Excess deaths associated with the Iranian COVID-19 epidemic: A province-level analysis

Mahan Ghafari,Alireza Kadivar,Aris Katzourakis

doi:10.1016/j.ijid.2021.04.015

Mahan Ghafari, Alireza Kadivar + Show 1 more

Open Access

https://doi.org/10.1016/j.ijid.2021.04.015

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Abstract

ObjectiveThere has been no province-level data on the number of coronavirus disease 2019 (COVID-19)-related deaths in Iran since the start of the pandemic. This study was performed to estimate the number of COVID-19 deaths and population-level exposure per province using seasonal all-cause mortality data. MethodsTime-series data were collected from the National Organization for Civil Registration on the seasonal all-cause mortality from spring 2015 to summer 2020 (from March 21, 2015 to September 21, 2020), in accordance with the Solar Hijri (SH) calendar, to estimate the expected number of seasonal deaths for each province using a piecewise linear regression model. A population-weighted infection fatality ratio was then applied to estimate the level of exposure per province during this period. ResultsFrom the start of winter to the end of summer (from December 22, 2019 to September 21, 2020), there were a total of 58 900 (95% confidence interval 46 900–69 500) excess deaths across all 31 provinces, with 27% (95% confidence interval 20–34%) estimated nationwide exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In particular, Qom and Golestan were among the hardest-hit provinces, with nearly 57% exposure, while another 27 provinces showed significant levels of excess mortality in at least one season with >20% population-level exposure to the virus. Unexpectedly high levels of excess mortality were also detected during fall 2019 (from September 23 to December 21, 2019) across 18 provinces, unrelated and prior to the start of the COVID-19 pandemic. ConclusionsThis study quantified the pattern of spread of COVID-19 across the country and identified areas with the largest epidemic growth requiring the most immediate interventions.

Highlights

Information on all-cause mortality in Iran and its changing pattern over time represents a major source for evaluating the burden of the coronavirus disease 2019 (COVID-19) epidemic across the country
For these extra deaths in the fall to be associated with COVID-19, it would be expected, due to the absence of any non-pharmaceutical interventions at the time, that similar levels of excess mortality would be detected in the same provinces during the winter
Mortality rates in 31 provinces of Iran from fall 1398 Solar Hijri (SH) to summer 1399 SH were compared, with the aim of detecting and measuring excess deaths related to the COVID-19 epidemic

Summary

Introduction

Information on all-cause mortality in Iran and its changing pattern over time represents a major source for evaluating the burden of the coronavirus disease 2019 (COVID-19) epidemic across the country. The National Organization for Civil Registration of Iran (NOCR) is responsible for the registration of births, marriages, divorces, and deaths across the country. It initially updates the number of registered (crude) deaths at the end of every season for all 31 provinces of Iran (in accordance with the Solar Hijri (SH) calendar date). More detailed data on the number of registered deaths per month follow at the end of each calendar year (on the March equinox) along with an annual report from the Ministry of Health and Medical Education (MoHME), which includes an aggregate record of causes of death (based on the International Statistical Classification of Diseases and Related Health Problems, 10th revision) according to individual age, sex, and place of residence (Khosravi et al, 2007a)

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