The toll of excess mortality in Europe in 2020-2023

INTRODUCTION

Excess total mortality has emerged as a crucial metric for assessing the direct and indirect effects of the COVID-19 pandemic. By capturing all deaths that occur above typical seasonal or historical trends, excess mortality estimates help clarify the full impact of the pandemic. They account for the delays in medical care, disruptions of healthcare systems, and changes in health behaviors during the pandemic.
In the first two years of the pandemic (2020-2021), over 1 million additional deaths were estimated in 29 European nations [1, 2]. While the direct toll of SARS-CoV-2 mainly contributed to these patterns, the complex interplay of factors such as hospital resource shortages, regional disparities, and delayed treatment for non-COVID illnesses also played essential roles. The demographic profile of these excess deaths indicates that older people were the most severely affected: approximately 90% or more of excess deaths occurred among individuals aged 65 and over [3, 4].
The pandemic’s progression, however, was far from uniform across Europe. Countries such as Bulgaria, Lithuania, and Slovakia exhibited the highest peaks of excess mortality, whereas Sweden consistently appeared at the lower end of the spectrum despite adopting less stringent mitigation measures [1, 2, 5, 6]. Economic and social determinants influenced these divergent outcomes, with a relationship between lower GDP per capita, limited healthcare resources, and higher excess mortality [1, 3, 7].
By 2023, concerns persisted that, despite widespread vaccination and improved clinical management, ongoing waves of COVID-19 – combined with seasonal influenza and respiratory syncytial virus (RSV) – continued to influence excess mortality trends [8]. The extended time frame of 2020-2023 thus offers a unique lens through which to analyze how countries managed successive surges, adapted their healthcare strategies, and mitigated (or failed to mitigate) the broader social and economic impacts of repeated outbreaks.

MATERIAL AND METHODS

LITERATURE SEARCH STRATEGY

A comprehensive literature search was conducted using Scopus AI, focusing on articles published between January 2020 and early 2025, with the topic “Excess mortality from 2020 to 2023 in Europe”. The search also included cross-referencing citations from relevant articles and reviews to ensure coverage of seminal works in the field.

STUDY SELECTION

To determine eligibility, titles and abstracts were screened; articles were retained if they:
1. Addressed excess mortality in European countries from 2020 to 2023.
2. Included quantitative assessments of mortality trends (e.g., all-cause mortality).
3. Investigated potential contributing factors such as healthcare infrastructure, socioeconomic status, or demographic characteristics.
Studies that focused exclusively on non-European regions or did not provide excess mortality estimates were excluded.
This paper summarizes the findings of studies identified via Scopus AI [2, 4-12] to explore the primary drivers of excess mortality in Europe from 2020 to 2023, with particular emphasis on:
1. Geographical and temporal patterns – Identification of hot spots and periods in which mortality deviated most significantly from pre-pandemic norms.
2. Demographic dynamics – Exploration of how age, sex, and socioeconomic status shaped vulnerability to both COVID-19 and its indirect health consequences.
3. Healthcare infrastructure and policy responses – Analysis of how national and regional policies, including vaccination coverage and hospital preparedness, influenced outcomes.
4. Methodological approaches to measuring excess mortality – Overview of how different models and statistical methods contributed to our understanding of the pandemic’s true toll.
Through these focal areas, this review provides an analysis of the pandemic’s impact across Europe and highlights the importance of multi-faceted public health strategies to mitigate mortality in current and future crises.

DATA SYNTHESIS

Extracted data were synthesized qualitatively to capture overarching themes, geographic variations, and temporal patterns of excess mortality in Europe. The synthesis was organized around four main areas:
1. Overall trends in excess mortality.
2. Regional disparities.
3. Demographic and socioeconomic factors.
4. Healthcare infrastructure and policy measures.

RESULTS

The search resulted in twelve unique articles, and their main characteristics are summarized in Table 1.

OVERALL TRENDS IN EXCESS MORTALITY (2020-2023)

A consistent finding across the reviewed studies was the markedly higher mortality in Europe from 2020 onward compared to pre-pandemic baselines. Although country-specific estimates varied, multiple analyses concluded that the first two years of the pandemic (2020-2021) accounted for a substantial proportion of the total excess deaths observed through 2023 [3, 12]. In 29 European countries, for instance, Pizzato et al. [1] estimated more than 1 million additional deaths over the first two years of the pandemic (Table 2).
Early peaks were particularly pronounced in the spring of 2020, corresponding to the first wave of SARS-CoV-2 infections in Italy, Spain, and France. Subsequent surges in the autumn and winter of 2020-2021 contributed to further excess deaths, in many cases exceeding those recorded during the first wave [1, 4]. While advances in clinical management and the rollout of vaccines during 2021-2022 helped reduce COVID-19 mortality, the cumulative burden remained. By 2023, preliminary data showed that ongoing circulation of COVID-19, influenza, and RSV in the winter season continued to drive periods of elevated mortality – particularly among older populations with high baseline vulnerability [8].

REGIONAL DISPARITIES

Highest-burden regions
Considerable heterogeneity emerged within and across European nations. Estimates indicate that Bulgaria had some of the highest documented excess mortality rates, especially in 2021 and 2022. Studies proposed that uneven vaccination coverage, limited healthcare resources, and structural socioeconomic challenges exacerbated the crisis [9]. Likewise, spikes were consistently reported in parts of Central and Eastern Europe, including Slovakia and Lithuania, where rapid case surges encountered under-resourced healthcare systems [1].

Lowest-burden regions
On the other end of the spectrum, Sweden and other Nordic countries (Norway and Denmark) generally reported lower excess mortality relative to many EU countries during the initial phase of the pandemic [5]. In Sweden, for example, Lindström [5] found that while the country experienced a sizable excess in mortality during 2020, the overall excess remained comparatively moderate in 2020-2022. However, it followed a unique temporal pattern (i.e., significant mortality in 2020, less so in subsequent surges). France and Germany also exhibited somewhat lower excess mortality, likely owing to robust healthcare networks, policy responses that were coordinated and consistent over time, and relatively high vaccination uptake [11].

Intranational differences
Several countries showed internal heterogeneity, as illustrated by a multicountry cross-sectional study that examined 561 European regions [11]. This analysis revealed that significant inequalities existed even within the same nation, with specific densely populated urban centers (e.g., Madrid, Lombardy, Île-de-France) facing higher peaks than their rural counterparts. Such variation was linked to population density, prevalence of comorbidities, economic disparities, and local policy decisions (e.g., speed of lockdown implementation).

DEMOGRAPHIC AND SOCIOECONOMIC FACTORS

Age distribution
Older adults (≥ 65) disproportionately contributed to excess mortality, accounting for 80-90% or more of the observed surplus deaths in most contexts [3]. High-risk long-term care facility environments and a greater baseline burden of chronic illnesses (e.g., cardio­vascular disease) likely magnified vulnerability within these age groups.

>Sex differences
Studies reported moderately higher overall excess mortality rates among men, although this pattern varied across age groups and timeframes [10]. While men faced higher COVID-19 mortality initially, the gap between sexes narrowed during later waves. This shift was partly attributed to differential vaccination uptake and evolving transmission patterns, though more granular data remain necessary for definitive conclusions.

Socioeconomic inequalities
Lower GDP per capita, higher poverty rates, and reduced healthcare capacity correlated with elevated mortality burdens [1, 3, 7]. For instance, poorer regions in Eastern and Southern Europe often experienced pronounced mortality peaks, despite sometimes having younger populations. This phenomenon suggested that vulnerabilities stemming from structural inequities (e.g., inadequate healthcare funding, lack of universal access to care) may have offset potential demographic advantages.

HEALTHCARE INFRASTRUCTURE AND POLICY MEASURES

Healthcare system preparedness
Countries with well-funded and highly accessible healthcare systems tended to fare better in limiting extreme mortality surges [1]. The availability of hospital beds, intensive care units, and integrated primary care networks facilitated earlier interventions and more efficient triage of severe COVID-19 cases. On the other hand, research highlighted that countries with underfunded hospitals and disjointed public health services faced increased mortality during peak times waves [1].

Vaccination coverage
The rollout of COVID-19 vaccines, beginning in early 2021, served as a critical intervention across Europe, substantially reducing mortality in populations with high uptake [2, 12]. Countries with broader vaccine coverage (e.g., Portugal, Spain) generally recorded fewer COVID-19- related deaths per capita. Nonetheless, their success was contingent upon sustained vaccine access, efforts to address vaccine hesitancy, and robust distribution channels.

Non-pharmaceutical interventions (NPIs)
Policy interventions – such as lockdowns, mandatory masking, and physical distancing – also shaped mortality patterns. Strict NPIs in the early waves were associated with lower-than-anticipated mortality surges in several Northern European nations [5], but also in Greece. However, protracted lockdowns had downstream impacts on routine healthcare (e.g., postponed surgery, delayed cancer screening), which some studies suggested may have contributed to non-COVID excess deaths in later phases of the pandemic [1].

METHODOLOGICAL APPROACHES TO MEASURING EXCESS MORTALITY

Diverse statistical tools for estimating excess mortality, ranging from simple year-over-year comparisons to statistical modeling based on historical trends and sophisticated time-series models, have been used (e.g., EuroMOMO methodology). Despite methodological differences, a consensus emerged that all-cause excess mortality provided a more robust indicator of the pandemic’s overall burden than confirmed COVID-19 death alone.

DISCUSSION

Overall, the results highlight substantial temporal, geographic, and demographic disparities in excess mortality across Europe from 2020 to 2023. This spectrum reflected differences in COVID-19 transmission and response strategies and broader issues of healthcare equity and resource allocation.
The excess mortality in Europe between 2020 and 2023 was shaped by an intricate combination of factors, including the sustained impact of COVID-19, the seasonal reemergence of other respiratory pathogens (particularly influenza and RSV), a range of policy interventions, and deep-seated socioeconomic and healthcare inequalities. Although the introduction of vaccines and improvements in clinical management have helped reduce mortality in numerous European countries, the overall pattern continues to reveal a complex relationship among viral transmission, public health measures, healthcare capacity, and broader social structures.
In the early stages of the pandemic, the lack of vaccines and limited knowledge of SARS-CoV-2 contributed to rapid mortality increases in countries experiencing substantial caseloads. As additional SARS-CoV-2 variants emerged and population immunity evolved, subsequent waves continued to drive excess death rates, although the peaks were generally lower in countries achieving high vaccination coverage [1, 2, 12]. By 2023, the co-circulation of influenza, RSV, and SARS-CoV-2 (especially in the winter months) further complicated mortality trends, leading to spikes in hospital admissions and fatalities among older populations [8]. These dynamics underscore the importance of integrated surveillance systems and the need for seasonal immunization programs that address multiple respiratory pathogens simultaneously.
Socioeconomic and demographic variables added another layer of complexity. Regions with lower GDP per capita or limited healthcare access consistently saw more severe mortality surges [1, 3, 7]. These vulnerabilities were especially acute among older age groups, who already faced higher risks of severe illness due to underlying health conditions [4]. Consequently, strengthening healthcare systems and taking active measures to alleviate deeper social inequalities stand out as critical strategies for reducing mortality in future health crises.
Geographical differences both across and within nations also played a decisive role. Northern Italy, parts of Spain, and areas of Eastern Europe recorded notably high excess mortality rates, often linked to factors such as delayed lockdowns, overcrowded hospitals, and higher prevalence of chronic conditions [1, 11]. In contrast, some Nordic regions and Western France appeared to fare better, owing in part to robust healthcare infrastructures, effective public health messaging, and successful vaccination campaigns [5, 11]. At the same time, the significant intranational disparities remind us that even in wealthier countries, resource distribution and localized policy decisions can lead to markedly different health outcomes.
Rapidly imposed non-pharmaceutical measures – such as early lockdowns – did help contain transmission in several regions during the initial waves of the pandemic. However, when sustained for long periods, these measures created secondary consequences, including postponements in routine healthcare services and mental health and socio-economic challenges [1]. As vaccination coverage rose, most countries adopted more targeted approaches, relying on increased testing, contact tracing, and the promotion of vaccines. Although these measures reduced mortality from COVID-19, the persistence of notable excess deaths in 2023 suggests that structural vulnerabilities and a sense of public fatigue may have tempered their overall effectiveness.
From a methodological viewpoint, the variation in how excess mortality was modeled and in the baseline periods used for comparison reflects the challenges of accurately capturing the dynamic nature of a global health crisis. While simple year-over-year comparisons can highlight broad patterns, more refined time-series models (such as those recommended by EuroMOMO) can yield deeper insights into the interplay of infections, healthcare capacity, and policy responses [4]. Future research that delves beyond aggregate mortality and incorporates additional health outcomes – such as long-term post-COVID effects or the repercussions of disrupted care for chronic conditions – would help clarify the broader toll of the pandemic.
These findings reveal how deeply structural inequalities, healthcare preparedness, and timely policy actions affect mortality outcomes. Addressing these systemic vulnerabilities is an urgent concern for policy­makers who must navigate the ongoing ramifications of COVID-19 and the potential for future health emergencies. Strengthening healthcare infrastructures, maintaining comprehensive immunization programs, and improving surveillance systems remain essential. Equally critical are efforts to ensure equitable healthcare access and engage communities at risk due to socioeconomic constraints. Although the pandemic has shown the resilience of some systems and populations, the continued excess mortality well into 2023 highlights the uneven distribution of this resilience – and emphasizes the vital need for policies that bolster preparedness, bridge resource gaps, and safeguard public health more equitably in the years ahead.

CONCLUSIONS

This paper examined excess mortality in Europe from 2020 to 2023, drawing on multiple studies identified through Scopus AI. The overall evidence underscores the complexity of mortality patterns driven by COVID-19, the co-circulation of other respiratory pathogens (e.g., influenza, RSV), and the interplay of broader socioeconomic and demographic factors. Despite advancements in clinical management and the rollout of vaccination campaigns, substantial heterogeneity persists among and within European countries.
Regions facing structural healthcare limitations, economic constraints, or delayed policy measures saw especially pronounced mortality peaks, while areas with robust healthcare infrastructure and rapid interventions generally reported lower excess mortality. Disparities in excess deaths, particularly among older adults, also highlight the pivotal role of prevention and timely access to care in high-risk groups. Moreover, non-COVID factors – such as deferred medical care and socioeconomic stress – likely contributed to the overall surplus in mortality.
The findings emphasize the necessity of continued vigilance in monitoring emerging viral threats and bolstering public health systems. Investments in resource allocation, integrated surveillance, and community- centric interventions are crucial to mitigate the mortality burden of future health crises. By addressing health’s medical and socioeconomic determinants, European countries can enhance their preparedness and resilience against forthcoming challenges, ensuring that gains made since 2020 translate into long-term improvements in population health and well-being.

DISCLOSURES

This research was supported by European Union (EU) funding within the NextGeneration EU-MUR PNRR Extended Partnership initiative on Emerging Infectious Diseases (Project no. PE00000007, INF-ACT).
The authors asked Scopus AI to suggest the papers to analyze.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

References