International Journal of Health Policy and Management

International Journal of Health Policy and Management

All-Cause and Cause-Specific Excess Mortality During the First Two Years of the COVID-19 Pandemic in NorthEast of Iran: Reiterating the Significance of High-Quality Healthcare Systems

Document Type : Original Article

Authors
Seyedeh Vajiheh Kazemian 1
Maliheh Dadgarmoghaddam 1
Hamed Tabesh 2
Amirreza Khajedaluee 3
Mohammad Khajedaluee 1
1 Community Medicine Department, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
2 Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
3 Sinus and Surgical Endoscopic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
10.34172/ijhpm.8757
Abstract
Background 
Excess mortality provides a comprehensive measure to assess the true impact of the disease on mortality rates. This study aimed to quantify excess mortality attributable to COVID-19 in northeastern Iran during the pandemic period (2020–2022).
 
Methods 
This population-based cross-sectional study utilized population and mortality data extracted from electronic systems linked to Mashhad University of Medical Sciences (MUMS). Data analysis was conducted using R Version 4.3.3. A log-linear model was employed to predict expected deaths during the two-year pandemic period, incorporating predictor variables such as the year of interest, the presence of COVID-19, and the population size for each respective year. Excess deaths were calculated as the difference between the expected and observed mortality. Furthermore, by considering the confirmed deaths directly attributed to COVID-19 and the difference between these and the excess deaths, the number of indirect deaths during the pandemic was determined.
 
Results 
The total count of recorded deaths from all causes exceeded the expected deaths by 31.15% (6750 cases) in the first year and 44.74% (10 078 cases) in the second year. The excess deaths were 1.48 and 1.79 times greater than the official reports of COVID-19 for the first and second years, respectively. It was also found that men experienced increased rates of excess deaths in each of the two years. Moreover, urban residents experienced higher rates of excess death in the same years. Based on cause-specific excess mortality, following infectious diseases, cardiovascular diseases (CVDs) accounted for the largest proportion of excess deaths in both years of the pandemic.
 
Conclusion 
The overall mortality burden during the COVID-19 pandemic exceeded the official reports, highlighting the undercounting of the number of direct effects and emphasizing the significance of indirect effects. These findings underscore the importance of preparedness and organization of healthcare systems prior to a pandemic. 
Keywords
COVID-19 Pandemic
All-Cause Excess Deaths
All-Cause Excess Mortality
Cause-Specific Excess Death
Cause-Specific Excess Mortality
Iran
  1. Saraceni V, Cruz OG, Cavalcante JR, et al. Excess mortality from all causes during the COVID-19 pandemic in the city of Rio de Janeiro, Brazil. Rev Bras Epidemiol. 2023;26:e230013. doi:1590/1980-549720230013
  2. Thong PM, Chong HT, Chang AJW, Ong CWM. COVID-19, the escalation of diabetes mellitus and the repercussions on tuberculosis. Int J Infect Dis. 2023;130 Suppl 1:S30-S33. doi:1016/j.ijid.2023.02.009
  3. Acosta E. Global Estimates of Excess Deaths from COVID-19. London, UK: Nature Publishing Group; 2023.
  4. Aborode AT, Hasan MM, Jain S, et al. Impact of poor disease surveillance system on COVID-19 response in Africa: time to rethink and rebuilt. Clin Epidemiol Glob Health. 2021;12:100841. doi:1016/j.cegh.2021.100841
  5. Fantin R, Barboza-Solís C, Hildesheim A, Herrero R. Excess mortality from COVID 19 in Costa Rica: a registry-based study using Poisson regression. Lancet Reg Health Am. 2023;20:100451. doi:1016/j.lana.2023.100451
  6. Han L, Zhao S, Li S, et al. Excess cardiovascular mortality across multiple COVID-19 waves in the United States from March 2020 to March 2022. Nat Cardiovasc Res. 2023;2(3):322-333. doi:1038/s44161-023-00220-2
  7. Gmanyami JM, Jarynowski A, Belik V, Lambert O, Amuasi J, Quentin W. Excess mortality during the COVID-19 pandemic in low-income and lower middle-income countries: protocol for a systematic review and meta-analysis. BMJ Open. 2024;14(1):e079862. doi:1136/bmjopen-2023-079862
  8. Colonia SR, Cardeal LM, de Oliveira RA, Trinca LA. Assessing COVID-19 pandemic excess deaths in Brazil: years 2020 and 2021. PLoS One. 2023;18(5):e0272752. doi:1371/journal.pone.0272752
  9. Kontopantelis E, Mamas MA, Deanfield J, Asaria M, Doran T. Excess mortality in England and Wales during the first wave of the COVID-19 pandemic. J Epidemiol Community Health. 2021;75(3):213-223. doi:1136/jech-2020-214764
  10. Rhee C. Deconstructing improvements and hospital variation in COVID-19 mortality rates during the early pandemic wave: the effects of wave evolution and advances in testing, treatment, and hospital care quality. BMJ Qual Saf. 2022;31(3):168-171. doi:1136/bmjqs-2021-013809
  11. Laliotis I, Stavropoulou C, Ceely G, Brett G, Rushton R. Excess deaths by cause and place of death in England and Wales during the first year of COVID-19. Health Econ. 2023;32(9):1982-2005. doi:1002/hec.4698
  12. Matz M, Allemani C, van Tongeren M, et al. Excess mortality among essential workers in England and Wales during the COVID-19 pandemic. J Epidemiol Community Health. 2022;76(7):660-666. doi:1136/jech-2022-218786
  13. Murhekar MV, Bhatnagar T, Thangaraj JW, et al. SARS-CoV-2 seroprevalence among the general population and healthcare workers in India, December 2020-January 2021. Int J Infect Dis. 2021;108:145-155. doi:1016/j.ijid.2021.05.040
  14. Ruhm CJ. Excess deaths in the United States during the first year of COVID-19. Prev Med. 2022;162:107174. doi:1016/j.ypmed.2022.107174
  15. Weinberger DM, Chen J, Cohen T, et al. Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020. JAMA Intern Med. 2020;180(10):1336-1344. doi:1001/jamainternmed.2020.3391
  16. Alicandro G, Gerli AG, Centanni S, Remuzzi G, La Vecchia C. Excess total mortality in Italy: an update to February 2023 with focus on working ages. Med Lav. 2023;114(3):e2023028. doi:23749/mdl.v114i3.14740
  17. Jain V, Clarke J, Beaney T. Association between democratic governance and excess mortality during the COVID-19 pandemic: an observational study. J Epidemiol Community Health. 2022;76(10):853-860. doi:1136/jech-2022-218920
  18. Ledesma JR, Isaac CR, Dowell SF, et al. Evaluation of the Global Health Security Index as a predictor of COVID-19 excess mortality standardised for under-reporting and age structure. BMJ Glob Health. 2023;8(7):e012203. doi:1136/bmjgh-2023-012203
  19. Ebrahimoghli R, Abbasi-Ghahramanloo A, Moradi-Asl E, Adham D. The COVID-19 pandemic's true death toll in Iran after two years: an interrupted time series analysis of weekly all-cause mortality data. BMC Public Health. 2023;23(1):442. doi:1186/s12889-023-15336-0
  20. Safavi-Naini SAA, Farsi Y, Alali WQ, Solhpour A, Pourhoseingholi MA. Excess all-cause mortality and COVID-19 reported fatality in Iran (April 2013-September 2021): age and sex disaggregated time series analysis. BMC Res Notes. 2022;15(1):130. doi:1186/s13104-022-06018-y
  21. Riou J, Hauser A, Fesser A, Althaus CL, Egger M, Konstantinoudis G. Direct and indirect effects of the COVID-19 pandemic on mortality in Switzerland. Nat Commun. 2023;14(1):90. doi:1038/s41467-022-35770-9
  22. Lewnard JA, B CM, Kang G, Laxminarayan R. Attributed causes of excess mortality during the COVID-19 pandemic in a south Indian city. Nat Commun. 2023;14(1):3563. doi:1038/s41467-023-39322-7
  23. Esmaeilzadeh N, Hoseini SJ, Jafari Nejad Bajestani M, et al. Excess mortality in Northeast Iran caused by COVID-19: neglect of offset community transformations of health. Asian Pac J Trop Med. 2023;16(6):261-267. doi:4103/1995-7645.378563
  24. Pirayesh Z, Riahi SM, Bidokhti A, Kazemi T. Evaluation of the effect of the COVID-19 pandemic on the all-cause, cause-specific mortality, YLL, and life expectancy in the first 2 years in an Iranian population-an ecological study. Front Public Health. 2023;11:1259202. doi:3389/fpubh.2023.1259202
  25. Paul E, Brown GW, Kalk A, Van Damme W, Ridde V, Sturmberg J. "When my information changes, I alter my conclusions." What can we learn from the failures to adaptively respond to the SARS-CoV-2 pandemic and the under preparedness of health systems to manage COVID-19? Int J Health Policy Manag. 2022;11(7):1241-1245. doi:34172/ijhpm.2020.240
  26. Bozorgmehr K, Zick A, Hecker T. Resilience of health systems: understanding uncertainty uses, intersecting crises and cross-level interactions: Comment on "Government actions and their relation to resilience in healthcare during the COVID-19 pandemic in New South Wales, Australia and Ontario, Canada". Int J Health Policy Manag. 2022;11(9):1956-1959. doi:34172/ijhpm.2022.7279
  27. Karlinsky A, Kobak D. Tracking excess mortality across countries during the COVID-19 pandemic with the World Mortality Dataset. Elife. 2021;10:e69336. doi:7554/eLife.69336
  28. Vice President of Health M, Network Management Center, Network System Information and Statistics Department. Instructions for completing the vital poster of rural and urban areas [Persian]. https://www.medsab.ac.ir/uploads/Final-Dastoramalzij_31_04_94_51706.pdf. Accessed January 5, 2024.
  29. Vice President of Health M, Network Management Center, Network System Information and Statistics Department. Guide to the death registration and classification system [Persian]. https://tinylink.info/Y8Cr. Accessed January 5, 2024.
  30. 2024 ICD-10-CM Codes. https://www.icd10data.com/ICD10CM/Codes. Accessed January 5, 2024.
  31. World Health Organization (WHO). International Guidelines for Certification and Classification (CODING) of COVID-19 as Cause of Death. Available from: https://www.who.int/docs/default-source/classification/icd/covid-19/guidelines-cause-of-death-covid-19-20200420-en.pdf. Accessed January 5, 2024.
  32. Nucci LB, Enes CC, Ferraz FR, da Silva IV, Rinaldi AE, Conde WL. Excess mortality associated with COVID-19 in Brazil: 2020-2021. J Public Health (Oxf). 2023;45(1):e7-e9. doi:1093/pubmed/fdab398
  33. Quast T, Andel R. Excess mortality associated with COVID-19 by demographic group: evidence from Florida and Ohio. Public Health Rep. 2021;136(6):782-790. doi:1177/00333549211041550
  34. Sanmarchi F, Golinelli D, Lenzi J, et al. Exploring the gap between excess mortality and COVID-19 deaths in 67 countries. JAMA Netw Open. 2021;4(7):e2117359. doi:1001/jamanetworkopen.2021.17359
  35. Ferrara P, Dallagiacoma G, Alberti F, Gentile L, Bertuccio P, Odone A. Prevention, diagnosis and treatment of cervical cancer: a systematic review of the impact of COVID-19 on patient care. Prev Med. 2022;164:107264. doi:1016/j.ypmed.2022.107264
  36. Pearson-Stuttard J, Caul S, McDonald S, Whamond E, Newton JN. Excess mortality in England post COVID-19 pandemic: implications for secondary prevention. Lancet Reg Health Eur. 2024;36:100802. doi:1016/j.lanepe.2023.100802
  37. Ackley CA, Lundberg DJ, Ma L, Elo IT, Preston SH, Stokes AC. County-level estimates of excess mortality associated with COVID-19 in the United States. SSM Popul Health. 2022;17:101021. doi:1016/j.ssmph.2021.101021
  38. Vieira A, Peixoto VR, Aguiar P, Abrantes A. Rapid estimation of excess mortality during the COVID-19 pandemic in Portugal-beyond reported deaths. J Epidemiol Glob Health. 2020;10(3):209-213. doi:2991/jegh.k.200628.001
  39. McCoy RG, Campbell RL, Mullan AF, et al. Changes in all-cause and cause-specific mortality during the first year of the COVID-19 pandemic in Minnesota: population-based study. BMC Public Health. 2022;22(1):2291. doi:1186/s12889-022-14743-z
  40. Raknes G, Fagerås SJ, Sveen KA, Júlíusson PB, Strøm MS. Excess non-COVID-19 mortality in Norway 2020-2022. BMC Public Health. 2024;24(1):244. doi:1186/s12889-023-17515-5
  41. Vamos EP, Khunti K. Indirect effects of the COVID-19 pandemic on people with type 2 diabetes: time to urgently move into a recovery phase. BMJ Qual Saf. 2022;31(7):483-485. doi:1136/bmjqs-2021-014079
  42. Rachamin Y, Meyer MR, Rosemann T, Grischott T. Impact of the COVID-19 pandemic on elective and emergency inpatient procedure volumes in Switzerland - a retrospective study based on insurance claims data. Int J Health Policy Manag. 2023;12:6932. doi:34172/ijhpm.2022.6932
  43. Dubé JP, Smith MM, Sherry SB, Hewitt PL, Stewart SH. Suicide behaviors during the COVID-19 pandemic: a meta-analysis of 54 studies. Psychiatry Res. 2021;301:113998. doi:1016/j.psychres.2021.113998
  44. Bridge JA, Ruch DA, Sheftall AH, et al. Youth suicide during the first year of the COVID-19 pandemic. Pediatrics. 2023;151(3):e2022058375. doi:1542/peds.2022-058375
  45. Lee WE, Woo Park S, Weinberger DM, et al. Direct and indirect mortality impacts of the COVID-19 pandemic in the United States, March 1, 2020 to January 1, 2022. Elife. 2023;12:e77562. doi:7554/eLife.77562
  46. Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707-712. doi:1093/qjmed/hcaa202
  47. Martínez-Alés G, Szmulewicz A, López-Cuadrado T, Morrison CN, Keyes KM, Susser ES. Suicide following the COVID-19 pandemic outbreak: variation across place, over time, and across sociodemographic groups. A systematic integrative review. Curr Psychiatry Rep. 2023;25(7):283-300. doi:1007/s11920-023-01427-7
  48. Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry. 2020;7(6):468-471. doi:1016/s2215-0366(20)30171-1
International Journal of Health Policy and Management
Volume 14, Issue 1
2025
Pages 1-9

  • Received Date 13 August 2024
  • Revised Date 22 February 2025
  • Accepted Date 08 April 2025
  • First Published Date 12 April 2025
  • Published Date 01 December 2025