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The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries: A 9-Country Demographic Study.

ABSTRACT: BACKGROUND:There is wide variation in coronavirus disease 2019 (COVID-19) case-fatality rates (CFRs) across countries, leading to uncertainty about the true lethality of the disease. A large part of this variation may be due to the ages of individuals who are tested and identified. OBJECTIVE:To measure the contribution of distortions from the age distributions of confirmed cases to CFRs within and across populations. DESIGN:Cross-sectional demographic study using aggregate data on COVID-19 cases and deaths by age. SETTING:Population-based data from China, France, Germany, Italy, the Netherlands, South Korea, Spain, Switzerland, and the United States. PARTICIPANTS:All individuals with confirmed COVID-19, as reported by each country as of 19 April 2020 (N = 1 223 261). MEASUREMENTS:Age-specific COVID-19 CFRs and age-specific population shares by country. RESULTS:The overall observed CFR varies widely, with the highest rates in Italy (9.3%) and the Netherlands (7.4%) and the lowest rates in South Korea (1.6%) and Germany (0.7%). Adjustment for the age distribution of cases explains 66% of the variation of across countries, with a resulting age-standardized median CFR of 1.9%. Among a larger sample of 95 countries, the observed variation in COVID-19 CFRs is 13 times larger than what would be expected on the basis of just differences in the age-composition of countries. LIMITATION:The age-adjusted rates assume that, conditional on age, COVID-19 mortality among diagnosed cases is the same as that among undiagnosed cases and that individuals of all ages are equally susceptible to severe acute respiratory syndrome coronavirus 2 infection. CONCLUSION:Selective testing and identifying of older cases considerably warps estimates of the lethality of COVID-19 within populations and comparisons across countries. Removing age distortions and focusing on differences in age-adjusted case fatality will be essential for accurately comparing countries' performance in caring for patients with COVID-19 and for monitoring the epidemic over time. PRIMARY FUNDING SOURCE:Alexander von Humboldt Foundation.

SUBMITTER: Sudharsanan N

PROVIDER: S-EPMC7397549 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries : A Nine-Country Demographic Study.

Sudharsanan Nikkil N Didzun Oliver O Bärnighausen Till T Geldsetzer Pascal P

Annals of internal medicine 20200722 9

<h4>Background</h4>There is wide variation in coronavirus disease 2019 (COVID-19) case-fatality rates (CFRs) across countries, leading to uncertainty about the true lethality of the disease. A large part of this variation may be due to the ages of individuals who are tested and identified.<h4>Objective</h4>To measure the contribution of distortions from the age distributions of confirmed cases to CFRs within and across populations.<h4>Design</h4>Cross-sectional demographic study using aggregate ...[more]

PMID: 32698605

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Project description:ObjectiveTo investigate the influence of demographic and socioeconomic factors on the COVID-19 case-fatality rate (CFR) globally.DesignPublicly available register-based ecological study.SettingTwo hundred and nine countries/territories in the world.ParticipantsAggregated data including 10 445 656 confirmed COVID-19 cases.Primary and secondary outcome measuresCOVID-19 CFR and crude cause-specific death rate were calculated using country-level data from the Our World in Data website.ResultsThe 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.ConclusionThe 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.

Dataset Information

The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries: A 9-Country Demographic Study.

Publications

The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries : A Nine-Country Demographic Study.

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