Country‐level determinants of COVID‐19 case rates and death rates: An ecological study

Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic has had a variable worldwide impact, likely related to country-level characteristics. In this ecological study, we explored the association of COVID-19 case rates (per 100,000 people) and death rates (per 100,000 people) with country-level population health characteristics, economic and human development indicators, and habitat-related variables. Methods: To calculate country-level COVID-19 case and death rates, the number of cases and deaths were extracted from the Johns Hopkins Coronavirus Resource Center for 2020. Country-level population health characteristics, economic and human development indicators, and habitat-related variables were extracted from several publicly available online sources of international organizations. Results were tabulated according to world zones and country economies. Univariate and multivariable linear regression analyses were performed to examine determinants of COVID-19 case rates and death rates. Results: A total of 187 countries and territories were analyzed, with an aggregate COVID-19 case rate of 779 per 100,000 people, a death rate of 19 per 100,000 people, and a case-fatality rate of 2.4%. For country-level population health characteristics, a higher percentage rate of adults with obesity and a higher percentage rate of adults with high blood pressure was independently associated with a higher COVID-19 case rate, and a higher percentage rate of adults with obesity was associated with a higher COVID-19 death rate. For country-level economic and human development indicators, only a higher gross domestic product percentage rate spent on total health expenditure and a higher human development index was independently associated with a higher COVID-19 case rate and death rate. A higher percentage of urban population was independently associated with a higher COVID-19 death rate, whereas a higher income per capita was independently associated with a lower COVID-19 death rate. For country-level habitat-related variables, a higher average household size and a higher percentage rate of population with primary reliance on polluting fuels and technologies was independently associated with a lower COVID-19 case rate and death rate whereas a higher percentage rate of households with at least one-member age 65 years or over was associated with a higher case rate and death rates. Conclusion: This ecological study informs the need to develop country-specific public health interventions to better target populations at high risk for COVID-19, and test environmental interventions to prevent indoor transmission of SARS-CoV-2, taking into consideration population health characteristics, economic and human development indicators, and habitat-related variables that are unique to each country.

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Country-level determinants of the severity of the first global wave of the COVID-19 pandemic: an ecological study

BMJ Open ◽

10.1136/bmjopen-2020-042034 ◽

2021 ◽

Vol 11 (2) ◽

pp. e042034

Author(s):

Tiberiu A Pana ◽

Sohinee Bhattacharya ◽

David T Gamble ◽

Zahra Pasdar ◽

Weronika A Szlachetka ◽

...

Keyword(s):

Mortality Rate ◽

Vaccination Coverage ◽

Urban Areas ◽

Ecological Study ◽

Environmental Parameters ◽

The Philippines ◽

International Travel ◽

Bcg Vaccination ◽

Country Level ◽

The Mean

ObjectiveWe aimed to identify the country-level determinants of the severity of the first wave of the COVID-19 pandemic.DesignEcological study of publicly available data. Countries reporting >25 COVID-19 related deaths until 8 June 2020 were included. The outcome was log mean mortality rate from COVID-19, an estimate of the country-level daily increase in reported deaths during the ascending phase of the epidemic curve. Potential determinants assessed were most recently published demographic parameters (population and population density, percentage population living in urban areas, population >65 years, average body mass index and smoking prevalence); economic parameters (gross domestic product per capita); environmental parameters (pollution levels and mean temperature (January–May); comorbidities (prevalence of diabetes, hypertension and cancer); health system parameters (WHO Health Index and hospital beds per 10 000 population); international arrivals; the stringency index, as a measure of country-level response to COVID-19; BCG vaccination coverage; UV radiation exposure; and testing capacity. Multivariable linear regression was used to analyse the data.Primary outcomeCountry-level mean mortality rate: the mean slope of the COVID-19 mortality curve during its ascending phase.ParticipantsThirty-seven countries were included: Algeria, Argentina, Austria, Belgium, Brazil, Canada, Chile, Colombia, the Dominican Republic, Ecuador, Egypt, Finland, France, Germany, Hungary, India, Indonesia, Ireland, Italy, Japan, Mexico, the Netherlands, Peru, the Philippines, Poland, Portugal, Romania, the Russian Federation, Saudi Arabia, South Africa, Spain, Sweden, Switzerland, Turkey, Ukraine, the UK and the USA.ResultsOf all country-level determinants included in the multivariable model, total number of international arrivals (beta 0.033 (95% CI 0.012 to 0.054)) and BCG vaccination coverage (−0.018 (95% CI −0.034 to –0.002)), were significantly associated with the natural logarithm of the mean death rate.ConclusionsInternational travel was directly associated with the mortality slope and thus potentially the spread of COVID-19. Very early restrictions on international travel should be considered to control COVID-19 outbreaks and prevent related deaths.

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The closer to the Europe Union headquarters, the higher risk of COVID-19? Cautions regarding ecological studies of COVID-19

10.1101/2020.04.23.20077008 ◽

2020 ◽

Cited By ~ 1

Author(s):

Shuai Li ◽

Xinyang Hua

Keyword(s):

European Country ◽

Ecological Study ◽

Ecological Fallacy ◽

Group Level ◽

Ecological Studies ◽

Public Concern ◽

Individual Level ◽

The Public ◽

Country Level ◽

Level Data

AbstractSeveral ecological studies of the coronavirus disease 2019 (COVID-19) have reported correlations between group-level aggregated exposures and COVID-19 outcomes. While some studies might be helpful in generating new hypotheses related to COVID-19, results of such type of studies should be interpreted with cautions. To illustrate how ecological studies and results could be biased, we conducted an ecological study of COVID-19 outcomes and the distance to Brussels using European country-level data. We found that, the distance was negatively correlated with COVID-19 outcomes; every 100 km away from Brussels was associated with approximately 6% to 17% reductions (all P<0.01) in COVID-19 cases and deaths in Europe. Without cautions, such results could be interpreted as the closer to the Europe Union headquarters, the higher risk of COVID-19 in Europe. However, these results are more likely to reflect the differences in the timing of and the responding to the outbreak, etc. between European countries, rather than the ‘effect’ of the distance to Brussels itself. Associations observed at the group level have limitations to reflect individual-level associations – the so-called ecological fallacy. Given the public concern over COVID-19, ecological studies should be conducted and interpreted with great cautions, in case the results would be mistakenly understood.

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Does Cyberbullying Prevalence Among Adolescents Relate With Country Socioeconomic and Development Indicators? An Ecological Study of 31 Countries

Violence and Victims ◽

10.1891/0886-6708.vv-d-15-00139 ◽

2017 ◽

Vol 32 (5) ◽

pp. 771-790

Author(s):

Sara Soares ◽

Sandra Brochado ◽

Henrique Barros ◽

Sílvia Fraga

Keyword(s):

Ecological Study ◽

Tertiary Education ◽

National Income ◽

Significant Negative Correlation ◽

Individual Characteristics ◽

Development Indicators ◽

Country Level ◽

Cyberbullying Victimization ◽

The World Bank ◽

Internet Users

Background: In addition to individual characteristics, it is also important to evaluate how the environment may influence the dynamics of cyberbullying. We aim to study the correlation between cyberbullying prevalence among adolescents and selected country-level indicators. Methods: We used two different data sources: data from a previously published literature review, to identify information on cyberbullying prevalence across countries, and data from the World Bank databases, to extract information on country-level indicators. A correlation matrix was used to present the association between the selected country-level indicators and the prevalence of cyberbullying. Results: We observed a statistically significant negative correlation between cyberbullying victimization (cybervictims and cyberbully-victims, respectively) and gross domestic product (r = −.474 and −.842), gross national income (r = −.485 and −.758), enrollment in secondary (r = −.446 and −.898) and tertiary education (r = −.222 and −.881), the number of secure Internet servers (r = −.118 and −.794), and the number of Internet users (r = −.190 and −.818). Conclusions: A country’s educational level seems to be an important contributor to the occurrence of cyberbullying.

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Country-level Determinants of the Severity of the First Global Wave of the COVID-19 Pandemic: An Ecological Study

10.1101/2020.05.13.20100677 ◽

2020 ◽

Cited By ~ 1

Author(s):

Tiberiu A Pana ◽

Sohinee Bhattacharya ◽

David T Gamble ◽

Zahra Pasdar ◽

Weronika A Szlachetka ◽

...

Keyword(s):

Mortality Rate ◽

Study Design ◽

Vaccination Coverage ◽

Death Rate ◽

Ecological Study ◽

The Philippines ◽

International Travel ◽

Bcg Vaccination ◽

Country Level ◽

The Mean

ABSTRACTObjectiveWe aimed to identify the country-level determinants of the severity of the first wave of the COVID-19 pandemic.DesignAn ecological study design of publicly available data was employed. Countries reporting >25 COVID-related deaths until 08/06/2020 were included. The outcome was log mean mortality rate from COVID-19, an estimate of the country-level daily increase in reported deaths during the ascending phase of the epidemic curve. Potential determinants assessed were most recently published demographic parameters (population and population density, percentage population living in urban areas, median age, average body mass index, smoking prevalence), Economic parameters (Gross Domestic Product per capita); environmental parameters: pollution levels, mean temperature (January-May)), co-morbidities (prevalence of diabetes, hypertension and cancer), health system parameters (WHO Health Index and hospital beds per 10,000 population); international arrivals, the stringency index, as a measure of country-level response to COVID-19, BCG vaccination coverage, UV radiation exposure and testing capacity. Multivariable linear regression was used to analyse the data.Primary OutcomeCountry-level mean mortality rate: the mean slope of the COVID-19 mortality curve during its ascending phase.ParticipantsThirty-seven countries were included: Algeria, Argentina, Austria, Belgium, Brazil, Canada, Chile, Colombia, the Dominican Republic, Ecuador, Egypt, Finland, France, Germany, Hungary, India, Indonesia, Ireland, Italy, Japan, Mexico, the Netherlands, Peru, the Philippines, Poland, Portugal, Romania, the Russian Federation, Saudi Arabia, South Africa, Spain, Sweden, Switzerland, Turkey, Ukraine, the United Kingdom and the United States.ResultsOf all country-level predictors included in the multivariable model, total number of international arrivals (beta 0.033 (95% Confidence Interval 0.012,0.054)) and BCG vaccination coverage (−0.018 (−0.034,-0.002)), were significantly associated with the mean death rate.ConclusionsInternational travel was directly associated with the mortality slope and thus potentially the spread of COVID-19. Very early restrictions on international travel should be considered to control COVID outbreak and prevent related deaths.ARTICLE SUMMARYStrengths and limitationsA comparable and relevant outcome variable quantifying country-level increases in the COVID-19 death rate was derived which is largely independent of different testing policies adopted by each countryOur multivariable regression models accounted for public health and economic measures which were adopted by each country in response to the COVID-19 pandemic by adjusting for the Stringency IndexThe main limitation of the study stems from the ecological study design which does not allow for conclusions to be drawn for individual COVID-19 patientsOnly countries that had reported at least 25 daily deaths over the analysed period were included, which reduced our sample and consequently the power.

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National Consumption of Antimalarial Drugs and COVID-19 Deaths Dynamics: An Ecological Study

10.1101/2020.04.18.20063875 ◽

2020 ◽

Author(s):

Maxime Izoulet

Keyword(s):

Ecological Study ◽

Univariate Analysis ◽

Public Health Problem ◽

High Rate ◽

Potential Candidate ◽

Death Rates ◽

Ecological Aspects ◽

Good Potential ◽

The Difference ◽

The Way

COVID-19 (Coronavirus Disease-2019) is an international public health problem with a high rate of severe clinical cases. Several treatments are currently being tested worldwide. This paper focuses on anti-malarial drugs such as chloroquine or hydroxychloroquine, which have been currently reviewed by a systematic study as a good potential candidate and that has been reported as the most used treatment by a recent survey of physicians. We compare the dynamics of COVID-19 death rates in countries using anti-malaria drugs as a treatment from the start of the epidemic versus countries that do not, the day of the 3rd death and the following 10 days. We show that the first group have a much slower dynamic in death rates that the second group. This univariate analysis is of course only one additional piece of evidence in the debate regarding the efficiency of anti-malaria drugs, and it is also limited as the two groups certainly have other systemic differences in the way they responded to the pandemic, in the way they report death or in their population that better explain differences in dynamics (systematic differences that may also explain their choice to rely on anti-malaria drugs in the first place). Nevertheless, the difference in dynamics is so striking that we believe that the urgency context commands presenting the univariate analysis before delving into further analysis. In the end, this data might ultimately be either a piece of evidence in favor or anti-malaria drugs or a stepping stone in understanding further what other ecological aspects place a role in the dynamics of COVID-19 deaths.

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Screening is not associated with reduced incidence of gonorrhoea or chlamydia in men who have sex with men (MSM); an ecological study of 23 European countries

F1000Research ◽

10.12688/f1000research.17955.2 ◽

2019 ◽

Vol 8 ◽

pp. 160

Author(s):

Chris Kenyon

Keyword(s):

Ecological Study ◽

Incidence Rates ◽

Negative Association ◽

Internet Survey ◽

Transmitted Infection ◽

Sexual Transmitted Infection ◽

Randomized Controlled ◽

Country Level ◽

Sex With Men ◽

Spearman’S Correlation

Background: Increasing rates of antimicrobial resistance has motivated a reassessment of if intensive screening for gonorrhoea and chlamydia is associated with a reduction in the prevalence of these infections in men who have sex with men (MSM). Methods: Spearman’s correlation was used to evaluate the country-level correlation between the intensity of self-reported sexual transmitted infection (STI) screening in MSM (both anal and urethral screening, taken from a large internet survey of MSM) and the incidence (taken from ECDC surveillance figures) and prevalence (taken from a literature review of studies estimating prevalence in MSM attending STI clinics) of gonorrhoea and chlamydia. Results: The intensity of both anal and genital screening was found to be positively associated with country level gonorrhoea incidence rates (rho 0.74; p=0.0004; rho=0.73; p=0.0004, respectively) and Ct incidence rates (rho 0.71; p=0.001; rho=0.78; p=0.0001, respectively). No associations were found between anal or genital screening intensity and Ng prevalence in clinic populations (Table 2). Conclusions: We found no evidence of a negative association between screening intensity and the prevalence of gonorrhoea or chlamydia in MSM. Randomized controlled trials are urgently required to evaluate if the high antimicrobial exposure resulting from intensive screening programmes is justified.

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ACE-1 I/D Polymorphism Associated with COVID-19 Incidence and Mortality: An Ecological Study

10.20944/preprints202004.0262.v1 ◽

2020 ◽

Cited By ~ 2

Author(s):

Chris Kenyon

Keyword(s):

Literature Review ◽

Angiotensin Converting Enzyme ◽

Study Design ◽

Ecological Study ◽

High Income ◽

Converting Enzyme ◽

Country Level ◽

Incidence And Mortality

A literature review was conducted to summarize the frequency of the D-allele of the angiotensin-converting enzyme-1 in all countries with available data. Using an ecological study design limited to high income countries, we found that the country-level frequency of the D-allele was associated with increased COVID-19 incidence and mortality.

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Differences by country-level income in COVID-19 cases, deaths, case-fatality rates, and rates per million population in the first five months of the pandemic

10.1101/2020.07.13.20153064 ◽

2020 ◽

Cited By ~ 1

Author(s):

Wrishmeen Sabawoon

Keyword(s):

Low Income ◽

Case Fatality Rate ◽

Case Fatality ◽

Incidence Rates ◽

High Income ◽

Fatality Rate ◽

Middle Income ◽

Death Rates ◽

Middle Income Countries ◽

Country Level

Abstract Objective: To describe differences by country-level income in COVID-19 cases, deaths, case-fatality rates, incidence rates, and death rates per million population. Methods: Publicly available data on COVID-19 cases and deaths from December 31, 2019 to June 3, 2020 were analyzed. Kruskal-Wallis tests were used to examine associations of country-level income with COVID-19 cases, deaths, case-fatality rates, incidence rates, and death rates. Results: A total of 380,803 deaths out of 6,348,204 COVID-19 cases were reported from 210 countries and territories globally in the period under study, and the global case-fatality rate was 6.0%. Of the total globally reported cases and deaths, the percentages of cases and deaths were 59.9% and 75.0% for high-income countries, and 30.9% and 20.7% for upper-middle-income countries. Countries in higher-income categories had higher incidence rates and death rates. Between April and May, the incidence rates in higher-income groups of countries decreased, but in other groups, it increased. Conclusions In the first five months of the COVID-19 pandemic, most cases and deaths were reported from high-income and upper-middle-income countries, and those countries had higher incidence rates and death rates per million population than did lower-middle and low-income countries. Keywords: COVID-19, incidence rate, death rate, case fatality rate, income, and country

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Screening is not associated with reduced incidence of gonorrhoea or chlamydia in men who have sex with men (MSM); an ecological study of 23 European countries

F1000Research ◽

10.12688/f1000research.17955.1 ◽

2019 ◽

Vol 8 ◽

pp. 160 ◽

Cited By ~ 3

Author(s):

Chris Kenyon

Keyword(s):

Ecological Study ◽

Incidence Rates ◽

Negative Association ◽

Internet Survey ◽

Transmitted Infection ◽

Sexual Transmitted Infection ◽

Randomized Controlled ◽

Country Level ◽

Sex With Men ◽

Spearman’S Correlation

Background:Increasing rates of antimicrobial resistance has motivated a reassessment of if intensive screening for gonorrhoea and chlamydia is associated with a reduction in the prevalence of these infections in men who have sex with men (MSM).Methods:Spearman’s correlation was used to evaluate the country-level correlation between the intensity of self-reported sexual transmitted infection (STI) screening in MSM (both anal and urethral screening, taken from a large internet survey of MSM) and the incidence (taken from ECDC surveillance figures) and prevalence (taken from a literature review of studies estimating prevalence in MSM attending STI clinics) of gonorrhoea and chlamydia.Results:The intensity of both anal and genital screening was found to be positively associated with country level gonorrhoea incidence rates (rho 0.74; p=0.0004; rho=0.73; p=0.0004, respectively) and Ct incidence rates (rho 0.71; p=0.001; rho=0.78; p=0.0001, respectively). No associations were found between anal or genital screening intensity and Ng prevalence in clinic populations (Table 2).Conclusions:We found no evidence of a negative association between screening intensity and the prevalence of gonorrhoea or chlamydia in MSM. Randomized controlled trials are urgently required to evaluate if the high antimicrobial exposure resulting from intensive screening programmes is justified.

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