Background Sweden has one of the highest numbers of COVID-19 deaths per inhabitant globally. However, absolute death counts can be misleading. Estimating age- and sex-specific mortality rates is necessary in order to account for the underlying population structure. Furthermore, given the difficulty of assigning causes of death, excess all-cause mortality should be estimated to assess the overall burden of the pandemic. Methods By estimating weekly age- and sex-specific death rates during 2020 and during the preceding five years, our aim is to get more accurate estimates of the excess mortality attributed to COVID-19 in Sweden, and in the most affected region Stockholm. Results Eight weeks after Sweden’s first confirmed case, the death rates at all ages above 60 were higher than for previous years. Persons above age 80 were disproportionally more affected, and men suffered greater excess mortality than women in ages up to 75 years. At older ages, the excess mortality was similar for men and women, with up to 1.5 times higher death rates for Sweden and up to 3 times higher for Stockholm. Life expectancy at age 50 declined by less than 1 year for Sweden and 1.5 years for Stockholm compared to 2019. Conclusions The excess mortality has been high in older ages during the pandemic, but it remains to be answered if this is because of age itself being a prognostic factor or a proxy for comorbidity. Only monitoring deaths at a national level may hide the effect of the pandemic on the regional level.

Background Both age and comorbidity are established risk factors for death among those infected with COVID-19. Because they often co-exist, it is difficult to assess if age is a risk factor on its own. Methods We used administrative register data of the total Swedish population from 01/2015 until 07/2020. We stratified the population aged 70+ into three groups according to level of care (in care homes, with home care, and in independent living). Within these groups, we explored the level of excess mortality in 2020 by estimating expected mortality with Poisson regression and compared it to observed levels. We investigated if excess mortality has been of the same magnitude in the three groups, and if age constitutes a risk factor for death during the pandemic regardless of level of care. Findings Individuals living in care homes experienced the highest excess mortality (75- >100% in April, 25–50% in May, 0–25% in June, depending on age). Individuals with home care showed the second highest magnitude (30–60% in April, 15–40% in May, 0–25% in June), while individuals in independent living experienced excess primarily at the highest ages (5–50% in April, 5–50% in May, 0–25% in June). Although mortality rates increased, the age-pattern of mortality during the pandemic resembled the age-pattern observed in previous years. Interpretation We found stepwise elevated excess mortality by level of care during the first wave of the COVID-19 pandemic in Sweden, suggesting that level of frailty or comorbidities plays a more important role than age for COVID-19 associated deaths. Part of our findings are likely attributable to differences in exposure to the virus between individuals receiving formal care and those living independently, and not only different case fatality between the groups. Although age is a strong predictor for mortality, the relative effect of age on mortality was no different during the pandemic than before. We believe this is an important contribution to the discussion of the pandemic, its consequences, and which groups need the most protection. Funding This study was funded by the Swedish Research Council for Health, Working Life and Welfare (FORTE: grant 2016-07115).

BACKGROUNDIn most developed countries, mortality reductions in the first half of the 20th century were highly associated with changes in lifespan disparities. In the second half of the 20th century, changes in mortality are best described by a shift in the mortality schedule, with lifespan variability remaining nearly constant. These successive mortality dynamics are known as compression and shifting mortality, respectively.

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