More than four years after the acute phase of the COVID-19 pandemic ended, one of the most persistent questions in public health is how much the virus still kills. A new nationwide analysis from Austria offers a striking answer: perhaps far less than official statistics suggest. In a retrospective study published in the European Journal of Epidemiology, researchers led by Uwe Riedmann of the Medical University of Graz, together with Stefan Pilz and Stanford University’s Michael Levitt and John Ioannidis, examined mortality patterns in 2024 and compared them with the pre-pandemic years 2017 to 2019. Their conclusion is twofold and, in places, uncomfortable. COVID-19 appears to have left no visible imprint on Austria’s mortality patterns in 2024, and the official count of COVID-19 deaths may have been substantially inflated throughout the pandemic.
The study’s foundation is a simple but powerful epidemiological logic. If SARS-CoV-2 were still exerting a serious toll on the population, the age groups most vulnerable to the virus, principally those aged 60 and older, should show mortality rates above their pre-pandemic baselines. The researchers therefore calculated mortality rate ratios for every combination of sex and ten-year age band, dividing the 2024 death rate by the average rate across 2017 to 2019. A ratio above 1.00 would signal excess mortality; a ratio below 1.00 would suggest that deaths have fallen relative to before the pandemic. Confidence intervals were derived using the delta method on the log scale, allowing the team to distinguish signal from statistical noise.
The results were unambiguous for older Austrians. Despite 1,212 officially reported COVID-19 deaths in 2024, all-cause mortality rates in every stratum aged 40 and over were equal to or lower than before the pandemic, and in the 60-plus groups, the very populations at risk from the virus, rates were equal or lower in 2024 compared with 2019. In many of these strata the ratios fell well below 1.00. The team stress-tested this finding against several counterfactuals. An optimistic sensitivity analysis assumed that mortality would have continued improving after 2019 at the pace seen between 2012 and 2014, yielding an expected ratio of 0.929; five of the twelve age-sex strata aged 40 and over beat even that demanding benchmark. A trend-of-trends model trained on Austrian data from 2003 to 2019 produced an expected ratio of 0.976, and ten of twelve strata performed better than that. A Lee-Carter mortality forecasting model, fitted to age- and sex-specific rates from 2003 to 2019 and projected to 2024 via ARIMA with bootstrapped confidence intervals, showed observed 2024 life expectancy to be numerically higher than predicted in every age-sex stratum, significantly so for females across all age groups.
The picture for young Austrians was markedly different, and more troubling. Mortality rate ratios were elevated in the 10-to-19, 20-to-29 and 30-to-39 age bands, significantly so among men aged 30 to 39. Crucially, these increases cannot be attributed to COVID-19 itself: only a single individual across these young strata was recorded as having died of the disease in 2024. When the researchers decomposed the excess by cause, they found moderate increases spread across multiple high-level categories, with consistent rises in mental and behavioural disorders, external causes and diseases of the nervous system, though only external causes in the 10-to-19 group reached statistical significance. The authors suggest these patterns may reflect adverse consequences of the pandemic and the pandemic response, noting that escalating violence, alcohol problems, drug overdoses and suicides among young people have been documented in several countries and may constitute a lasting legacy that requires tracking and intervention.
The second half of the study tackles a subtler problem: how to count a COVID-19 death. Death certificates record an underlying cause of death, the condition that initiates the chain leading to death, along with other contributing conditions. In practice, anyone who dies with a positive SARS-CoV-2 test may be coded as a COVID-19 death even when other conditions are more relevant, a distinction that matters enormously in elderly and chronically ill populations. To address this, the team applied a weighted multiple-cause methodology to the full text of Austrian death certificates. In their main analysis, the underlying cause received a weight of 50 percent and all other mentioned causes shared the remaining 50 percent; when no other cause was listed, the underlying cause carried full weight. Ill-defined and duplicate causes were excluded. From more than 538,000 death certificates spanning 2019 to 2024, containing over 2.5 million non-duplicate ICD code mentions, the researchers constructed age-standardised rates for both unweighted underlying-cause counts and weighted counts.
The comparison between the two measures is the study’s most technically revealing result. If a cause is genuinely driving deaths, it should appear disproportionately as the underlying cause, and its weighted rate should approach its unweighted rate. For COVID-19 in the 60-plus age groups, the ratio of weighted to unweighted rates sat between 0.51 and 0.58, both in 2020 and in 2024, meaning the virus was far more likely to be listed as the underlying cause than other conditions were, and that this preference barely changed even as absolute death counts collapsed. Sensitivity analyses using alternative weighting schemes, equal weighting of all causes or double weight for the underlying cause, produced even lower weighted estimates, for example 4.15 versus a main-analysis 7.12 for 2024, and more stringent data-cleaning criteria left the COVID-19 findings intact. Taken together, the authors argue, these patterns point to systematic overcounting of COVID-19 deaths, potentially throughout the entire pandemic rather than only in its aftermath.
Supporting evidence comes from how COVID-19 behaved within the broader cause-of-death landscape. Respiratory diseases traditionally show a weighted-to-unweighted ratio well above 1.00, around 1.47 in 2019, because they are typically recorded as contributing rather than underlying conditions. During the pandemic years 2020 to 2023, once COVID-19 was stripped out of the respiratory category, other respiratory diseases fell markedly, and the category’s ratio rose to 1.64, as if COVID-19 had absorbed deaths that would otherwise have been attributed to pneumonia and related conditions. The causes most frequently co-mentioned with COVID-19 in 2024 were pneumonia, residual infections, hypertensive disease, ischaemic heart disease and renal failure, and even in 2024 COVID-19 was still listed as the underlying cause in 68 to 85 percent of those co-occurrences, down from 88 to 98 percent in 2020. Meanwhile, the apparent decline in ischaemic heart disease between 2019 and 2024 was, in the authors’ view, too large to reflect genuine improvement and may partly represent recoding of deaths with multiple comorbidities.
The Austrian findings align with a growing international literature based on clinical record audits. In Greece, only 64.9 percent of hospital deaths listed as COVID-19 were judged attributable or related to the virus upon audit. In Sweden, auditors found that 24 percent of certificate-listed COVID-19 deaths had absolutely no relationship to the infection, and that in most of the remainder COVID-19 was contributing rather than underlying; death certificates counted 799 underlying-cause COVID-19 deaths where clinical audit supported only 213. In Ireland, clinicians considered COVID-19 the primary cause in only 72.7 percent of audited deaths during the winter of 2021 to 2022, and Danish surveillance documented increasing overcounting with the Omicron variants. Notably, the feared undercounting in lower-income settings appears smaller than assumed: a Colombian audit found only 6 percent undercounting in 2021, although an Iranian audit of 339 certificates found major errors in 58 percent. The overall pattern suggests overcounting, not undercounting, has been the dominant error in well-resourced countries.
The study has limitations the authors acknowledge candidly. Without comorbidity data, the results cannot be generalised to specific high-risk populations such as immunocompromised patients or nursing home residents, among whom COVID-19 mortality may remain meaningful. Death certificate reporting itself is imperfect, with empirical studies suggesting major errors exceed 50 percent even in pre-pandemic years, and Austria’s automated IRIS coding algorithms may have favoured selecting COVID-19 as the underlying cause. There is also genuine uncertainty about the right counterfactual: whether mortality should have continued declining after 2019 at all, given that life expectancy gains in Austria and other high-income countries had already slowed dramatically in the decade before the pandemic, adding just 0.41 years between 2014 and 2019 compared with more than a year in each of the three preceding five-year periods. Some of the lower mortality among the very old in 2024 may reflect mortality displacement, the premature deaths during the pandemic of people who would otherwise have died a few years later.
Even so, the implications for policy are concrete. Accurate post-pandemic burden estimates directly shape vaccination recommendations, which currently diverge widely across Europe, from yearly boosters offered from age 12 in Austria to age 65 and older in Denmark. The authors’ earlier work estimated that, assuming correct COVID-19 death counts, the only Austrian group with a mortality rate implying a number needed to vaccinate below 1,000, residents of nursing homes aged 85 and over, had average life expectancies below one year. With an estimated 2.8 million SARS-CoV-2 infections in Austria in 2024, the reported 1,212 deaths already imply an infection fatality rate of just 0.043 percent, and the weighted analysis suggests even that figure is too high. The study’s most urgent message, however, may be the one about the young: a post-pandemic rise in mortality driven by mental health, external and neurological causes demands confirmation, explanation and intervention, long after the virus itself has faded from the mortality statistics.
Subject of Research: Post-pandemic all-cause mortality patterns and estimation of the residual COVID-19 death burden using weighted multiple-cause-of-death analysis in Austria
Article Title: Post-pandemic mortality patterns and COVID-19 burden considering multiple death causes
Article References: Riedmann, U., Levitt, M., Pilz, S., & Ioannidis, J. P. (2026). Post-pandemic mortality patterns and COVID-19 burden considering multiple death causes. European Journal of Epidemiology. https://doi.org/10.1007/s10654-026-01462-7
Image Credits: AI Generated
DOI: 10.1007/s10654-026-01462-7
Keywords: COVID-19, mortality, Austria, death certificates, multiple causes of death, excess mortality, epidemiology, vaccination policy, life expectancy, infection fatality rate, public health, youth mortality
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Kristina Jarvis. (September 23, 2026). Austria’s Post-Pandemic Deaths Point to Overcounted COVID-19 Mortality. Scienmag. https://scienmag.com/austrias-post-pandemic-deaths-point-to-overcounted-covid-19-mortality/
Kristina Jarvis. “Austria’s Post-Pandemic Deaths Point to Overcounted COVID-19 Mortality.” Scienmag, 23 September 2026, https://scienmag.com/austrias-post-pandemic-deaths-point-to-overcounted-covid-19-mortality/. Accessed 23 September 2026.
Kristina Jarvis. “Austria’s Post-Pandemic Deaths Point to Overcounted COVID-19 Mortality.” Scienmag. September 23, 2026. https://scienmag.com/austrias-post-pandemic-deaths-point-to-overcounted-covid-19-mortality/
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