. Numerous studies expressed that SARS-­
CoV-­2 infection was likely a leading cause ofdeath among older patients with pre-­existingcomorbidities and obesity in the early phaseof the pandemic, that various containment
measures were effective in reducing viraltransmission and that COVID-­
19 vaccines
prevented severe disease, especially among
the elderly population.1 8–14 Although
COVID-­
19 containment measures andMostert S, et al. BMJ Public Health 2024;2:e000282. doi:10.1136/bmjph-2023-000282



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Excess mortality across countries in theWestern World since the COVID-­19
pandemic: ‘Our World in Data’ estimatesof January 2020 to December 2022

BMJ Public Health2of vaccinations, prior infections and the evolution of new
and milder variants.37 38
Although COVID-­
1 9 vaccines were provided toguard civilians from suffering morbidity and mortality
by the COVID-­1 9 virus, suspected adverse events havebeen documented as well. 15 The secondary analysis of
the placebo-­controlled, phase III randomised clinical
trials of mRNA COVID-­1 9 vaccines showed that the
Pfizer trial had a 36% higher risk of serious adverse
events in the vaccine group. The risk difference was
18.0 per 10 000 vaccinated (95% CI 1.2 to 34.9), andthe risk ratio was 1.36 (95% CI 1.02 to 1.83). The
Moderna trial had a 6% higher risk of serious adverse
events among vaccine recipients. The risk difference
was 7.1 per 10 000 vaccinated (95% CI −23.2 to 37.4),
and the risk ratio was 1.06 (95% CI 0.84 to 1.33).39 By
definition, these serious adverse events lead to either
death, are life-­t hreatening, require inpatient (prolongation of) hospitalisation, cause persistent/significant
disability/incapacity, concern a congenital anomaly/birth defect or include a medically important event
according to medical judgement.39–41 The authorsof the secondary analysis point out that most ofthese serious adverse events concern common clinical conditions, for example, ischaemic stroke, acutecoronary syndrome and brain haemorrhage. This
commonality hinders clinical suspicion and consequently its detection as adverse vaccine reactions.39
Both medical professionals and citizens have reported
serious injuries and deaths following vaccination tovarious official databases in the Western World, such
as VAERS in the USA, EudraVigilance in the European Union and Yellow Card Scheme in the UK.42–48 A
study comparing adverse event reports to VAERS andEudraVigilance following mRNA COVID-­1 9 vaccines
versus influenza vaccines observed a higher risk ofserious adverse reactions for COVID-­
1 9 vaccines.
These reactions included cardiovascular diseases,
coagulation, haemorrhages, gastrointestinal eventsand thromboses. 39 49 Numerous studies reported
that COVID-­1 9 vaccination may induce myocarditis,
pericarditis and autoimmune diseases. 50–57 Postmortem examinations have also ascribed myocarditis,
encephalitis, immune thrombotic thrombocytopenia,
intracranial haemorrhage and diffuse thrombosis
to COVID-­1 9 vaccinations. 58–67 The Food and Drug
Administration noted in July 2021 that the following
potentially serious adverse events of Pfizer vaccines
deserve further monitoring and investigation: pulmonary embolism, acute myocardial infarction, immune
thrombocytopenia and disseminated intravascular
coagulation. 39 68
Insight into the excess death rates in the years following
the declaration of the pandemic by WHO is crucial forgovernment leaders and policymakers to evaluate theirhealth crisis policies.1–4 This study therefore explores
excess mortality in the Western World from 1 January
2020 until 31 December 2022.
Mostert S, et al. BMJ Public Health 2024;2:e000282. doi:10.1136/bmjph-2023-000282

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COVID-­19 vaccines were thus implemented to protect
citizens from suffering morbidity and mortality by the
COVID-­19 virus, they may have detrimental effects thatcause inferior outcomes as well.1 2 15 It is noteworthy that
excess mortality during a crisis points to a more extensive underlying burden of disease, disablement andhuman suffering.16
On 11 March 2020, WHO declared the COVID-­
19
pandemic.17 Countries in the Western World promptly
implemented COVID-­
19 containment measures (suchas lockdowns, school closures, physical distancing, travel
restrictions, business closures, stay-­at-­home orders,
curfews and quarantine measures with contact tracing)to limit virus spread and shield its residents frommorbidity and mortality.18 These non-­pharmaceuticalinterventions however had adverse indirect effects (suchas economic damage, limited access to education, foodinsecurity, child abuse, limited access to healthcare,disrupted health programmes and mental health challenges) that increased morbidity and mortality fromother causes.19 Vulnerable populations in need of acuteor complex medical treatment, such as patients withcardiovascular disease, cerebrovascular conditions,diabetes and cancer, were hurt by these interventions dueto the limited access to and delivery of medical services.
Shortage of staff, reduced screening, delayed diagnostics, disrupted imaging, limited availability of medicines,
postponed surgery, modified radiotherapy and restrictedsupportive care hindered protocol adherence and worsened the condition and prognosis of patients.19–26 A
recent study investigated excess mortality from somemajor non-­COVID causes across 30 countries in 2020.
Significant excess deaths were reported from ischaemic
heart diseases (in 10 countries), cerebrovascular diseases(in 10 countries) and diabetes (in 19 countries).27 On
14 October 2020, Professor Ioannidis from Stanford
University published an overall Infection Fatality Rate of
COVID-­19 of 0.23%, and for people aged <70 years, theInfection Fatality Rate was 0.05%.28 Governments in theWestern World continued to impose lockdowns until theend of 2021.
In December 2020, the UK, the USA and Canada were
the first countries in the Western World that started withthe roll-­out of the COVID-­19 vaccines under emergency
authorisation.29–31 At the end of December 2020, a large
randomised and placebo-­
controlled trial with 43 548
participants was published in the New England Journal of
Medicine, which showed that a two-­dose mRNA COVID-­19
vaccine regimen provided an absolute risk reductionof 0.88% and relative risk reduction of 95% against
laboratory-­confirmed COVID-­19 in the vaccinated group(8 COVID-­19 cases/17 411 vaccine recipients) versus theplacebo group (162 COVID-­
19 cases/17 511 placebo
recipients).32 33 At the beginning of 2021, most other
Western countries followed with rolling out massive
vaccination campaigns.34–36 On 9 April 2021, the overall
COVID-­19 Infection Fatality Rate was reduced to 0.15%
and expected to further decline with the widespread use

BMJ Public HealthStudy designAll-­cause mortality reports were abstracted for countriesof the Western World using the ‘Our World in Data’ database.12 Only countries that had all-­cause mortality reports
available for all three consecutive years (2020–2022) were
included. If coverage of one of these years was missing,
the country was excluded from the analysis.
The ‘Our World in Data’ database retrieves theirreported number of deaths from both the Human
Mortality Database (HMD) and the World Mortality
Dataset (WMD).5 HMD is sustained by research teams ofboth the University of California in the USA and the Max
Planck Institute for Demographic Research in Germany.
HMD recovers its data from Eurostat and national statistical agencies on a weekly basis.5 70 The ‘Our World in
Data’ database used HMD as their only data source until
February 2021.5 WMD is sustained by the researchers
Karlinsky and Kobak. WMD recovers its data from HMD,
Eurostat and national statistical agencies on a weekly
basis.5 71 The ‘Our World in Data’ database started to use
WMD as a data source next to HMD since February 2021.5‘Excess mortality’ is assessed as the deviation between
the reported number of deaths in a country duringa certain week or month in 2020 until 2022 and the
expected or projected number of deaths in a country
for that period under normal conditions.5 For the baseline of expected deaths, the estimate model of Karlinsky
and Kobak was used. This linear regression model uses
historical death data in a country from 2015 until 2019
and accounts for seasonal variation in mortality and year-­to-­year trends due to changing population structure or
socioeconomic factors.5 7
Karlinsky and Kobak fit their regression model separately
for every country: Dt,Y=αt+β ⋅ Y+ϵ. In this formula, Dt,Y is thenumber of deaths observed on week (or month) t in year Y, β
is a linear slope across years, ‍αt‍are separate intercepts (fixed
effects) for each week (month/quarter) and ϵ∼N(0,σ2)
is the Gaussian noise.7 The model prediction for 2020 istaken as the baseline for the excess mortality calculations:7t = αt + β · 2020
mortality estimate
is as‍B( .‍ The final) excess)∑∑ (�t + t Dt,2021 − B
�t , where tfollows: t≥t1 Dt,2020 − B
[ 1]
‍
‍
7
indicates the summation onset in 2020. The variance ‍Var ∆ ‍of estimator ﻿‍∆‍is computed as follows: X is the predictor matrix()−1 T
in the regression, y is the response vector, ‍β� = XT X
X y‍is the vector of estimated regression coefficients, andMostert S, et al. BMJ Public Health 2024;2:e000282. doi:10.1136/bmjph-2023-000282

2 = ∥y − Xβ̂∥2 /(n − p)‍ is the unbiased estimate of noise‍σvariance, in which ﻿‍n‍is the sample size and P is the number of()−1predictors. ‍cov[
�2 [ xT x ]‍is the covariance matrix of[ ]β̂] = σ()−1 T�2 X2020 XT X
X2020
‍β̂.‍ S‍ = Cov β̂t = Cov X2020 β̂ = σ‍
is the covariance matrix of predicted baseline values ‍β̂t ,‍where X2020 is the predictor matrix for 2020. Karlinsky
and Kobak depict vector w with elements wt of length
equal to the number of rows in X2020. They set all elements
before t1 to zero, all elements from t1 forward to 1, andraise by one all elements corresponding to 2021 data.7
The predictive[ varianceof ﻿‍∆‍is denoted as follows:] ∑∑�Var[∆] = Varw
B+�2 = wT Sw + σ�2 ∥w∥1 int t t
t wt σ‍‍which the first term represents the uncertainty of ‍β̂t‍ andthe second term represents
the additive Gaussian noise. The[ ]square root of ‍Var ∆ ‍is regarded as the standard error of ‍∆.‍� � √ [ ]When the fraction z = �∆� / var ∆ is below 2, the excess‍‍
mortality of that country is considered not significantly
different from zero.7
The model regards excess mortality during the
COVID-­19 pandemic as the sum of the following factors:(a) deaths directly generated by SARS-­CoV-­2 infection,(b) deaths generated by medical system overload owing
to the pandemic, (c) excess deaths from other naturalcauses (eg, influenza and other infectious respiratory diseases during winter seasons), (d) excess deaths
from unnatural causes (eg, traffic accidents, homicides,
suicides, deaths from drug overdoses and unintentional
injuries) and (e) excess deaths from extreme events(such as heat waves, wars, power outages and natural
disasters).7 Karlinsky and Kobak’s model expressly takes
factor (e) into account and acknowledges that the contribution of factors (b), (c) and (d) is in general minor forthe majority of nations compared with factor (a).7 The
researchers have used the officially reported national
COVID-­
19 death counts from the WHO dataset.72 In
their model, common seasonal influenza during 2015
and 2019 contributes to the projected baseline of
expected deaths.7 In addition, the model corrects forpeaks of excess deaths during heat waves.7 Because thenumber of excess deaths is impacted by the population
size of a nation, the excess mortality estimates have beennormalised by the population size.7 Population size estimates of the United Nations World Population Prospectdataset have been used to estimate excess deaths per
100 000 population for 2020 until 2022.7 73 Because theInfection Fatality Rate of SARS-­CoV-­2 is age dependentand nations have different age structures, the excess
mortality estimates have been normalised by the yearlysum of the baseline mortality to account for the nation’s
age structure.7 Because the projected baseline uses a
linear trend, the model can also reckon for ameliorations in death registration across recent years.7 For eachcountry separately, Karlinsky and Kobak have taken thesevarious factors into account when predicting the baseline
mortality for 2020 until 2022. If required, adjustments

3

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MATERIALS AND METHODS
Setting
The Western World is primarily defined by culture rather
than geography. It refers to various countries in Europe
and to countries in Australasia (Australia, New Zealand)and North America (the USA, Canada) that are basedon European cultural heritage. The latter countries wereonce British colonies that acquired Christianity andthe Latin alphabet and whose populations comprised
numerous descendants from European colonists or
migrants.69

BMJ Public HealthPatient and public involvement
Patients and/or the public were not involved in thedesign, or conduct, or reporting, or dissemination plansof this research.
4

RESULTSThe ‘Our World in Data’ database contained all-­cause
mortality reports of 47 countries (96%) in the WesternWorld for the years 2020, 2021 and 2022. Only Andorra
and Gibraltar were excluded. Both countries lacked all-­cause mortality reports for the year 2022. Most countries(n=36, 77%) present weekly all-­cause mortality reports,
whereas 11 countries (23%) report monthly. The lattercountries include the following: Albania, Bosnia Herzegovina, Faeroe Islands, Greenland, Kosovo, Liechtenstein, Moldova, Monaco, North Macedonia, San Marino
and Serbia.
The all-­cause mortality reports were abstracted fromthe ‘Our World in Data’ database on 20 May 2023. At thisdate, four countries (9%) still lacked all-­cause mortality
reports for various periods: Canada (1 month), Liechtenstein (3 months), Monaco (3 months) and Montenegro(4 months). It is noteworthy that all-­cause mortality
reports are also still being updated for the other countries due to registration delays which may take weeks,months or even years.
Excess mortality
Online supplemental table 1 illustrates that the total
number of excess deaths in the 47 countries of theWestern World was 3 098 456 from 1 January 2020 until 31
December 2022. Excess mortality was documented in 41
countries (87%) in 2020, in 42 countries (89%) in 2021
and in 43 countries (91%) in 2022.
In 2020, the year of the COVID-­
19 pandemic andimplementation of the containment measures, 1 033 122
excess deaths (P-­score 11.4%) were recorded. In 2021,
the year in which both COVID-­19 containment measures
and COVID-­19 vaccines were used to address virus spreadand infection, a total of 1 256 942 excess deaths (P-­score
13.8%) were reported. In 2022, the year in which mostcontainment measures were lifted and COVID-­
19
vaccines were continued, preliminary available data
counts 808 392 excess deaths (P-­score 8.8%).
Figure 1 presents the excess mortality and cumulative
excess mortality in 47 countries of the Western World
over the years 2020, 2021 and 2022. The linear excess
mortality trendline is almost horizontal.
Excess mortality P-scores
Figure 2 shows the excess mortality P-­scores per country
in the Western World. Only Greenland had no excess
deaths between 2020 and 2022. Among the other 46
countries with reported excess mortality, the percentage
difference between the reported and projected numberof deaths was highest in 13 countries (28%) during 2020,in 21 countries (46%) during 2021 and in 12 countries(26%) during 2022. Figure 3 exemplifies excess mortalityP-­score curves of the highest-­populated country of North
America (the USA), the four highest-­populated countriesof Europe (Germany, France, the UK and Italy) and thehighest-­populated country of Australasia (Australia).
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have been made accordingly.7 For example, in the USA,the weekly death data (R2=0.89, F=31.7) give rise to thefollowing: ‍β̂ ‍=773±57. This implies that every year, thenumber of weekly deaths rises on average by ~800. The
predicted weekly deaths for 2020 are thus higher thanthe 2015–2019 average. Regarding the strong and statistically significant annual trend, it is therefore not accurate
to employ the 2015–2019 data as a baseline.7 Anotherexample of correction concerns Belgium, the Netherlands, France, Luxembourg and Germany. In August
2020, a peak of excess deaths was observed during a heatwave in these countries. To account for this, weeks 32–34
were excluded from the excess mortality calculation inthese nations. This decreased the excess mortality estimates for these countries by 1500 for Belgium, 660 for the
Netherlands, 1600 for France, 35 for Luxembourg and
3700 for Germany.7 Karlinsky and Kobak present moredetails about the used method in their joint publication.7‘Excess mortality P-­
score’ concerns the percentage
difference between the reported number of deaths
and the projected number of deaths in a country.5 Thismeasure permits comparisons between various countries. Although presenting the raw number of excess
deaths provides insight into the scale, it is less useful tocompare countries because of their large population size
variations.5 The ‘Our World in Data’ database presents
P-­scores in a country during a certain week or month in2020 until 2022.5 These P-­scores are calculated from both
the reported number of deaths in HMD and WMD andthe projected number of deaths using the estimate modelof Karlinsky and Kobak in WMD.5 7 70 71
For correct interpretation of excess mortality provided
by the ‘Our World in Data’ database, the following needs
to be taken into consideration: the reported number ofdeaths may not represent all deaths, as countries maylack the infrastructure and capacity to document andaccount for all deaths.5 In addition, death reports may
be incomplete due to delays. It may take weeks, months
or years before a death is actually reported. The date ofa reported death may refer to the actual death date or to
its registration date. Sometimes, a death may be recorded
but not the date of death. Countries that provide weekly
death reports may use different start and end dates of theweek. Most countries define the week from Monday until
Sunday, but not all countries do. Weekly and monthly
reported deaths may not be completely comparable,
as excess mortality derived from monthly calculations
inclines to be lower.5 7
For our analysis, weekly all-­cause mortality reports
from the ‘Our World in Data’ database were converted tomonthly reports. Subsequently, the monthly reports wereconverted to annual reports.

BMJ Public Health

Figure 4 highlights a map of excess mortality P-­scoresin the Western World over the years 2020, 2021 and2022.74 Table 1 presents a classification of excess mortalityP-­scores in the Western World.
DISCUSSION
This study explored the excess all-­cause mortality in 47
countries of the Western World from 2020 until 2022.
The overall number of excess deaths was 3 098 456.
Excess mortality was registered in 87% of countries in
2020, in 89% of countries in 2021 and in 91% of countries in 2022. During 2020, which was marked by the
COVID-­19 pandemic and the onset of mitigation measures, 1 033 122 excess deaths (P-­score 11.4%) were to be
regretted.17 18 A recent analysis of seroprevalence studies
in this prevaccination era illustrates that the Infection
Mostert S, et al. BMJ Public Health 2024;2:e000282. doi:10.1136/bmjph-2023-000282

Fatality Rate estimates in non-­elderly populations wereeven lower than prior calculations suggested.37 At a
global level, the prevaccination Infection Fatality Rate was
0.03% for people aged <60 years and 0.07% for people
aged <70 years.38 For children aged 0–19 years, the Infection Fatality Rate was set at 0.0003%.38 This implies thatchildren are rarely harmed by the COVID-­19 virus.19 38
During 2021, when not only containment measures but
also COVID-­19 vaccines were used to tackle virus spreadand infection, the highest number of excess deaths wasrecorded: 1 256 942 excess deaths (P-­score 13.8%).26 37
Scientific consensus regarding the effectiveness of non-­pharmaceutical interventions in reducing viral transmission is currently lacking.75 76 During 2022, when most mitigation measures were negated and COVID-­19 vaccines
were sustained, preliminary available data count 808 392
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Figure 1 Excess mortality and cumulative excess mortality in the Western World (n=47 countries). Preliminary and incompleteall-­cause mortality reports are available for 2022.

BMJ Public Healthexcess deaths (P-­score 8.8%).39 The percentage difference between the documented and projected number ofdeaths was highest in 28% of countries during 2020, in
46% of countries during 2021, and in 26% of countries
during 2022.
This insight into the overall all-­cause excess mortality
since the start of the COVID-­19 pandemic is an importantfirst step for future health crisis policy decision-­making.1–4

The next step concerns distinguishing between the various
potential contributors to excess mortality, including
COVID-­
19 infection, indirect effects of containment
measures and COVID-­19 vaccination programmes. Differentiating between the various causes is challenging.16
National mortality registries not only vary in quality andthoroughness but may also not accurately document
the cause of death.1 19 The usage of different models to

Figure 3 Excess mortality P-­score curves of six countries in the Western World. Preliminary and incomplete all-­cause
mortality reports are available for 2022.

6

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Figure 2 Excess mortality P-­scores per country in the Western World (n=47 countries). Preliminary and incomplete all-­cause
mortality reports are available for 2022.

BMJ Public Health
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Figure 4 Map of excess mortality P-­scores in the Western World (n=47 countries).74 Preliminary and incomplete all-­cause
mortality reports are available for 2022.

investigate cause-­specific excess mortality within certain
countries or subregions during variable phases of thepandemic complicates elaborate cross-­country comparative analysis.1 2 16 Not all countries provide mortality
Mostert S, et al. BMJ Public Health 2024;2:e000282. doi:10.1136/bmjph-2023-000282

reports categorised per age group.2 12 Also testing policies for COVID-­19 infection differ between countries.1 2Interpretation of a positive COVID-­19 test can be intricate.77 Consensus is lacking in the medical community
7

BMJ Public Health

2020

2021

2022*

Excess mortalityP-­scores

Number ofcountries

ExcessdeathsNumber ofcountries

ExcessdeathsNumber ofcountries

Excessdeaths

−20% to −10%
−10% to 0%

1 (2%)
5 (11%)−60−6,5830 (0%)
5 (11%)

0−660

1 (2%)
3 (6%)−1,112−256

0% to 10%21 (45%)149 276

18 (38%)249 071

25 (53%)631 094

10% to 20%

16 (34%)875 598

8 (17%)

639 757

18 (38%)178 666

20% to 30%

2 (4%)

11 4786 (13%)

215 4970 (0%)

030% to 40%
40% to 50%

2 (4%)
0 (0%)3414
0

8 (17%)
2 (4%)

135 905
17 3730 (0%)
0 (0%)

00*Preliminary and incomplete all-­cause mortality reports are available for 2022.

regarding when a deceased infected with COVID-­
19
should be registered as a COVID-­19 death.1 77 Indirect
effects of containment measures have likely altered thescale and nature of disease burden for numerous causesof death since the pandemic. However, deaths causedby restricted healthcare utilisation and socioeconomic
turmoil are difficult to prove.1 78–81 A study assessing excess
mortality in the USA observed a substantial increase inexcess mortality attributed to non-­COVID causes during
the first 2 years of the pandemic. The highest number ofexcess deaths was caused by heart disease, 6% above baseline during both years. Diabetes mortality was 17% overbaseline during the first year and 13% above it during
the second year. Alzheimer’s disease mortality was 19%
higher in year 1 and 15% higher in year 2. In terms ofpercentage, large increases were recorded for alcohol-­related fatalities (28% over baseline during the first year
and 33% during the second year) and drug-­related fatalities (33% above baseline in year 1 and 54% in year 2).82
Previous research confirmed profound under-­reportingof adverse events, including deaths, after immunisation.83 84 Consensus is also lacking in the medical community regarding concerns that mRNA vaccines mightcause more harm than initially forecasted.85 French
studies suggest that COVID-­19 mRNA vaccines are genetherapy products requiring long-­term stringent adverse
events monitoring.85 86 Although the desired immunisation through vaccination occurs in immune cells, somestudies report a broad biodistribution and persistence ofmRNA in many organs for weeks.85 87–90 Batch-­dependent
heterogeneity in the toxicity of mRNA vaccines was foundin Denmark.48 Simultaneous onset of excess mortality
and COVID-­19 vaccination in Germany provides a safety
signal warranting further investigation.91 Despite theseconcerns, clinical trial data required to further investigate these associations are not shared with the public.92
Autopsies to confirm actual death causes are seldom
done.58 60 90 93–95 Governments may be unable to release
their death data with detailed stratification by cause,
although this information could help indicate whether
COVID-­
19 infection, indirect effects of containment
8

measures, COVID-­
19 vaccines or other overlookedfactors play an underpinning role.1 8–14 20–25 39–60 68 90
This absence of detailed cause-­of-­death data for certain
Western nations derives from the time-­consuming procedure involved, which entails assembling death certificates,coding diagnoses and adjudicating the underlying originof death. Consequently, some nations with restrictedresources assigned to this procedure may encounterdelays in rendering prompt and punctual cause-­of-­deathdata. This situation existed even prior to the outbreak of
the pandemic.1 5
A critical challenge in excess mortality research ischoosing an appropriate statistical method for calculating the projected baseline of expected deaths to which
the observed deaths are compared.96 Although the analyses and estimates in general are similar, the method canvary, for instance, per length of the investigated period,
nature of available data, scale of geographic area, inclusion or exclusion of past influenza outbreaks, accounting
for changes in population ageing and size and modelling
trend over years or not.7 96 Our analysis of excess mortality
using the linear regression model of Karlinsky and Kobak
varies thus to some extent from previous attempts to estimate excess deaths. For example, Islam et al conducted
an age- and sex-­
disaggregated time series analysis ofweekly mortality data in 29 high-­income countries during2020.97 They used a more elaborate statistical approach,an overdispersed Poisson regression model, for estimating the baseline of expected deaths on historicaldeath data from 2016 to 2019. In contrast to the modelof Karlinsky and Kobak, their baseline is weighing downprior influenza outbreaks so that every novel outbreak
evolves in positive excess mortality.7 97 Islam’s study foundthat age-­standardised excess death rates were higher in
men than in women in nearly all nations.97 Alicandro et
al investigated sex- and age-­specific excess total mortality
in Italy during 2020 and 2021, using an overdispersed
Poisson regression model that accounts for temporal
trends and seasonal variability. Historical death data from2011 to 2019 were used for the projected baseline. When
comparing 2020 and 2021, an increased share of the total

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Table 1 Classification of excess mortality P-­scores in the Western World (n=47 countries)

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Mostert S, et al. BMJ Public Health 2024;2:e000282. doi:10.1136/bmjph-2023-000282

In conclusion, excess mortality has remained high in
the Western World for three consecutive years, despite
the implementation of COVID-­19 containment measures
and COVID-­
19 vaccines. This is unprecedented andraises serious concerns. During the pandemic, it wasemphasised by politicians and the media on a daily
basis that every COVID-­19 death mattered and every life
deserved protection through containment measures and
COVID-­19 vaccines. In the aftermath of the pandemic,
the same morale should apply. Every death needs tobe acknowledged and accounted for, irrespective of its
origin. Transparency towards potential lethal drivers is
warranted. Cause-­specific mortality data therefore need
to be made available to allow more detailed, direct androbust analyses to determine the underlying contributors. Postmortem examinations need to be facilitated toallot the exact reason for death. Government leaders andpolicymakers need to thoroughly investigate underlying
causes of persistent excess mortality and evaluate theirhealth crisis policies.
Dissemination to participants and related patient and public
communities
We will disseminate findings through a press release on
publication and contact government leaders and policymakers to raise awareness about the need to investigate
the underlying causes of persistent excess mortality.
Acknowledgements We are grateful for the support received from the Foundation
World Child Cancer NL.
Contributors SM, MH and GK conceived and designed the study. SM and MH
acquired and analysed the data. All authors interpreted the results. SM wrote thefirst draft of the manuscript. All other authors provided feedback and approved
the final version of the manuscript. The corresponding author attests that all listed
authors meet authorship criteria and that no others meeting the criteria have been
omitted. SM is responsible for the overall content as guarantor.
Funding The study was supported by the Foundation World Child Cancer NL.
The sponsor had no role in the design and conduct of the study; collection,
management, analysis and interpretation of the data; preparation, review orapproval of the manuscript; and decision to submit the manuscript for publication.
Map disclaimer The inclusion of any map (including the depiction of any
boundaries there), or of any geographic or locational reference, does not imply theexpression of any opinion whatsoever on the part of BMJ concerning the legal statusof any country, territory, jurisdiction or area or of its authorities. Any such expression
remains solely that of the relevant source and is not endorsed by BMJ. Maps areprovided without any warranty of any kind, either expressed or implied.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available in a public, open accessrepository. The data for this study have been retrieved from the ‘Our World in Data’
database and are publicly available at: https://ourworldindata.org/excess-mortality-​
covid#.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely thoseof the author(s) and are not endorsed by BMJ. BMJ disclaims all liability andresponsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliabilityof the translations (including but not limited to local regulations, clinical guidelines,

9

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excess mortality was attributed to the working-­age population in 2021. Excess deaths were higher in men than inwomen during both periods.98 Msemburi et al provided
WHO estimates of the global excess mortality for its 194
member states during 2020 and 2021. For most countries, the historical period 2015–2019 was used to determine the expected baseline of excess deaths. In locations
missing comprehensive data, the all-­cause deaths were
forecasted employing an overdispersed Poisson framework that uses Bayesian inference techniques to measureincertitude. This study describes huge differences inexcess mortality between the six WHO regions.99 Paglino
et al used a Bayesian hierarchical model trained on historical death data from 2015 to 2019 and provided spatiallyand temporally granular estimates of monthly excess
mortality across counties in the USA during the first 2
years of the pandemic. The authors found that excess
mortality decreased in large metropolitan counties but
increased in non-­metropolitan counties.100 Ruhm examined the appropriateness of reported excess death estimates in the USA by four previous studies and concluded
that these investigations have likely understated the
projected baseline of excess deaths and therewith overestimated excess mortality and its attribution to non-­
COVID causes. Ruhm explains that the overstatement ofexcess deaths may partially be explained by the fact thatthe studies did not adequately take population growth
and age structure into account.96 101–104 Although all theabove-­mentioned studies used more elaborate statistical
approaches for estimating baseline mortality, Karlinsky
and Kobak argue that their method is a trade-­off between
suppleness and chasteness.7 It is the simplest method
to captivate seasonal fluctuation and annual trends andmore transparent than extensive approaches.7
This study has various significant limitations. Deathreports may be incomplete due to delays. It may takeweeks, months or years before a death is registered.5
Four nations still lack all-­cause mortality reports for
1–4 months. Some nations issue complete data withprofound arrears, whereas other nations publish prompt,
yet incomplete data.5 7 The presented data, especially for
2022, are thus preliminary and subject to backward revisions. The more recent data are usually more incomplete
and therefore can undergo upward revisions over time.
This implies that several of the reported excess mortality
estimates can be underestimations.7 The completenessand reliability of death registration data can also differ
per nation for other reasons. The recorded numberof deaths may not depict all deaths accurately, as theresources, infrastructure and registration capacity may
be limited in some nations.5 7 Most countries report per
week, but some per month. Weekly reports generally
provide the date of death, whereas monthly reports often
provide the date of registration. Weekly and monthly
reports may not be entirely comparable.5 7 Our data arecollected at a country level and provide no detailed stratification for sociodemographic characteristics, such as age
or gender.5 7

BMJ Public HealthOpen access This is an open access article distributed in accordance with theCreative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link to the licence is given,and indication of whether changes were made. See: https://creativecommons.org/​
licenses/by/4.0/.
ORCID iD
Saskia Mostert http://orcid.org/0000-0002-4583-8603

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