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The global COVID-19 death toll may be three times higher than official tallies suggest, according to a systematic analysis of excess mortality during the pandemic.

From Jan. 1, 2020 to Dec. 31, 2021, global deaths directly attributed to COVID-19 reached 5.9 million, yet estimates put excess deaths during this period at a staggering 18.2 million (95% uncertainty interval [UI] 17.9-19.6), Haidong Wang, PhD, of the University of Washington in Seattle, and the COVID-19 Excess Mortality Collaborators reported in .

India had the highest number of excess deaths (4.07 million, 95% UI 3.71-4.36), an estimated eight times higher than its 489,000 reported COVID-19 deaths, which was followed by the U.S. (1.13 million, 95% UI 1.08-1.18), where the official count reached 824,000 by the end of 2021.

The excess mortality rate in the U.S. (179.3 per 100,000) was about on par with Brazil (186.9 per 100,000), the study found.

"Understanding the true death toll from the pandemic is vital for effective public health decision-making," Wang said in a statement. "Studies from several countries including Sweden and the Netherlands, suggest COVID-19 was the direct cause of most excess deaths, but we currently don't have enough evidence for most locations."

The researchers undertook a massive effort, deriving models by using all-cause mortality reports for 74 countries and territories and 266 "subnational locations," which included 31 locations in low and middle-income countries. These locations reported all-cause death from 2020-2021, and up to 11 years prior. They also obtained excess mortality reports for 12 states in India.

Overall, the global rate of estimated excess mortality from COVID was 120.3 deaths per 100,000, with 21 countries exceeding 300 excess deaths per 100,000. The highest estimated excess mortality rate from COVID was in Bolivia at 734.9 deaths per 100,000, followed by Bulgaria, Eswatini, North Macedonia, and Lesotho. Iceland had the lowest excess mortality rate (-47.8 per 100,000). Australia, Singapore, New Zealand, and Taiwan also had negative excess mortality rates.

Behind India and the U.S. for most excess deaths were Russia (1.07 million), Mexico (798,000), Brazil (792,000), Indonesia (736,000), and Pakistan (664,000). Wang's group noted that these seven countries accounted for more than half of the excess deaths globally during the study period.

Wang's team acknowledged the "convincing evidence" that rates of anxiety and depression rose during the pandemic, which might lead to increases in death by suicide, but added that "to date, evidence of increased suicide mortality is scarce apart from in Japan, where reported suicide deaths increased during the pandemic."

"The most compelling evidence to date of a change in cause-specific mortality in the pandemic period is the decrease, especially in the Northern Hemisphere, in flu and respiratory syncytial virus (RSV) deaths seen in the months of January to March, 2021," they added. "Given the scarce and inconsistent evidence of the effect of the COVID-19 pandemic on cause-specific deaths, and the extremely scarce high-quality data on causes of death during the pandemic, our excess mortality estimates reflect the full impact of the pandemic on mortality around the world ... not just the deaths directly attributable to SARS-CoV-2 infection."

Limitations to the data include that different modeling strategies were used to estimate excess mortality rate, and that they did not estimate excess mortality rate by week or month.

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