Magnitude and time-course of excess mortality during COVID-19 outbreak: population-based empirical evidence from highly impacted provinces in northern Italy

Sara Conti; Pietro Ferrara; Giampiero Mazzaglia; Marco I D'Orso; Roberta Ciampichini; Carla Fornari; Fabiana Madotto; Michele Magoni; Giuseppe Sampietro; Andrea Silenzi; Claudio V Sileo; Alberto Zucchi; Giancarlo Cesana; Lamberto Manzoli; Lorenzo G Mantovani

doi:10.1183/23120541.00458-2020

Magnitude and time-course of excess mortality during COVID-19 outbreak: population-based empirical evidence from highly impacted provinces in northern Italy

ERJ Open Res. 2020 Sep 28;6(3):00458-2020. doi: 10.1183/23120541.00458-2020. eCollection 2020 Jul.

Authors

Sara Conti¹, Pietro Ferrara¹, Giampiero Mazzaglia¹, Marco I D'Orso¹, Roberta Ciampichini², Carla Fornari¹, Fabiana Madotto^{1

3}, Michele Magoni⁴, Giuseppe Sampietro², Andrea Silenzi^{4

5}, Claudio V Sileo⁴, Alberto Zucchi², Giancarlo Cesana¹, Lamberto Manzoli⁶, Lorenzo G Mantovani^{1

3}

Affiliations

¹ Center for Public Health Research, University of Milano - Bicocca, Monza, Italy.
² Health Protection Agency of Bergamo (ATS Bergamo), Bergamo, Italy.
³ Value-based Healthcare Unit, IRCCS Multimedica, Sesto San Giovanni, Italy.
⁴ Health Protection Agency of Brescia (ATS Brescia), Brescia, Italy.
⁵ Center for Leadership in Medicine Research and Studies, Università Cattolica del Sacro Cuore, Rome, Italy.
⁶ Dept of Medical Sciences, University of Ferrara, Ferrara, Italy.

Abstract

Background: The real impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on overall mortality remains uncertain as surveillance reports have attributed a limited number of deaths to novel coronavirus disease 2019 (COVID-19) during the outbreak. The aim of this study was to assess the excess mortality during the COVID-19 outbreak in highly impacted areas of northern Italy.

Methods: We analysed data on deaths that occurred in the first 4 months of 2020 provided by the health protection agencies (HPAs) of Bergamo and Brescia (Lombardy), building a time-series of daily number of deaths and predicting the daily standardised mortality ratio (SMR) and cumulative number of excess deaths through a Poisson generalised additive model of the observed counts in 2020, using 2019 data as a reference.

Results: We estimated that there were 5740 (95% credible set (CS) 5552-5936) excess deaths in the HPA of Bergamo and 3703 (95% CS 3535-3877) in Brescia, corresponding to a 2.55-fold (95% CS 2.50-2.61) and 1.93 (95% CS 1.89-1.98) increase in the number of deaths. The excess death wave started a few days later in Brescia, but the daily estimated SMR peaked at the end of March in both HPAs, roughly 2 weeks after the introduction of lockdown measures, with significantly higher estimates in Bergamo (9.4, 95% CI 9.1-9.7).

Conclusion: Excess mortality was significantly higher than that officially attributed to COVID-19, disclosing its hidden burden likely due to indirect effects on the health system. Time-series analyses highlighted the impact of lockdown restrictions, with a lower excess mortality in the HPA where there was a smaller delay between the epidemic outbreak and their enforcement.