Introduction: We previously reported an increase in respiratory mortality in 2020 in Spain after COVID-19 [PMID: 35340748]. It is unclear if this rise is sustained in the longer-term.

Aims: We aimed to determine whether mortality in 2021 in Spain returned to pre-pandemic levels.

Methods: We explored deaths due to respiratory diseases, that is all causes of death by the standard WHO list of diseases of the respiratory system plus COVID-19, tuberculosis and lung cancer. Using the latest available official data (INE) of Spain, we analyzed mortality trends in Spain from January 2019 to December 2021.

Results: There were 98,714 deaths due to respiratory diseases in 2021 in Spain, corresponding to 21.9% of all deaths, becoming second in the ranking of causes of death. Respiratory mortality in Spain has not returned to pre-pandemic levels in 2021, still with an increase of 30.3% compared to background rates in 2019. All respiratory-specific causes of death decreased in 2021, except for lung cancer, that increased in women and decreased in men compared to 2019 (both p <0.05). In a multivariate analysis some established risk factors for respiratory mortality were confirmed, such as male gender and older age; further, a protection in rural Spain was observed, still with a large geographical variability; and those born from elsewhere in Europe and Latin America had significantly lower respiratory mortality compared to others born in any other continents.

Conclusions: The pandemic has had a lasting impact on deaths due to respiratory diseases and certain specific causes of death in 2021, and it has disproportionately affected certain regions.