All‑cause excess mortality in Germany peaked during the late‑2022 influenza period, exceeding peaks during SARS‑CoV‑2 waves (2020–2023)

INTRODUCTION: Numerous studies have examined mortality during the SARS-CoV-2 pandemic in Germany and worldwide. In Germany, excess mortality was highest in 2022 compared to the other pandemic years. In a small-scale analysis in Frankfurt am Main, Germany, the excess mortality 2022 was associated with an influenza wave at the end of the year. The aim of this study was to investigate this for the whole of Germany. METHODS: We used publicly available data for the number of deaths, for the population data and for notifications of SARS-CoV-2 and influenza. Standardized mortality ratios (SMR) were estimated for Germany for the years 2020-2023, for seven SARS-CoV-2 waves and for the influenza wave at the end of 2022. Expected numbers of deaths were estimated by two methods: in the first, average mortality in the pre-pandemic years 2016-2019 was used; in the latter, an exponential extrapolation was used to consider the increase in life expectancy. RESULTS: Relative excess mortality was highest in 2022 (SMR = 1.069 (95% confidence interval: 1.066-1.071) by method 1, SMR = 1.094 (1.092-1.096) by method 2). During the influenza wave from calendar week 47 / 2022 to calendar week 1 / 2023, the SMR was higher than that of any SARS-CoV-2 wave: SMR = 1.252 (95% CI: 1.246-1.258) by method 1, and SMR = 1.374 (95% CI: 1.367-1.380) by method 2. Among all waves considered, the mean number of excess deaths per week was highest during the influenza wave by both methods (5,043, and 6,812, respectively). Age-stratified analyses showed that the excess mortality during the influenza wave at the end of 2022 was highest in individuals aged 70 years and older. DISCUSSION: During an influenza wave at the end of 2022, excess mortality was higher than in any SARS-CoV-2 wave in 2020-2022 in Germany. Because this study is based on all‑cause mortality and population‑level surveillance indicators, it cannot establish causation or quantify the proportion of excess deaths directly attributable to influenza infection.