Uncovering the social vulnerabilities behind excess and premature mortality during the COVID-19 pandemic in Serbia

The COVID-19 pandemic altered mortality patterns worldwide, raising questions about its direct and indirect effects on population health. Assessing these impacts requires approaches that go beyond registered COVID-19 deaths and capture both excess and premature mortality. This study quantified excess mortality and years of life lost (YLL) due to COVID-19 in Serbia and examined variation across sociodemographic groups. We analyzed national all-cause mortality data from 2010 to 2023 and individual-level COVID-19 deaths from 2020 to 2022. Expected mortality was estimated using generalized additive models fitted to pre-pandemic data, allowing estimation of age-, sex-, and cause-specific excess mortality. Individual-level regression analyses were conducted to examine sociodemographic differences across epidemic periods and in age at death. Between 2020 and 2022, Serbia experienced 53,970 excess deaths, corresponding to a 17.5% increase compared to expected mortality, with the highest burden observed in 2021. Registered COVID-19 deaths accounted for 46,374 deaths and were associated with 560,266 YLL over the study period. Excess mortality was higher among older women, whereas deaths before age 65, particularly among men, contributed disproportionately to total YLL. Lower educational attainment and non-urban residence were associated with differences in the distribution of deaths across epidemic periods and in age at death among COVID-19 decedents. The COVID-19 pandemic resulted in a substantial mortality burden in Serbia, exceeding registered COVID-19 deaths and revealing marked premature mortality. Excess deaths were concentrated among older populations, while the premature mortality burden was higher among men. Differences were also observed in the distribution of deaths across epidemic periods and in age at death across educational and residential groups. The COVID-19 pandemic affected how and when people died, but its full impact cannot be understood by counting only officially reported COVID-19 deaths. This study examined how the pandemic changed overall mortality in Serbia and how many years of life were lost when deaths occurred earlier than expected. We used national death records from before and during the pandemic to compare observed deaths with those expected under normal conditions. We also examined the age and basic social characteristics of those who died. The highest number of deaths occurred in 2021. Although most deaths were among older adults, deaths at younger ages accounted for a large share of the total years of life lost, particularly among men. Differences were also observed in when deaths occurred and in age at death across social groups. These findings highlight the importance of considering both the number and timing of deaths as well as the social context in which they occur when planning future public health responses. Stevanović et al. examine national death records and individual COVID-19 mortality data to estimate excess deaths and years of life lost in Serbia during the COVID-19 pandemic. Findings show excess deaths are higher among older women, while deaths before age 65, especially among men, account for a large share of years of life lost.