Excess mortality at ages 20-64 from 2020 to 2024: a comparative analysis of 16 European countries

Introduction: Emerging evidence suggests that young and middle-aged adults may experience postacute sequelae of COVID-19, increasing their risk of cardiovascular complications. However, it remains unclear whether these risks translated into higher all-cause mortality. Methods: We analysed mortality and population data from 16 European countries to estimate excess mortality among individuals aged 20-64 years during the period 2020-2024. Excess mortality was defined as the difference between observed and expected age-standardised mortality rates. Expected values were modelled using three approaches based on different assumptions: (1) a long-trend linear model based on 2010-2019 data; (2) a non-linear model using the same baseline and (3) a short-trend linear model based on 2015-2019 data. Results: In 2020 and 2021, all models consistently estimated substantial excess mortality in several countries, with the highest estimates in 2021 for Bulgaria (34.7%-37.3% in males, 45.1%-51.6% in females), Hungary (21.0%-28.9% in males, 30.7%-35.4% in females), Poland (19.1%-24.1% in males, 23.6-24.0 in females) and Slovakia (32.1%-36.6% in males, 34.2%-38.1% in females). In 2022, model estimates diverged, with significant excess mortality persisting only under the long-trend linear model. By 2023, residual excess mortality was found only among males in Austria (according to the long-trend linear and non-linear models) and Finland (according to the long-trend linear model), while in 2024 persisted only in Austria under the same models. Assuming a continuing linear mortality trend appeared to overestimate excess mortality in some age groups. Conclusions: Our analysis indicates substantial excess mortality among adults aged 20-64 in 2020 and in 2021 in Europe but does not support a sustained postpandemic increase in all-cause mortality. The estimates were sensitive to the choice of the baseline period and modelling approach, underscoring the importance of presenting results under multiple analytical assumptions.