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Monitoring excess mortality in Europe

BMJ 2013; 347 doi: (Published 18 September 2013) Cite this as: BMJ 2013;347:f5568

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Mortality rate in Italy in 2015: an increase of 9.1% to be explained

On 19th February 2016 the Italian National Institute of Statistics (ISTAT) released 2015 mortality data reporting 9.1% excess mortality as compared to 2014, this corresponding to 54,000 excess deaths and representing the highest reported mortality rate (10.7 per 1000) since World War 2 (1).

These figures confirm the alarming news of an estimated 11.3% increase for the first semester which got great media resonance last December. Analysis from other independent national and regional-level sources confirmed such trend and estimated excess mortality to have mainly affected subjects aged ≥65 with two seasonal peaks: December 2014-March 2015 and July 2015 (2).

Data are in line with European patterns (3, 4). In fact, back in March 2015 data from 14 European countries were published on excess mortality between December 2014 and Februrary 2015 among individuals ≥65 yeras being significantly higher than in the four previous winter seasons (4). Such figure passed over in silence.

Although the drastic excess mortality generated concern among researchers, health authorities and public health experts, it has been hard to identify its determinants as data were (and still are) not available by cause of death. Preliminary analysis (2) reported this rise to be associated with meteorological factors (high and low temperatures, heat-waves) and demographic changing patterns (birth rate decrease in 1917-1920 and population ageing). Other hypotheses are the association between excess mortality and air pollution due to air quality deterioration in Italian urban areas in 2015. In addition, we believe that the decrease in influenza coverage in the elderly reported over the 2014-15 flu season (-12%) due to the ‘Fluad case’ (5) might have contributed to the observed increase in death rates.

Such episode calls upon health institutions to reflect on the efficiency and promptness of monitoring system to allow action to be taken when a rise in mortality is detected. This time the alarm was raised by news media far before any response system activation (6).

In Italy healthcare provides universal health coverage. Although the ongoing economic crisis is putting its sustainability into question – differently from other countries - austerity measures are unlikely to be entirely responsible for this mortality increase . We do believe such trends need to be further explored, taking into account mortality trends in previous years, demographic transitions, and all possible risk factors. National and regional health authorities - as well as the scientific community - should engage in a strengthened effort to explore in details the causes behind the observed excess mortality and its trend so that prevention strategies can promptly be planned, implemented and monitored.


1. ISTAT. Indicatori demografici. Stime per l'anno 2015 [accessed 19.02.2015].

2. Michelozzi P, de’ Donato F, Scortichini M, De Sario M, Asta F, Agabiti N, Guerra R, de Martino A, Davoli M. Sull’incremento della mortalità in Italia nel 2015: analisi della mortalità stagionale nelle 32 città del Sistema di sorveglianza della mortalità giornaliera [On the increase in mortality in Italy in 2015: analysis of seasonal mortality in the 32 municipalities included in the Surveillance system of daily mortality] Epidemiol Prev 2016; 40(1):22-28.

3. Laurent MR. Monitoring excess mortality in Europe. BMJ. 2013;347:f5568.

4. Molbak K, Espenhain L, Nielsen J, Tersago K, Bossuyt N, Denissov G, et al. Excess mortality among the elderly in European countries, December 2014 to February 2015. Euro Surveill. 2015;20(11).

5. Signorelli C, Odone A, Conversano M, Bonanni P. Deaths after Fluad flu vaccine and the epidemic of panic in Italy. BMJ. 2015;350:h116.

6. Cislaghi C, Costa G, Rosano A. Una strage o solo un dato statistico? Il surplus di decessi nel 2015 [A mass murder or mere statistical data? The 2015 surplus of deaths]. Epidemiol Prev 2016; 40(1):9-11.

Competing interests: No competing interests

26 February 2016
Carlo Signorelli
Professor of Public Health, President of the Italian Society of Hygiene, Preventive Medicine and Public Health
Anna Odone, University of Parma
University of Parma and University Vita-Salute San Raffaele
Via Volturno, 39