
==== Front
Lancet Reg Health Eur
Lancet Reg Health Eur
The Lancet Regional Health - Europe
2666-7762
Elsevier

S2666-7762(24)00227-8
10.1016/j.lanepe.2024.101060
101060
Correspondence
More or less “modest” versus significant excess mortality due to COVID-19 deaths in Europe
Soriano Joan B. jbsoriano2@gmail.com
abc∗
Peláez Adrián cd
Lumbreras Sara e
Fernández Esteve cfgh
Ancochea Julio abc
a Servicio de Neumología, Hospital Universitario de la Princesa, Madrid, Spain
b Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
c Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
d Facultad de Ciencias de la Salud-HM Hospitales, Universidad Camilo José Cela, Madrid, Spain
e Departamento de Organización Industrial, Escuela Técnica Superior de Ingeniería (ICAI), Universidad Pontificia Comillas - IIT, Madrid, Spain
f Tobacco Control Unit, WHO Collaborating Center for Tobacco Control, Institut Català d’Oncologia-ICO, L’Hospitalet de Llobregat, Barcelona, Spain
g Tobacco Control Research Group, Institut d’Investigació Biomèdica de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
h Department of Clinical Sciences, School of Medicine and Clinical Sciences, Universitat de Barcelona, L’Hospitalet del Llobregat, Barcelona, Spain
∗ Corresponding author. Servicio de Neumología, Hospital Universitario de la Princesa-Universidad Autónoma de Madrid, Diego de León 62, Madrid 28006, Spain. jbsoriano2@gmail.com
11 9 2024
10 2024
11 9 2024
45 10106029 7 2024
22 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
==== Body
pmcWe read with great interest the excellent article by Pizzato M et al.,1 giving a fascinating narrative on the distribution of COVID-19 excess deaths during the first four years of the pandemic in 29 European countries. This excess mortality was highly variable but largely explained by country-level socioeconomic indicators, interventions, and vaccination.

However, we were surprised that Spain was not amongst the top countries with excess deaths, even in 2020 and 2021, contrary to our observations.2,3 We reckon this discrepancy may stem from different methods of calculating excess deaths, comparing a relative increase from the observed deaths from 2010 to 2019,1 versus actual COVID-19 deaths defined as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID-19 disease, e.g. trauma,3 as endorsed by EUROSTAT. These two metrics, while related, measure different things. However, at the least in Spain it simply cannot be that the former is less than the later in 2020 and 2021, and likely in 2022 and 2023 (Table 1).1,3,4Table 1 Excess deaths versus actual deaths due to COVID-19 in Spain from 2020 to 2023.

Year	Excess deaths1	Actual deaths3	
n (95% C.I.)	% (95% C.I.)	n (%)a	n (%)b	n (%)c	Total	
2020	61,437 (59,362; 63,511)	14.0 (13.5; 14.6)	60,358 (12.2%)	14,481 (2.9%)	0 (0.0%)	74,839 (15.1%)	
2021	17,690 (15,352; 20,027)	4.1 (3.6; 4.7)	39,444 (8.8%)	595 (0.1%)	44 (0.0%)	40,083 (8.9)	
2022	27,176 (24,518; 29,833)	6.3 (5.6; 6.9)	31,606 (6.8%)	66 (0.0%)	25 (0.0%)	31,697 (6.8%)	
2023	−740 (−3718; 2238)	−0.2 (−0.8; 0.5)	7885 (1.8%)	7 (0.0%)	6 (0.0%)	7898 (1.8%)	
Total	105,561 (95,531; 115,590)	6.1 (5.5; 6.7)	139,293 (7.6%)	15,149 (0.8%)	75 (0.0%)	154,517 (8.4%)	
Note: Excess deaths extracted from Tables 1 and 2 of Pizzato M et al.1 Spain actual deaths in 2020 and 2021 as per Soriano JB et al.,3 with

a Covid-19 virus identified.

b Covid-19 unidentified virus (suspected).

c Covid-19 associated multisystemic inflammatory syndrome COVID-19; and in italics in 2022 and 2023 from the latest public repository of the national statistics institute (INE).4

The language used in the paper, such as “… About half a million excess deaths occurred in each of the first three pandemic years, while only a modest excess was observed in 2023”; “… its impact was modest in 2023, indicating a trend towards pre-pandemic levels”; “… while a smaller excess was estimated for 2023 (108,629 deaths, +2.1%)” warrants careful consideration. Describing the 2023 excess mortality as “modest” could be misleading, as it risks downplaying the significance of the observed excess deaths. It is important to approach such characterizations with precision, ensuring that the terminology accurately reflects the data and its implications.

Contributors

JBS had the original idea and wrote the first draft of this correspondence. AP performed the statistics. All authors contributed to the discussion, the writing, and approved the final submitted version.

Declaration of interests

JBS has received pharmaceutical company grants from 2020 to 2024 from Chiesi, GSK, Linde and Novartis via Hospital Universitario de La Princesa. Participated in speaking activities, advisory committees, and consultancies from 2020 to 2024 sponsored by Air Liquide, Almirall, AstraZeneca, Boehringer Ingelheim, CHEST, Chiesi, CNPT, ERS, FTH, Gebro, Grifols, GSK, IHME, Laminar Pharma, Linde, Lipopharma, Menarini, Mundipharma, Novartis, OMS/WHO, Pfizer, ResApp, RiRL, ROVI, SEPAR, Seqirus, WHO EUR, Takeda and Zambon. EF is partly supported by the Ministry of Universities and Research, Government of Catalonia (2021SGR00906) and acknowledges support from CERCA Programme to IDIBELL. Finally, JBS declares never, directly or indirectly, received any funding from tobacco manufacturers or their affiliates. All other authors declare there are no conflicts of interest related with this submission.
==== Refs
References

1 Pizzato M. Gerli A.G. La Vecchia C. Alicandro G. Impact of COVID-19 on total excess mortality and geographic disparities in Europe, 2020–2023: a spatio-temporal analysis Lancet Reg Health Eur 2024 10.1016/j.lanepe.2024.100996
2 Gerli A.G. Centanni S. Miozzo M.R. COVID-19 mortality rates in the European Union, Switzerland, and the UK: effect of timeliness, lockdown rigidity, and population density Minerva Med 111 4 2020 308 314 10.23736/S0026-4806.20.06702-6 Epub 2020 Jun 2. PMID: 32491297 32491297
3 Soriano J.B. Peláez A. Fernández E. Ancochea J. Impact of the COVID-19 pandemic in mortality due to respiratory diseases: a comparative analysis of 2021 and 2020 vs 2019 in Spain Med Clin 161 5 2023 192 198 10.1016/j.medcli.2023.04.020 Epub 2023 May 9. PMID: 37394353
4 Estadística de Defunciones según la Causa de Muerte Año 2023. Datos provisionales Available at: https://www.ine.es/dyngs/Prensa/es/pEDCM2023.htm
