Abstract
BACKGROUND: Evaluating mortality effects of the COVID-19 pandemic using all-cause mortality data for national populations is inevitably associated with the risk of masking important subnational differentials and hampering targeted health policies. This study aims at assessing simultaneously cause-specific, spatial and seasonal mortality effects attributable to the pandemic in Germany in 2020. METHODS: Our analyses rely on official cause-of-death statistics consisting of 5.65 million individual death records reported for the German population during 2015-2020. We conduct differential mortality analyses by age, sex, cause, month and district (N = 400), using decomposition and standardisation methods, comparing each strata of the mortality level observed in 2020 with its expected value, as well as spatial regression to explore the association of excess mortality with pre-pandemic indicators. RESULTS: The spatial analyses of excess mortality reveal a very heterogenous pattern, even within federal states. The coastal areas in the north were least affected, while the south of eastern Germany experienced the highest levels. Excess mortality in the most affected districts, with standardised mortality ratios reaching up to 20%, is driven widely by older ages and deaths reported in December, particularly from COVID-19 but also from cardiovascular and mental/nervous diseases. CONCLUSIONS: Our results suggest that increased psychosocial stress influenced the outcome of excess mortality in the most affected areas during the second lockdown, thus hinting at possible adverse effects of strict policy measures. It is essential to accelerate the collection of detailed mortality data to provide policymakers earlier with relevant information in times of crisis.