Excess deaths associated with the Iranian COVID-19 epidemic: A province-level analysis.

OBJECTIVE: There has been no province-level data on the number of COVID-19-related deaths in Iran since the start of the pandemic. We estimate the number of COVID-19 deaths and population-level exposure per province using seasonal all-cause mortality data. METHODS: We gather time series data on the seasonal all-cause mortality from spring 2015 to summer 2020 (from 21 March 2015 to 21 September 2020), in accordance with the Solar Hijri (SH) calendar, from the National Organization for Civil Registration (NOCR) to estimate the expected number of seasonal deaths for each province using a piecewise linear regression model. We then apply a population-weighted infection fatality ratio to estimate the level of exposure per province during this period. RESULTS: We find that from the start of winter to the end of summer (from 22 December 2019 to 21 September 2020), there were a total of 58.9 K (95%CI: 46.9 K-69.5 K) excess deaths across all the 31 provinces with 27% (20%-34%) estimated nationwide exposure to SARS-CoV-2. In particular, Qom and Golestan, had among the hardest-hit provinces with nearly 57% exposure while another 27 provinces showed significant levels of excess mortality in at least one season with >20% population-level exposure to the virus. We also detected unexpectedly high levels of excess mortality during fall 2019 (from 23 September to 21 December 2019) across 18 provinces, unrelated and prior to the start of the COVID-19 pandemic. CONCLUSION: Our study quantifies the pattern of spread of the COVID-19 across the country for the first time and identifies areas with the largest epidemic growth requiring the most immediate interventions.