Articles

Estimating excess 1-year mortality associated with the

COVID-19 pandemic according to underlying conditions and
age: a population-based cohort study
Amitava Banerjee, Laura Pasea, Steve Harris, Arturo Gonzalez-Izquierdo, Ana Torralbo, Laura Shallcross, Mahdad Noursadeghi, Deenan Pillay,
Neil Sebire, Chris Holmes, Christina Pagel, Wai Keong Wong, Claudia Langenberg, Bryan Williams, Spiros Denaxas, Harry Hemingway

Summary
Background The medical, societal, and economic impact of the coronavirus disease 2019 (COVID-19) pandemic has Lancet 2020; 395: 1715–25
unknown effects on overall population mortality. Previous models of population mortality are based on death over Published Online
days among infected people, nearly all of whom thus far have underlying conditions. Models have not incorporated May 12, 2020
https://doi.org/10.1016/
information on high-risk conditions or their longer-term baseline (pre-COVID-19) mortality. We estimated the excess
S0140-6736(20)30854-0
number of deaths over 1 year under different COVID-19 incidence scenarios based on varying levels of transmission
Institute of Health Informatics
suppression and differing mortality impacts based on different relative risks for the disease. (A Banerjee DPhil, L Pasea PhD,
A Gonzalez-Izquierdo PhD,
Methods In this population-based cohort study, we used linked primary and secondary care electronic health records A Torralbo PhD, L Shallcross PhD,
Prof S Denaxas PhD,
from England (Health Data Research UK–CALIBER). We report prevalence of underlying conditions defined by Public
Prof H Hemingway FMedSci),
Health England guidelines (from March 16, 2020) in individuals aged 30 years or older registered with a practice Division of Infection and
between 1997 and 2017, using validated, openly available phenotypes for each condition. We estimated 1-year mortality Immunity
in each condition, developing simple models (and a tool for calculation) of excess COVID-19-related deaths, assuming (Prof M Noursadeghi PhD,
Prof D Pillay PhD), Clinical
relative impact (as relative risks [RRs]) of the COVID-19 pandemic (compared with background mortality) of 1·5, 2·0,
Operational Research Unit
and 3·0 at differing infection rate scenarios, including full suppression (0·001%), partial suppression (1%), mitigation (Prof C Pagel PhD), and Institute
(10%), and do nothing (80%). We also developed an online, public, prototype risk calculator for excess death estimation. of Cardiovascular Science
(Prof B Williams PhD),
University College London,
Findings We included 3 862 012 individuals (1 957 935 [50·7%] women and 1 904 077 [49·3%] men). We estimated that
London, UK; University College
more than 20% of the study population are in the high-risk category, of whom 13·7% were older than 70 years and London Hospitals NHS Trust,
6·3% were aged 70 years or younger with at least one underlying condition. 1-year mortality in the high-risk population London, UK (A Banerjee,
was estimated to be 4·46% (95% CI 4·41–4·51). Age and underlying conditions combined to influence background S Harris PhD, W K Wong PhD,
Prof B Williams); Barts Health
risk, varying markedly across conditions. In a full suppression scenario in the UK population, we estimated that there
NHS Trust, The Royal London
would be two excess deaths (vs baseline deaths) with an RR of 1·5, four with an RR of 2·0, and seven with an RR of Hospital, London, UK
3·0. In a mitigation scenario, we estimated 18 374 excess deaths with an RR of 1·5, 36 749 with an RR of 2·0, and (A Banerjee); Great Ormond
73 498 with an RR of 3·0. In a do nothing scenario, we estimated 146 996 excess deaths with an RR of 1·5, 293 991 with Street Hospital, London, UK
(Prof N Sebire PhD); University
an RR of 2·0, and 587 982 with an RR of 3·0. of Oxford, Oxford, UK
(Prof C Holmes PhD);
Interpretation We provide policy makers, researchers, and the public a simple model and an online tool for Alan Turing Institute, London,
understanding excess mortality over 1 year from the COVID-19 pandemic, based on age, sex, and underlying UK (Prof C Holmes,
Prof S Denaxas); MRC
condition-specific estimates. These results signal the need for sustained stringent suppression measures as well as Epidemiology Unit, University
sustained efforts to target those at highest risk because of underlying conditions with a range of preventive of Cambridge, Cambridge, UK
interventions. Countries should assess the overall (direct and indirect) effects of the pandemic on excess mortality. (C Langenberg PhD); University
College London Hospitals
National Institute for Health
Funding National Institute for Health Research University College London Hospitals Biomedical Research Centre, Research Biomedical Research
Health Data Research UK. Centre, London, UK
(Prof B Williams); and Health
Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 Data Research UK, London, UK
(Prof S Denaxas,
license. Prof H Hemingway)
Correspondence to:
Introduction societal changes. One way of estimating and monitoring Dr Amitava Banerjee, Institute of
Excess deaths from the coronavirus disease 2019 excess mortality is to compare observed numbers of Health Informatics,
(COVID-19) pandemic might arise both in those infected deaths with those expected based on the background University College London,
London NW1 2DA, UK
(direct effects), as well as those affected (indirectly, not (pre-COVID-19) mortality risks in the population.1 ami.banerjee@ucl.ac.uk
infected) by altered access to health services; the physical, One model of the population mortality impact of
psychological, and social effects of distancing; and COVID-19 is based on age-stratified death rates over days
economic changes. Understanding the effect of COVID-19 in infected patients, but excludes prevalence of underlying
on mortality during this emergency requires modelling of conditions, their differing pre-COVID-19 background long-
an infectious disease, as well as wider medical and term mortality risks, or the additional risk associated with

www.thelancet.com Vol 395 May 30, 2020 1715

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Research in context
Evidence before this study
We searched PubMed, medRxiv, bioRxiv, arXiv, and Wellcome
Open Research for peer-reviewed articles, preprints, and
research reports on mortality and comorbidities at baseline in
coronavirus disease 2019 (COVID-19), using the search terms
“coronavirus”, “COVID-19”, and similar terms, and “mortality”,
up to March 21, 2020. We found no previous studies of excess
deaths due to the COVID-19 pandemic. Previous tools and
models to estimate COVID-19-related deaths have not
considered the prevalence of underlying conditions,
background pre-COVID-19 mortality, long-term estimates,
or the relative impact (relative risk) of COVID-19 on mortality.
Without these data, it is challenging to predict and prepare
health systems to respond to the COVID-19 health-care burden.
Added value of this study
We produced a model to estimate the excess COVID-19-related
mortality by incorporating population infection rate in different
scenarios relating to degree of social isolation, differing degrees
COVID-19.2 Few reports of excess deaths beyond specific
high-risk populations have been published3,4 (most deaths
have occurred in people with underlying health conditions
or those of older ages5–7). This situation is changing, with
severe infections being treated in younger patients with
COVID-19 who do not have underlying conditions.8 Case
fatality rates for COVID-19 vary from 0·27% to 10%,9
possibly explained by differing demography, testing strat­
egies, and prev­alence of under­lying conditions. The UK
has relatively high case fatality rates (8·2%), but mortality
rates are unknown at this stage of the pandemic because
testing is more common among sicker patients who are
admitted to hospital (the context where most testing has
been done) rather than milder cases. On April 14, the Office
for National Statistics reported 6000 excess deaths
registered in the week March 28 to April 3, 2020, of which
about 2500 deaths did not have COVID-19 recorded on the
death certificates, providing the first indication of indirect
effects of the pandemic on mortality.10
Physical distancing and other strategies focus on high-
risk groups, with US Centers for Disease Control and
Prevention specifying “older adults, and people who have
serious chronic medical conditions such as heart disease,
diabetes and lung disease”.11 On March 16, 2020, the UK
Government announced that particular subgroups are at
high risk from COVID-19,12 and recommended stringent
distancing measures, telling people how to stay away from
others. On March 22, 2020, the Government announced
that 1·5 million ”extremely vulnerable” people in England
with underlying conditions (including severe chronic
obstructive pulmonary disease [COPD]) should ”shield”
for 12 weeks, but did not explain how these conditions
were selected.13 The UK Government did not implement
full suppression (during which only key workers are likely
1716 www.thelancet.com Vol 395 May 30, 2020
of impact of COVID-19 on health systems, and prevalence of
underlying conditions. We showed that in a full suppression
scenario, even if COVID-19 has high relative impact on health
systems, excess mortality over 1 year can be minimised.
Conversely, with mitigation (ie, less rigorous and voluntary
measures), we predict between 18 000 and 37 000 deaths.
We have provided a prototype risk calculator for the researchers
and policy makers to make estimates and change the
assumptions in the model. We also highlight the value of
routine electronic health records and use of large, linked
datasets at the country level in responding to the pandemic.
Implications of all the available evidence
Our models allow the estimation of overall (direct and indirect)
effects on excess mortality of the COVID-19 pandemic. For the
first time, we provide a model, a tool, and open-access data to
individualise risk prediction across underlying conditions,
which has clinical, public health, and research benefits for both
the COVID-19 pandemic and post-pandemic contexts.
to be exposed) until March 23, 2020. Up to that date, people
were still in close proximity in work and public places.
Here, we provide estimates of 1-year mortality by
underlying conditions to understand the broader health
impact of COVID-19. Our objectives were to provide the
research and policy community and public with par­
ameters (prevalence and background pre-COVID-19
1-year mortality risk by age and underlying conditions) to
assist modelling; and to provide initial estimates of the
excess COVID-19-related deaths over a 1-year period
based on differing rates and relative levels of impact of
infection. We define COVID-19-related mortality as both
direct and indirect effects of the pandemic.
Methods
Study design and data sources
This was a population-based cohort study, done with
clinical research using linked bespoke studies and
electronic health records (CALIBER), an open research
platform with validated, reusable definitions of several
hundred underlying conditions.14,15 It links electronic
health records from different data sources (via UK
unique individual identification data and National Health
Service [NHS] numbers), including primary care (Clinical
Practice Research Datalink-GOLD), hospital care (Hospital
Episodes Statistics), and death registry (Office of National
Statistics). Nearly all (>99%) of the English population has
general practice registration. CALIBER has been shown to
be representative of the general population in terms of
sociodemographic characteristics and overall mortality.
Approval for the study was granted by the Independent
Scientific Advisory Committee (20_074R) of the Medicines
and Healthcare products Regulatory Agency in the UK in
accordance with the Declaration of Helsinki.
 Articles

Study population number of underlying conditions. We then modelled the

Eligible individuals were aged 30 years or older and
registered with a general practice at any point between
Jan 1, 1997, and Jan 1, 2017, with at least 1 year of follow-up
data. Demographic characteristics (age, gender, index of
multiple deprivation quintiles, and geographical region)
and baseline characteristics (prevalence of underlying
conditions, risk factors, and medications) were recorded.14
The overall population at high risk of COVID-19 and
recommended for physical distancing was defined as per
Public Health England guidance.12
Open national portal for definitions of underlying
conditions
We used the Health Data Research (HDR) UK–CALIBER
open online portal to define underlying conditions from
records. The underlying conditions were defined using
Read codes in primary care and the International
Classification of Diseases 10th edition for hospital
admissions as per validated CALIBER pheno­ types.14
Hypertension was defined on the basis of recorded
values in primary care according to the most recent
guidelines (≥140 mm Hg systolic blood pressure [or
≥150 mm Hg for people aged ≥60 years without
diabetes and chronic kidney disease] or ≥90 mm Hg
diastolic blood pressure).16 Diabetes was defined at
baseline (including type 1, type 2, or uncertain type) on
the basis of coded diagnoses recorded in Clinical Practice
Research Datalink or Hospital Episode Statistics at or
before study entry.15 Severe obesity was defined as body-
mass index of 40 kg/m² or more.16 Cardiovascular disease
was defined as the 12 most common symptomatic
manifestations: chronic stable angina, unstable angina,
myocardial infarction, unheralded death from coronary
heart disease, heart failure, cardiac arrest or sudden
coronary death, transient ischaemic attack, ischaemic
stroke, intracerebral haemorrhage, subarachnoid haem­
or­
rhage, peripheral arterial disease, and abdominal
aortic aneurysm, as per previous studies.15–17 COPD and
chronic kidney disease were defined using previous
definitions.14–17 Multi­
morbidity was defined as the co-
occurrence of two or more conditions in an indi­vidual.18
excess COVID-19-associated mortality for relative impact
of mortality associated with COVID-19 (relative risk [RR]
compared with background mortality) of 1·5, 2·0, and 3·021
at the infection rate consequences of different strategies:
full suppression (0·001%), partial suppression (1%),
mitigation (10%), or do nothing (80%).22 Relative risk is a
comparison of risks or probabilities. For example, an RR
of 2·0 for COVID-19 describes a doubling of the risk of
mortality in individuals infected with or affected by
COVID-19 versus their background risk of death. A
definition of COVID-19-related mortality relevant to the
emergency includes both deaths among those infected
(direct), and deaths among those affected by health service,
societal, and economic changes (indirect). Considering
excess deaths in this way, it is reasonable to consider that a For the HDR UK–CALIBER online
high proportion (eg, 80% of the population) might be portal see www.caliberresearch.
org/portal
affected by the COVID-19 emergency. To extrapolate
our estimates of excess deaths to the whole population of
England older than 30 years, we used 2018 estimates of
overall population size and mortality.23 For illustration, we
applied our study estimates to UN Population Fund24
estimates of population size in other countries. All analyses
were done using R, version 3.4.3. Data were analysed in
the University College London ISO27001 safe haven.
Role of the funding source
The funders of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report. LP and SD had full access to all the
data in the study and AB and HH had final responsibility
for the decision to submit for publication.
Results
We included 3 862 012 individuals aged 30 years or older.
1 957 935 (50·7%) were women and 1 904 077 (49·3%)
16 >70 years
13·7% ≤70 years
14
12
10
Prevalence (%)

Given recent interest in the potential roles of angiotensin-

converting enzyme (ACE) inhibitors19 and non-steroidal 8

inflammatory drugs (NSAIDs),20 we also estimated 6

prevalence of their use.
4
2·3% 2·2% 1·9%
Statistical analysis 2 0·9% 0·6% 0·5% 0·2% 0·01% 0·02% 0·005% 0·001%
To assess prevalent underlying conditions, we only 0
included records from the year before baseline (date of
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and at each number of conditions cell to estimate by Figure 1: Prevalence of underlying conditions associated with high mortality in COVID-19 infection (n=3 862 012)

www.thelancet.com Vol 395 May 30, 2020 1717

 Articles

See Online for appendix
For the open-access repository
see https://doi.org/10.6084/
m9.figshare.12238118
were men; 3 331 280 (86·3%) were aged 70 years or (48·0 years [16·4]) and COPD (48·2 years [16·6]) 6·7%
younger (mean age 43·5 years [SD 11·7] in both sexes) without cardiovascular disease, 7·9% without diabetes,
and 530 732 (13·7%) were older than 70 years (mean age 9·1% without chronic kidney disease, and 9·7% without
78·1 years [6·1] in men and 80·2 years [7·0] in women; COPD still had a condition meeting criteria for physical
appendix p 1). distancing. Hypertension was common: 7·4% in the
More than 20·0% of the study population had at least individuals aged 70 years or younger and 31·7% in those
one high-risk condition defined by Public Health England older than 70 years. In individuals aged 70 years or
guidelines. 13·7% were older than 70 years and 6·3% younger, prescription of ACE inhibitors was lower (3·7%)
were aged 70 years or younger with at least one underlying than in those older than 70 years (14·9%). 14·0% of those
condition (figure 1). Age-specific (5-year age bands) and aged 70 years or younger and 21·1% of those older than
sex-specific estimates of prevalence for each underlying 70 years were prescribed NSAIDs.
condition are available online. Mortality at 1 year was estimated at 4·46% (95% CI
Multimorbidity was common (10·1%), especially 4·41–4·51) among individuals at high risk. 1-year
with cardiovascular disease, diabetes, chronic kidney mortality was 8·62% (8·32–8·92) for those with COPD,
disease, and COPD (appendix p 2). In individuals without 7·84% (7·62–8·06) for those with chronic kidney
cardio­vascular disease (mean age 47·5 years [SD 16·2]), disease, 6·37% (6·25–6·49) for those with cardiovas­
diabetes (48·0 years [16·5]), chronic kidney disease cular disease, and 4·1% (4·0–4·2) for those with

n (%) Deaths 1 year all-cause

mortality % (95% CI)

Risk factors
Any risk factor 774 639 (20·1%) 33 549 4·46% (4·41–4·51)
Chronic obstructive pulmonary disease 35 006 (0·9%) 2900 8·62% (8·32–8·92)
Chronic kidney disease 59 397 (1·5%) 4501 7·84% (7·62–8·06)
Cardiovascular disease 159 069 (4·1%) 9820 6·37% (6·25–6·49)
Age >70 530 732 (13·7%) 30 529 5·88% (5·82–5·95)
Corticosteroid 105 978 (2·7%) 4599 4·49% (4·37–4·62)
Diabetes 111 668 (2·9%) 4399 4·12% (4·00–4·24)
Body-mass index >40 mg/kg2 31 173 (2·7%) 194 0·66% (0·57–0·75)
Number of risk factors
≥3 15 030 (0·4%) 1890 13·10% (12·55–13·65)
2 63 578 (1·6%) 4612 7·53% (7·32–7·74)
1 327 544 (8·5%) 11 073 3·51% (3·44–3·57)
0 3 455 860 (89·5%) 21 272 0·64% (0·64–0·65)
Overall population 3 862 012 (100%) 38 847 1·05% (1·04–1·06)

0 5 10 15

Figure 2: Baseline 1-year mortality in England according to underlying conditions (n=3 862 012)

1 year all-cause mortality risk %

0 5 10 15 20 25 30
Men Women

4·63% 2·77% 7·04% 8·94% 12·22% 15·00% 19·41% 28·72% 3·95% 6·53% 5·24% 8·08% 8·36% 10·73% 16·38% 26·01%
≥3
n=576 n=443 n=717 n=1004 n=1217 n=1281 n=1099 n=956 n=704 n=462 n=663 n=882 n=1109 n=1301 n=1191 n=1425
Number of underlying conditions

1·54% 3·50% 3·50% 4·85% 5·86% 9·02% 14·65% 24·04% 1·25% 1·06% 2·18% 3·12% 4·75% 6·71% 11·17% 20·41%
2
n=4683 n=2614 n=3511 n=4241 n=4558 n=4589 n=3235 n=2835 n=5687 n=2171 n=2858 n=3514 n=4136 n=4819 n=4261 n=5866

0·61% 1·21% 1·77% 2·45% 3·43% 5·52% 0·41% 0·91% 1·05% 1·74% 2·41% 3·80% 7·03% 17·14%
10·10% 19·08%
1 n= n= n= n= n= n= n= n= n= n= n= n= n= n=
n=9459 n=7887
53 898 15 705 17 413 17 189 16 725 14 592 62 059 13 309 14 512 15 092 16 577 18 027 15 163 19 937

0·12% 0·37% 0·64% 1·07% 1·71% 2·99% 5·96% 12·43% 0·07% 0·25% 0·44% 0·66% 1·12% 2·14% 4·47% 11·97%
0 n= n= n= n= n= n= n= n= n= n= n= n= n= n= n= n=
1 293 080 121 928 91 312 68 414 54 706 42 431 23 511 18 268 1 218 784 121 895 95 619 76 341 68 089 63 302 44 787 53 393

30–55 56–60 61–65 66–70 71–75 76–80 81–85 >85 30–55 56–60 61–65 66–70 71–75 76–80 81–85 >85
Age group (years) Age group (years)

Figure 3: Baseline 1-year mortality in England according to number of underlying conditions, age category, and sex (n=3 862 012)

1718 www.thelancet.com Vol 395 May 30, 2020

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A Full suppression (0·001%) Absolute excess UK deaths

0 1000 5000 10 000 50 000 100 000 250 000
underlying conditions

0
Number of

RR 1·2

RR 1·5
Total excess deaths 1 Total excess deaths 2
2

≥3
underlying conditions

0
Number of

RR 2

RR 3
Total excess deaths 4 Total excess deaths 7
2

≥3

Partial supression (1%)

underlying conditions

0
Number of

1
RR 1·2

RR 1·5
Total excess deaths 735 Total excess deaths 1837
2

≥3
underlying conditions

0
Number of

1
RR 2

RR 3
Total excess deaths 3675 Total excess deaths 7 350
2

≥3

Mitigation (10%)
underlying conditions

0
Number of

1
RR 1·2

RR 1·5
Total excess deaths 7350 Total excess deaths 18 374
2

≥3
underlying conditions

0
Number of

1
RR 2

RR 3

Total excess deaths 36 749 Total excess deaths 73 498

2

≥3

Do nothing (80%)
underlying conditions

0
Number of

1
RR 1·2

RR 1·5

Total excess deaths 58 798 Total excess deaths 146 996

2

≥3
underlying conditions

0
Number of

1
Total excess deaths 293 991 Total excess deaths 587 982
RR 2

RR 3

≥3
5

5
0

0
–5

–6

–7

–8

>8

–5

–6

–7

–8

>8
–7

–8

–7

–8
–6

–6
71

71
30

30
66

66
61

81

61

81
76

76
56

56

Age group (years) Age group (years)

(Figure 4 continues on next page)

www.thelancet.com Vol 395 May 30, 2020 1719

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B Full suppression (0·001%) Absolute excess UK deaths

0 1000 5000 10 000 50 000 100 000 250 000
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
underlying conditions

0
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of

RR 1·2

RR 1·5
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
≥3 (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)

0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 2
underlying conditions

0 (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Number of

1 (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)

RR 2

RR 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
≥3 (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)

Partial supression (1%)

46 14 18 23 31 48 62 159 115 35 46 56 78 120 156 397
underlying conditions

0
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0·1)
11 6 8 13 18 27 37 90 27 14 21 31 45 68 93 226
Number of

1
RR 1·2

RR 1·5
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0·1)
3 2 3 6 9 14 17 34 7 5 8 14 21 34 44 86
2
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0·1) (0·1)
1 1 2 3 4 6 7 12 2 2 4 7 11 15 19 30
≥3 (0) (0) (0) (0) (0) (0) (0) (0·1) (0) (0) (0) (0) (0·1) (0·1) (0·1) (0·1)

231 70 92 113 155 240 312 794 462 139 183 226 311 481 1171 1588
underlying conditions

0 (0) (0) (0) (0) (0) (0) (0) (0·1) (0) (0) (0) (0) (0) (0) (0·1) (0·2)
53 28 42 63 89 137 185 451 106 57 84 125 178 273 695 902
Number of

1 (0) (0) (0) (0) (0) (0) (0·1) (0·2) (0) (0) (0) (0) (0·1) (0·1) (0·2) (0·4)
RR 2

RR 3
13 10 17 29 43 68 87 172 26 21 34 58 85 135 327 344
2 (0) (0) (0) (0) (0·1) (0·1) (0·1) (0·2) (0) (0) (0·1) (0·1) (0·1) (0·2) (0·3) (0·4)
5 4 8 15 22 30 37 59 10 8 16 30 44 61 140 118
≥3 (0) (0) (0·1) (0·1) (0·1) (0·1) (0·2) (0·3) (0·1) (0·1) (0·1) (0·2) (0·2) (0·3) (0·4) (0·5)

Mitigation (10%)
462 139 183 226 311 481 624 1588 1155 348 458 565 777 1202 1560 3971
underlying conditions

0
(0) (0) (0) (0) (0) (0) (0·1) (0·2) (0) (0) (0) (0) (0·1) (0·1) (0·2) (0·6)
106 57 84 125 178 273 371 902 265 142 211 313 446 683 927 2256
Number of

1
RR 1·2

RR 1·5
(0) (0) (0) (0) (0·1) (0·1) (0·2) (0·4) (0) (0·1) (0·1) (0·1) (0·1) (0·2) (0·4) (0·9)
26 21 34 58 85 135 174 344 66 52 85 144 213 338 435 861
2
(0) (0) (0·1) (0·1) (0·1) (0·2) (0·3) (0·4) (0·1) (0·1) (0·1) (0·2) (0·3) (0·4) (0·6) (1·1)
10 8 16 30 44 61 75 118 25 19 39 74 111 152 187 296
≥3 (0·1) (0·1) (0·1) (0·2) (0·2) (0·3) (0·4) (0·5) (0·2) (0·2) (0·3) (0·4) (0·5) (0·6) (0·9) (1·4)

·
2310 696 916 1130 1553 2403 3120 7941 4619 1392 1831 2259 3107 4807 6240 15 883
underlying conditions

0
(0) (0) (0·1) (0·1) (0·1) (0·2) (0·5) (1·2) (0) (0·1) (0·1) (0·2) (0·3) (0·5) (1) (2·4)
530 284 422 626 892 1365 1853 4511 1061 568 · 844 1253 1784 2731 3706 9023
Number of

1 (0) (0·1) (0·1) (0·2) (0·3) (0·5) (0·8) (1·8) (0·1) (0·2) (0·3) (0·4) (0·6) (0·9) (1·6) (3·5)
RR 2

131 105 170 289 425 676 871 1722 262 209 340 578 850 1352 1742 3444 RR 3
2
(0·1) (0·2) (0·3) (0·4) (0·5) (0·8) (1·3) (2·2) (0·3) (0·5) (0·6) (0·8) (1·1) (1·6) (2·5) (4·3)
50 39 78 148 221 304 374 592 100 78 156 295 442 608 749 1183
≥3 (0·4) (0·5) (0·6) (0·9) (1) (1·3) (1·8) (2·7) (0·9) (0·9) (1·2) (1·7) (2·1) (2·6) (3·6) (5·4)

Do nothing (80%)
3695 1114 1465 1807 2485 3846 4992 12 706 9239 2785 3663 4518 6213 9614 12 480 31 765
underlying conditions

0
(0) (0) (0·1) (0·1) (0·2) (0·4) (0·8) (1·9) (0) (0·1) (0·2) (0·3) (0·6) (1) (2) (4·8)
849 454 676 1002 1427 2185 2965 7218 2122 1136 1689 2505 3568 5462 7413 18 046
Number of

1
RR 1·2

RR 1·5

(0·1) (0·2) (0·2) (0·3) (0·5) (0·7) (1·3) (2·8) (0·2) (0·4) (0·6) (0·8) (1·2) (1·8) (3·3) (7·1)
210 168 272 462 680 1081 1394 2755 524 419 679 1156 1700 2703 3484 6888
2
(0·2) (0·4) (0·5) (0·7) (0·9) (1·3) (2) (3·5) (0·6) (1) (1·2) (1·6) (2·1) (3·1) (5·1) (8·6)
80 62 125 236 354 487 599 947 200 155 313 590 885 1216 1497 2367
≥3 (0·7) (0·7) (1) (1·4) (1·7) (2·1) (2·9) (4·3) (1·7) (1·9) (2·5) (3·4) (4·1) (5·1) (7·1) (10·8)

18 477 5569 7325 9036 12 427 19 228 24 960 63 531 36 954 11 138 14 651 18 073 24 854 38 456 49 921 127 062
underlying conditions

0
(0·1) (0·2) (0·4) (0·7) (1·1) (2) (4) (9·7) (0·2) (0·5) (0·9) (1·4) (2·2) (4) (8) (19·3)
Figure 4: Estimated number 4243 2272 3378 5011 7137 10 923 14 825 36 091 8487 4545 6755 10 022 14 273 21 847 29 650 72 183
Number of

of excess deaths at 1 year in 1 (0·4) (0·9) (1·2) (1·7) (2·3) (3·7) (6·6) (14·1) (0·8) (1·7) (2·3) (3·4) (4·7) (7·3) (13·1) (28·3)
RR 2

RR 3

the UK at different infection 2 1048 838 1359 2312 3401 5407 6968 13 777 2096 1676 2717 4623 6802 10 813 13 935 27 554
(1·1) (1·9) (2·3) (3·3) (4·3) (6·3) (10·1) (17·3) (2·2) (3·8) (4·7) (6·5) (8·5) (12·5) (20·3) (34·5)
rates and relative risks for 400 311 626 1181 1769 2433 2994 4734 800 621 1252 2362 3538 4866 5989 9468
the impact of COVID-19 ≥3 (3·4) (3·7) (4·9) (6·8) (8·3) (10·3) (14·3) (21·7) (6·8) (7·5) (9·9) (13·7) (16·6) (20·6) (28·5) (43·4)
(A) Total deaths. (B) Detailed
5

5
0

0
–5

–6

–7

–8

>8

–5

–6

–7

–8

>8
–7

–8

–7

–8

breakdown of deaths across

–6

–6
71

71
30

30
66

66
61

81

81
61
76

76
56

56

different categories. Age group (years) Age group (years)

RR=relative risk.

1720 www.thelancet.com Vol 395 May 30, 2020

 Articles

diabetes (figure 2). Among those older than 70 years,

General population High-risk group (millions) Baseline number
1-year mortality rates were 13·6% (12·9–14·3) for (millions) of deaths in
COPD, 11·5% (11·0–12·1) for chronic kidney disease, 1 year in
10·4% (10·1–10·7) for cardio­vascular disease, and 8·9% high-risk group
(8·5–9·4) for diabetes in men and 12·3% (11·6–13·0) for Total Older than Older than 70 years or Total at high
COPD, 9·6% (9·3–10·0) for chronic kidney disease, 30 years 70 years younger with risk
underlying
10·6% (10·3–10·9) for cardio­vascular disease, and 9·8% condition
(9·4–10·2) for diabetes in women.
Canada 37·06 23·44 3·22 1·48 4·70 209 732
We estimated baseline 1-year mortality risk by age
England 55·98 35·41 4·87 2·24 7·10 316 805
group, sex, and number of conditions, in the absence of
France 65·50 41·43 5·69 2·62 8·31 370 681
COVID-19 (figure 3). For example, a man aged 66–70 years
with no underlying high-risk conditions has a higher Germany 82·40 52·12 7·16 3·29 10·46 466 322

estimated 1-year mortality risk (1·07%) than a woman Italy 59·20 37·45 5·15 2·37 7·51 335 028

aged 56–60 years with one underlying condition (0·91%).
According to our online risk calculator, a 66-year-old
man with COPD has a 6·39% (95% CI 5·48–7·30)
baseline 1-year mortality risk; thus with 25 641 people in
England in this subgroup, we projected 1639 baseline
deaths over 1 year. The model (if set to 10% infection rate
and RR 2·0) estimates 164 excess COVID-related deaths
over a year in that demographic category.
At COVID-19 prevalence of 10% (mitigation) and
80% (do nothing), we estimate the number of excess
deaths to be 18 374 (mitigation) and 146 996 (do nothing)
with an RR of 1·5; 36 749 (mitigation) and 293 991 (do
nothing) with an RR of 2·0; and 73 498 (mitigation) and
587 982 (do nothing) with an RR of 3·0. Corres­ponding
numbers of deaths at full suppression (0·001%) and
partial suppression (1%) were two (full) and 1837 (partial)
with an RR of 1·5; four (full) and 3675 (partial) with an
RR of 2·0; and seven (full) and 7350 (partial) with an RR
of 3·0 (figure 4).
Extrapolating from our English sample to the whole UK
population, we estimate 8·43 million people are in the
high-risk group, of whom 5·77 million are older than
70 years of age, and 2·66 million have one or more
underlying condition and are 70 years or younger). Based
on the background (pre-COVID-19) 1-year mortality that
we observed in the CALIBER data of 4·46% for this group,
376 001 deaths would occur in the UK. Using these
estimates, numbers of people at high-risk other countries
were 4·70 million in Canada, 8·31 million in France,
10·46 million in Germany, 7·51 million in Italy,
1·28 million in Sweden, and 41·76 million in the USA
(table).
Discussion
Using NHS records, we provide an initial population-based
study estimating plausible ranges of excess COVID-19-
related mortality in England. We provide esti­ mates of
the prevalence and background (pre-COVID-19) 1-year
mortality risks according to underlying conditions at dif­
ferent ages in women and men, sharing these estimates
in online materials, and the disease definitions in the
HDR UK–CALIBER portal. These are major parameters in
understanding the emergency, and the best source of
estimates comes from electronic records, with implications
Sweden 10·10 6·39 0·88 0·40 1·28 57 158
UK 66·44 42·03 5·77 2·66 8·43 376 001
USA 329·10 208·17 28·60 13·16 41·76 1 862 459
All assumptions are based on England (CALIBER) estimates of 63·25% of the total population older than 30 years,
13·74% older than 70 years, 6·32% 70 years or younger with an underlying condition, and 20·06% total high-risk
group; and a 1-year mortality (Kaplan-Meier) for the total high-risk group of 4·46%.
Table: Projected deaths in 1 year in high-risk group pre-COVID-19 infection across countries
for policy makers, clinicians, and the public. Our results For our online risk calculator
support rigorous, sustained implementation of suppres­ prototype see http://covid19-
phenomics.org/
sion measures.25
PrototypeOurRiskCoV.html
With our definition of overall excess deaths, combining
direct and indirect effects among those with and without
infection, it is reasonable to consider that a high (eg, 80%)
proportion of the population might be affected by the
COVID-19 pandemic. We do not know what the relative
impact of excess deaths from the COVID-19 pandemic
will be over a 1-year period in any country. However,
clinical and societal concern internationally is that it is
not a regular seasonal flu. We show that if the pandemic
is associated with an RR of 1·5, then there will
be 18 374 excess deaths in a mitigation scenario and
146 996 excess deaths in a do nothing scenario; compared
with two deaths under a full suppression scenario. A
doubling of the risk is worth considering because of
uncertainty regarding the actual risk associated with
COVID-19 and mounting health-care burden around
the world. This RR of 2·0 would result in 36 749 excess
deaths in a mitigation scenario and 293 991 excess deaths
in a do nothing scenario.
A major concern is that relative risks will rise in a
non-linear fashion with infection rates if health systems
become overwhelmed by critically ill patients. Thus, at
high infection rates, relative risks for excess mortality
would almost certainly be much higher—and these
non-linear interactions are a subject for further
modelling. The impact of COVID-19 is likely to be much
greater if there is poor compliance with social isolation
policies and low treatment and health-system capacity.
The RR of COVID-19 infection and the case fatality rate
have been estimated,21 but the RR for mortality will
better capture the impact of infection on individuals
and health systems. Even in the RR of 2·0 model, full

www.thelancet.com Vol 395 May 30, 2020 1721

 Articles
suppression would lead to virtually no excess mortality,
because some patients with underlying conditions
would have died over a 1-year period regardless of the
COVID-19 outbreak. The prototype online risk calculator
allows exploration and visualisation of the age-specific,
sex-specific, and underlying condition-specific excess
mortality under different assumptions. Near real-time
cause-specific mortality, as reported by the Office for
National Statistics, ideally on a weekly basis, will greatly
aid understanding of the direct and indirect impacts of
the COVID-19 pandemic.10 Such information can inform
timing of exit strategies from lockdown. In future
analyses, the impact of the COVID-19 pandemic on
disease-specific health-care provision and use should be
assessed.
We have assumed the same impact (RR) of COVID-19
on excess mortality for each underlying condition—ie, it
is the same for a patient with COPD or with morbid
obesity. Although a reasonable starting point, this
assump­tion requires testing as empirical data become
available. An interaction between different comorbid­
ities almost certainly exists, meaning that some
combinations are worse than others, and this factor
needs to be investigated.
We used a 1-year time period because of concerns
regarding second waves of infection and the time
needed for health services and the wider socioeconomic
disruption to return to a new steady state. Complementary
future analyses might usefully address the temporal
resolution (daily and weekly) of excess mortality estimates,
which are likely to change at different phases of the
epidemic; specifically to focus on the first 3 months,
extending to 2 years and beyond.
We show that by Public Health England criteria, at least
20% of the population falls within the high-risk mortality
category for COVID-19: 13·7% based on age older than
70 years (an arbitrary cutoff) and a further 6·3% based on
having one or more underlying conditions. We show how
policy might consider age in combination with underlying
conditions. For example, a man aged 66–70 years with no
underlying conditions, who is not currently considered
high risk, has a higher background 1-year mortality (1·07%)
than that of a woman aged 56–60 years with one underlying
condition (0·91%), who is considered high risk.
The underlying conditions that we report (cardiovascular
diseases, COPD, and diabetes) are known to already be
suboptimally managed before COVID-19, with missed
opportunities for effective (secondary) preventive inter­
ventions common in many countries.26 With COVID-19
pressures, these practical actions for clinicians might not
be addressed, and chronic disease management care
might deteriorate. Primary and secondary health-care
workers have an important role in optimising guideline-
recommended management of underlying conditions
to lower background risk, particularly if shielding or
suppression measures are to be sustained over long
periods—eg, 3 or more months. The prototype online
1722 www.thelancet.com Vol 395 May 30, 2020
risk calculator might be relevant for clinicians to prioritise
such patients.
In England, 1·5 million individuals have been iden­
tified based on national health records as being extremely
vulnerable to COVID-19 infection, on the basis of one of
a wide range of factors (including pregnancy with
serious heart disease, chemotherapy, solid organ
transplants, and cystic fibrosis).12 These patients have
been identified and are being individually supported
(eg, with food parcels and medicine delivery) for the
life-changing intervention of 12 weeks of shielding. Such
policies, which require actionable knowledge across
multiple diseases have few, if any, historical precedents;
only countries with nationwide health-system data can
implement such policies. The list was probably designed
to identify patients who are most susceptible to infection
or have a degree of immunosuppression, which cannot
be quantified in a standardised way. The prognosis
research strategy initiative has previously made recom­
mendations for consistent approaches to understanding
prognosis across multiple diseases and clinical spe­
cialties, the importance of which is highlighted by the
COVID-19 pandemic.27
We found that patients with conditions not on the
vulnerable patient list may be at as high or greater
mortality than those who are. For example, cardiovascular
disease is not on the vulnerable patient list and has a
1-year mortality of 6%; we found that the 1-year mortality
risk of people with two or more conditions was 11%—
but multiple morbidities co-occurring in the same
individual do not yet qualify as extremely vulnerable. A
more systematic, transparent understanding is needed
of which underlying conditions are important for policy
and patients. Further research is required to identify the
extent to which patients with other physical conditions,
frailty, and mental health conditions as well as those
experiencing social exclusion (eg, homeless people and
intravenous drug users) might benefit from targeted
interventions.
We have deposited definitions of underlying conditions
relevant to COVID-19 in the HDR UK–CALIBER open
online portal. It is important for reproducible research
in COVID-19 that different research groups within
and between countries use clinical information from
electronic health records in consistent, transparent,
and validated ways to define underlying conditions and
the COVID-19 syndrome (electronic health record
phenotypes). It has previously been shown that in
defining one disease—asthma—research groups com­
bine clinical data in more than 60 different ways to reach
a definition.28 However, few efforts have been made to
harmonise definitions of diseases across national
electronic health records. To address the COVID-19
pandemic, international efforts are needed to harmonise
definitions of underlying conditions and the clinical
syndrome and progression of COVID-19 infection using
routine clinical health records.

We share age-specific (5-year age bands) and sex-
specific estimates of prevalence and 1-year mortality for
each underlying condition. These population-based esti­
mates might be relevant for other countries, particularly
those in which population-based records are neither
available nor accessible. As an illustration, we show
estimates of excess deaths in different countries if the
background (pre-COVID-19) mortality from England
were applied. It is known, based on disease-specific
registries, that mortality among people with underlying
conditions differs between countries, but few studies
using electronic health records compare outcomes across
countries. In one study, the long-term mortality among
patients who had survived a heart attack was broadly
consistent across France, Sweden, the UK, and the USA,29
suggesting that our findings might have international
relevance.
Like other researchers, we were able to access only a
sample of relevant NHS data, covering 5% of the UK
population, excluding any detailed information from
hospitals. Research is a key part of the COVID-19
response, and the UK Government is already acting to
increase publicly accountable access to NHS health
and social care data to a large number of researchers,
clinicians, and policy makers nationwide. Currently
researchers can access only small samples, in which
linkage to even simple data on hospital admissions
requires multiple approvals and can take years. It is
impossible to access NHS data on the COVID-19
epidemic as a nationwide whole (it is fragmented by
primary and secondary care and across countries).
Despite small networks for critical care,30 and coronary
disease,31 there are currently no national efforts to stream
real-time, actionable data on COVID-19 care and (non-
fatal) outcomes. With public and Government support,
the NHS has an opportunity to mobilise its data to create
a learning health system needed urgently for COVID-19,
in which high-quality clinical information is collected.
A system like this would need to include measures of
disease severity, which are often absent. Beyond the
COVID-19 pandemic, this system could have far-
reaching, long-term benefits for patient care by
accelerating knowledge generation and application.
We might have underestimated true 1-year mortality
risks because physical distancing policies might them­
selves influence the background mortality risks—people
might be less likely to access health and social care, and
physical isolation has in many previous studies been
shown to be associated with the onset and progression of
cardio­vascular and other diseases. Underlying diseases,
treatment, and health-care use need to be explored in
detail in the context of COVID-19. It is not known
whether sudden and systematic physical distancing,32
particularly if prolonged over months, has different
or additional health consequences from those reported
from earlier studies of isolation. Understanding how
to mitigate the emergency will require accessing and
www.thelancet.com Vol 395 May 30, 2020 1723
Articles
linking data about causes and consequences of the
emergency across sectors, including education, economy,
and transport.
We have presented our findings in a way that begins to
be understandable by the general public, because of calls
for information that might be relevant to an individual’s
risk—here defined by age, sex, and presence of an
underlying condition.1 No authoritative public-facing tools
are yet available, but they might provide context, motivation,
and support to comply with the multiple changes in daily
living that shielding entails. Particularly over prolonged
isolation, this could be important given concern about the
practical ability of patients to maintain shielding.
By contrast with the daily news feed in every country,
which reports the numbers of deaths (the numerator), we
report a risk: numbers of deaths over 1 year divided by the
population who was at risk of dying. Among the public it
might not be widely appreciated that 1400 people die on
average every day in the UK at baseline (ie, before
COVID-19).33 Of all those people dying within 1 year, it is
likely that COVID-19 brings forward the death earlier in
the year. In other words, there are competing causes for
the mortality.
Our study has important limitations. The study was
developed over a 72-h period before posting the results on
March 22, 2020, the day before the UK Prime Minister
announced lockdown. First, our models require further
data for their development. Commonly, research using
NHS data can take months, and even years, partly because
of the multiple steps in accessing such data for research.
Specifically, it is important to study a wider range of
underlying conditions, a wider range of hospital and
critical care admissions, linkage of primary care data to
nationally available information on COVID-19 testing,
linkage to richer, real-time hospital data, and use of
nationwide NHS data. Second, we believe it is both a
limitation and a strength that our model is simple and
supports public understanding. The assumptions we
make can be tested as empirical data become available,
such as the Office for National Statistics data.10 There
are many avenues for further modelling to better
understand how to target different preventive interven­
tions. An (incomplete) list includes statistical (dynamic
models, weekly rates of mortality, and competing risks),
public health (disease-specific data for high-risk and
extremely vulnerable conditions, regional variation, social
depri­vation, and ethnicity), clinical (including hospital
and critical care admissions), and health service factors
(including data on health-care workers and operational
features).
Health-care professionals, like those involved in this
paper, are being redirected to provide priority clinical
services during the emergency internationally. We
believe an important aspect of emergency response is to
support clinical academics to continue to contribute to
research into new preventive and treatment options, as
they take on new service responsibilities.
 Articles
If the relative risk of COVID-19 on mortality over 1 year
were 1·2 (ie, the same magnitude as the winter vs summer
mortality excess) then the number of excess deaths would
be zero when one in 100 000 individuals are infected (full
suppression scenario), 7350 when one in ten are infected
(mitigate scenario), and 58 798 when eight in ten are
infected (do nothing scenario). However, if the relative risk
is doubled to 2·0, then there would be 36 749 deaths in the
mitigation scenario and 293 991 deaths in the do nothing
scenario. These results should inform targeting of those at
highest risk for a range of preventive interventions.
Contributors
AB conceived the research question. SD and HH obtained funding.
AB, LP, CL, SD, and HH designed the study and analysis plan.
SD, AG-I, AT, WKW, and NS prepared the data, including electronic
health record phenotyping in the CALIBER open portal. LP and AB did
the statistical analysis. AB and HH drafted the initial and final versions
of the manuscript. All authors critically reviewed early and final versions
of the manuscript.
Declaration of interests
AB is supported by research funding from the National Institute for
Health Research (NIHR), British Medical Association, AstraZeneca,
and UK Research and Innovation. All other authors declare no
competing interests.
Data sharing
We will make available the estimates of age-specific, sex-specific,
and condition-specific prevalence and 1 year mortality estimates online,
the electronic health record phenotypes via the HDR UK–CALIBER
online portal, and the online risk calculator.
Acknowledgments
BW and HH are funded by the National Institute for Health Research
(NIHR) University College London Hospitals Biomedical Research Centre.
HH is supported by Health Data Research UK (HDR-UK; grant no
LOND1), which is funded by the UK Medical Research Council,
Engineering and Physical Sciences Research Council, Economic and
Social Research Council, Department of Health and Social Care (England),
Chief Scientist Office of the Scottish Government Health and Social Care
Directorates, Health and Social Care Research and Development Division
(Welsh Government), Public Health Agency (Northern Ireland), British
Heart Foundation, and Wellcome Trust. HH is also supported by the
BigData@Heart Consortium, funded by the Innovative Medicines
Initiative-2 joint undertaking under grant agreement no 116074. This joint
undertaking receives support from the EU’s Horizon 2020 research and
innovation programme and European Federation of Pharmaceutical
Industries and Associations. This work was supported by an NIHR
Clinician Scientist award (CS-2016-007) to LS. NS is supported by NIHR
Great Ormond Street Hospital Biomedical Research Centre and HDR-UK.
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