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Excess mortality in Wuhan city and other parts of China during the three months of the covid-19 outbreak: findings from nationwide mortality registries

BMJ 2021; 372 doi: (Published 24 February 2021) Cite this as: BMJ 2021;372:n415

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  1. Jiangmei Liu, research associate1,
  2. Lan Zhang, professor2,
  3. Yaqiong Yan, associate professor3,
  4. Yuchang Zhou, masters student1,
  5. Peng Yin, professor1,
  6. Jinlei Qi, associate professor1,
  7. Lijun Wang, professor1,
  8. Jingju Pan, associate professor2,
  9. Jinling You, research assistant1,
  10. Jing Yang, associate professor1,
  11. Zhenping Zhao, research associate1,
  12. Wei Wang, doctoral student1,
  13. Yunning Liu, associate professor1,
  14. Lin Lin, research assistant1,
  15. Jing Wu, professor1,
  16. Xinhua Li, professor4,
  17. Zhengming Chen, professor5,
  18. Maigeng Zhou, professor1
  1. 1The National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention (China CDC), Xicheng District, 100050, Beijing, China
  2. 2Hubei Provincial Center for Disease Control and Prevention, Wuhan, Hubei, China
  3. 3Wuhan Center for Disease Control and Prevention, Wuhan, Hubei, China
  4. 4Chinese Center for Disease Control and Prevention, Beijing, China
  5. 5Nuffield Department of Population Health, University of Oxford, Oxford, UK
  1. Correspondence to: M Zhou zhoumaigeng{at}
  • Accepted 11 February 2021


Objective To assess excess all cause and cause specific mortality during the three months (1 January to 31 March 2020) of the coronavirus disease 2019 (covid-19) outbreak in Wuhan city and other parts of China.

Design Nationwide mortality registries.

Setting 605 urban districts and rural counties in China’s nationally representative Disease Surveillance Point (DSP) system.

Participants More than 300 million people of all ages.

Main outcome measures Observed overall and weekly mortality rates from all cause and cause specific diseases for three months (1 January to 31 March 2020) of the covid-19 outbreak compared with the predicted (or mean rates for 2015-19) in different areas to yield rate ratio.

Results The DSP system recorded 580 819 deaths from January to March 2020. In Wuhan DSP districts (n=3), the observed total mortality rate was 56% (rate ratio 1.56, 95% confidence interval 1.33 to 1.87) higher than the predicted rate (1147 v 735 per 100 000), chiefly as a result of an eightfold increase in deaths from pneumonia (n=1682; 275 v 33 per 100 000; 8.32, 5.19 to 17.02), mainly covid-19 related, but a more modest increase in deaths from certain other diseases, including cardiovascular disease (n=2347; 408 v 316 per 100 000; 1.29, 1.05 to 1.65) and diabetes (n=262; 46 v 25 per 100 000; 1.83, 1.08 to 4.37). In Wuhan city (n=13 districts), 5954 additional (4573 pneumonia) deaths occurred in 2020 compared with 2019, with excess risks greater in central than in suburban districts (50% v 15%). In other parts of Hubei province (n=19 DSP areas), the observed mortality rates from pneumonia and chronic respiratory diseases were non-significantly 28% and 23% lower than the predicted rates, despite excess deaths from covid-19 related pneumonia. Outside Hubei (n=583 DSP areas), the observed total mortality rate was non-significantly lower than the predicted rate (675 v 715 per 100 000), with significantly lower death rates from pneumonia (0.53, 0.46 to 0.63), chronic respiratory diseases (0.82, 0.71 to 0.96), and road traffic incidents (0.77, 0.68 to 0.88).

Conclusions Except in Wuhan, no increase in overall mortality was found during the three months of the covid-19 outbreak in other parts of China. The lower death rates from certain non-covid-19 related diseases might be attributable to the associated behaviour changes during lockdown.


  • Contributors: JL, LZ, and YY contributed equally to the paper as joint first authors. MZ ( and ZC ( are joint corresponding authors. ZC, MZ, LW, PY, JW, LZ, and YY conceived and designed the study. JL, YZ, and WW performed the statistical analysis. JL, YZ, MZ, and ZC drafted the manuscript. All authors contributed to acquisition, analysis, or interpretation of data and revised the report and approved the final version before submission. MZ and ZC are the guarantors and attest that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This work was supported by the National Natural Science Foundation of China (grant No 82073675). The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or the writing of the report. One of the corresponding authors (MZ) had full access to all the data in the study, and both corresponding authors (MZ and ZC) had final responsibility for the decision to submit for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: funding for the project through a grant (No 82073675) from the National Natural Science Foundation of China; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: The mortality data can be applied for through a government data sharing portal (

  • The lead author (MZ) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: The results of this study will be reported through the media centre of the authors’ institutions under authors’ supervision.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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