Abstract
In this study we present the first comprehensive analysis of the spatio-temporal differences in excess mortality during the COVID-19 pandemic in Italy. We used a population-based design on all-cause mortality data, for the 7,904 Italian municipalities. We estimated sex-specific weekly mortality rates for each municipality, based on the first four months of 2016-2019, while adjusting for age, localised temporal trends and the effect of temperature. Then, we predicted all-cause weekly deaths and mortality rates at municipality level for the same period in 2020, based on the modelled spatio-temporal trends. Lombardia showed higher mortality rates than expected from the end of February, with 23,946 (23,013 to 24,786) total excess deaths. North-West and North-East regions showed one week lag, with higher mortality from the beginning of March and 6,942 (6,142 to 7,667) and 8,033 (7,061 to 9,044) total excess deaths respectively. We observed marked geographical differences also at municipality level. For males, the city of Bergamo (Lombardia) showed the largest percent excess, 88.9% (81.9% to 95.2%), at the peak of the pandemic. An excess of 84.2% (73.8% to 93.4%) was also estimated at the same time for males in the city of Pesaro (Central Italy), in stark contrast with the rest of the region, which does not show evidence of excess deaths. We provided a fully probabilistic analysis of excess mortality during the COVID-19 pandemic at sub-national level, suggesting a differential direct and indirect effect in space and time. Our model can be used to help policy-makers target measures locally to contain the burden on the health-care system as well as reducing social and economic consequences. Additionally, this framework can be used for real-time mortality surveillance, continuous monitoring of local temporal trends and to flag where and when mortality rates deviate from the expected range, which might suggest a second wave of the pandemic.
Highlights
The total impact of the COVID-19 pandemic on mortality should be the least controversial outcome to measure
We present plots of observed and predicted trends in mortality rates as well as maps and plots of percentage excess mortality, estimated as the difference between the observed number of Excess mortality at sub-national level in Italy during the COVID-19 pandemic deaths and the predicted number under current trends, divided by the observed number
We present the trend in mortality rates split by five macro-areas: the North-West (Piemonte, Valle d’Aosta, Liguria); Lombardia; the North-East (Veneto, Trentino-Alto Adige, Friuli Venezia Giulia, Emilia-Romagna); the Centre (Lazio, Marche, Toscana and Umbria); and the South and major Islands (Abruzzo, Basilicata, Calabria, Campania, Molise, Puglia, Sardegna and Sicilia)
Summary
The total impact of the COVID-19 pandemic on mortality should be the least controversial outcome to measure. There are important differences in the recording systems, both across and within countries (e.g. in the UK, England and Wales have consistently reported data on daily deaths based on different time of recording in comparison to Scotland and Northern Ireland [1]) In this context, estimating excess deaths for all causes at national level, with respect to past year trends has been used in several countries as an effective way to evaluate the total burden of the COVID-19 pandemic [2,3,4,5,6], including direct COVID-19-related, as well as indirect effects (e.g. people not being able to access healthcare). To the best of our knowledge, only two papers have analysed mortality at regional level (one in Italy [9] and another in England and Wales [10]), while there are no comprehensive studies that have looked at the impact of COVID-19 at sub-national level
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