Impact of the COVID-19 Pandemic on Mortality Patterns in Bushehr Port of Iran: A Comparative Analysis of the Prepandemic Period (2014?2019) and the Pandemic Era (2020?2023

Abstract Background: Industrial and coastal regions may experience unique pandemic-related mortality patterns, yet data from Middle Eastern occupational cohorts are extremely limited. Methods: In this retrospective cohort study, we analyzed 58,976 deaths in Bushehr Province, Iran (2014-2023). Autoregressive integrated moving average (ARIMA) models were used to estimate excess mortality, and Poisson regression calculated standardized mortality ratios (SMRs) by occupation and sex. Results: During the pandemic period (2020-2022), excess mortality reached 15.1%, peaking at 75% during the Delta wave. Males had 2.2 times higher mortality than females. The highest occupational mortality was among fishermen (SMR = 1.89, 95% CI: 1.75-2.04). Despite 78% vaccination coverage, acute myocardial infarction deaths increased by 27.3% (p < 0.001), comprising 41% of deaths during the BA.5 wave. Conclusion: Significant disparities in COVID-19 mortality were observed by sex and occupation. Industrial workers, particularly males, require targeted public health strategies, including workplace-based vaccination and cardiovascular screening.