COVID-19 case-fatality rate and demographic and socioeconomic influencers: worldwide spatial regression analysis based on country-level data

  1. Yang Cao
  2. Ayako Hiyoshi
  3. Scott Montgomery

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Abstract

To investigate the influence of demographic and socioeconomic factors on the COVID-19 case-fatality rate (CFR) globally.

Design

Publicly available register-based ecological study.

Setting

Two hundred and nine countries/territories in the world.

Participants

Aggregated data including 10 445 656 confirmed COVID-19 cases.

Primary and secondary outcome measures

COVID-19 CFR and crude cause-specific death rate were calculated using country-level data from the Our World in Data website.

Results

The average of country/territory-specific COVID-19 CFR is about 2%–3% worldwide and higher than previously reported at 0.7%–1.3%. A doubling in size of a population is associated with a 0.48% (95% CI 0.25% to 0.70%) increase in COVID-19 CFR, and a doubling in the proportion of female smokers is associated with a 0.55% (95% CI 0.09% to 1.02%) increase in COVID-19 CFR. The open testing policies are associated with a 2.23% (95% CI 0.21% to 4.25%) decrease in CFR. The strictness of anti-COVID-19 measures was not statistically significantly associated with CFR overall, but the higher Stringency Index was associated with higher CFR in higher-income countries with active testing policies (regression coefficient beta=0.14, 95% CI 0.01 to 0.27). Inverse associations were found between cardiovascular disease death rate and diabetes prevalence and CFR.

Conclusion

The association between population size and COVID-19 CFR may imply the healthcare strain and lower treatment efficiency in countries with large populations. The observed association between smoking in women and COVID-19 CFR might be due to the finding that the proportion of female smokers reflected broadly the income level of a country. When testing is warranted and healthcare resources are sufficient, strict quarantine and/or lockdown measures might result in excess deaths in underprivileged populations. Spatial dependence and temporal trends in the data should be taken into account in global joint strategy and/or policy making against the COVID-19 pandemic.

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  1. ScreenIT

    SciScore for 10.1101/2020.07.31.20165811: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    NIH rigor criteria are not applicable to paper type.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    All the analysis were conducted in R 4.02 (the R Foundation for Statistical Computing, Vienna, Austria) using the package spaMM (Rousset and Ferdy 2014) and in Python 3.6 (Python Software Foundation) (van Rossum 1995) using the packages geopandas and geoplot (Jordahl et al. 2019).
    Python
    suggested: (IPython, RRID:SCR_001658)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and Limitations: To our knowledge, this is the first study that investigated relationship between COVID-19 CFR and demographic and socioeconomic factors globally. The study included in total 10,445,656 confirmed COVID-19 cases and 511,030 deaths worldwide. Although numerous studies have investigated the aforementioned factors related to the COVID-19 CFR, either they used much smaller sample size and investigated the question locally, or they did not approach this issue from a geospatial perspective. Our study may inspire new reflections from the healthcare workers to work together against the COVID-19 pandemic geographically and globally. International comparison of CFR may be challenging when the ascertainment of COVID-19 cases differed by country. To tackle this, we performed a sensitivity analysis using CDR. Although some risk factors, such as CVD and diabetes, showed different pattern of association, population showed consistent and positive association (see Appendix). There are some limitations in our study. Firstly, the case-fatality analyzed here was based on the reported COVID-19 cases and deaths by countries/territories. According to the recent estimations, asymptomatic carriers and victims of COVID-19 could be as high as 10-80% in a population (Anastassopoulou et al. 2020; Day 2020; Kimball et al. 2020; Mizumoto et al. 2020; Nishiura et al. 2020; World Health Organization 2020b). However, this fraction was not taken into account in our analysis. Therefore,...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: Please consider improving the rainbow (“jet”) colormap(s) used on pages 18 and 19. At least one figure is not accessible to readers with colorblindness and/or is not true to the data, i.e. not perceptually uniform.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1136/bmjopen-2020-043560
  3. Version published to 10.1101/2020.07.31.20165811v1 on medRxiv