Unequal impact of COVID-19 on excess deaths, life expectancy, and premature mortality in Spanish regions (2020-2021)

Objective: We aimed to estimate regional inequalities in excess deaths and premature mortality in Spain during 2020 and 2021, before high vaccination coverage against COVID-19.

Method: With data from the National Institute of Statistics, within each region, sex, and age group, we estimated the excess deaths, the change in life expectancy at birth (e₀) and age 65 (e₆₅) and years of life lost as the difference between the observed and expected deaths using a time series analysis of 2015-2019 data and life expectancies based on Lee-Carter forecasting using 2010-2019 data.

Results: From January 2020 to June 2021, an estimated 89,200 (men: 48,000; women: 41,200) excess deaths occurred in Spain with a substantial regional variability (highest in Madrid: 22,000, lowest in Canary Islands: -210). The highest reductions in e₀ in 2020 were observed in Madrid (men -3.58 years, women -2.25), Castile-La Mancha (-2.72, -2.38), and Castile and Leon (-2.13, -1.39). During the first half of 2021, the highest reduction in e₀ was observed in Madrid for men (-2.09; -2.37 to -1.84) and Valencian Community for women (-1.63; -1.97 to -1.3). The highest excess years of life lost in 2020 was in Castile-La Mancha (men: 5370; women: 3600, per 100 000). We observed large differences between reported COVID-19 deaths and estimated excess deaths across the Spanish regions.

Conclusions: Regions performed highly unequally on excess deaths, life expectancy and years of life lost. The investigation of the root causes of these regional inequalities might inform future pandemic policy in Spain and elsewhere.