Nations with highest Covid-19 death toll

England, Wales and Scotland nations had among the highest rate of deaths from all causes, including COVID-19, as a result of the first wave of the pandemic, according to an international study.

The research, led by Imperial College London and published in the journal Nature Medicine, analysed weekly death data from 21 industrialised countries between mid-February and end of May.

Analysing deaths from all causes, not just from COVID-19, provides a comprehensive picture of the impact of the pandemic across each nation.

Although there have been over one million confirmed global deaths from COVID-19 infection, the pandemic can also result in an increase in deaths from other health conditions, due to a disruption in healthcare services, or economic and social factors.

To assess the total number of deaths in the first wave of the pandemic, from COVID-19 and all other causes, the researchers used a range of statistical models to estimate the ‘normal’ level of deaths that would have occurred in these nations without the pandemic, between mid-February and end of May. They also took into account a host of factors including temperature and other seasonal fluctuations, and general short-term and long-term trends in these countries.

These normal levels were then compared to the actual deaths, which showed the total death toll of the first wave of the COVID-19 pandemic.

Between mid-February and end of May, 206,000 more people died from all causes in these 21 countries than would have been expected had the pandemic not taken place. This amounts to an 18% increase in deaths over this period in these countries combined.

This number (206,000) is similar to the total number of deaths from lung cancer in these countries in an entire year, and more than twice the number of deaths from diabetes or breast cancer in these countries in an entire year.

England and Wales accounted for 28% of excess deaths across all countries combined, while Italy accounted for 24%, and Spain 22%.

The study team included researchers from Imperial’s MRC Centre for Environment and Health and Abdul Latif Jameel Institute for Disease and Emergency Analytics, and from collaborating institutions throughout Europe. They included countries in the analysis if their total population in 2020 was over four million, and if the team could access weekly data on total mortality, divided by age group and sex, that went back at least to 2015 and extended through late May 2020.

The 21 countries in the analysis were Australia, Austria, Belgium, Bulgaria, Czechia, Denmark, England and Wales, Finland, France, Hungary, Italy, Netherlands, New Zealand, Norway, Poland, Portugal, Scotland, Slovakia, Spain, Sweden and Switzerland.

There was very little difference in the death rate between men and women – 105,800 deaths were in men and 100,000 in women. This suggests the total death toll of the pandemic on men and women, during this study period, was similar.

Dr Vasilis Kontis, lead author of the research from the School of Public Health at Imperial, said: “The pandemic has affected people’s lives and health in so many ways. For instance, some people may have had an operation or treatment delayed, or might have lost the support they need with their day to day medical needs. Taking these factors into account, looking at deaths from COVID-19 infection alone is too limited; looking at deaths from all causes allows us to better understand how well countries handled the pandemic, and how well they have supported their people during lockdown measures.”

The research team were able to use their findings to group the countries in the study into four categories, depending on each country’s overall death toll during the first wave of the COVID-19 pandemic. The first group were those that avoided a detectable rise in deaths, and included Bulgaria, New Zealand, Slovakia, Australia, Czechia, Hungary, Poland, Norway, Denmark and Finland.

The second and third groups of countries experienced a low to medium impact of the pandemic. The low impact group included Austria, Switzerland and Portugal, while the medium impact group included France, the Netherlands and Sweden. The fourth group, which experienced the highest number of deaths from any disease during the study period, consisted of Belgium, Italy, Scotland, Spain and England and Wales.

England and Wales and Spain experienced the largest impact: around 100 excess deaths per 100,000 people, equivalent to a 37% relative increase in deaths in England and Wales, and 38% relative increase in deaths in Spain.

This data suggests a number of lessons, say the team, some of which may help avoid future waves of the pandemic from becoming as fatal as the first. For example, compared to countries such as New Zealand and Denmark, the UK, Spain, Italy and France introduced a lockdown after the pandemic was further along in the community.

England and Wales, together with Sweden (the only country that did not put in place a mandatory lockdown and only used voluntary social distancing measures), had the longest durations of excess mortality.

Dr Jonathan Pearson-Stuttard, co-author from the School of Public Health said: “Our research suggests a number of factors may influence why some countries had higher number of deaths than others. Countries with comprehensive and effective community-based testing and contact tracing programmes, or those without such systems but who implemented early and effective lockdowns, had lower death tolls during the first wave. As we enter the second wave, test and trace programmes, and supporting people who need to isolate, are our most important lever to minimise the impact of the pandemic on direct COVID-19 deaths and deaths from other conditions. Such programmes also reduce the need for further prolonged lockdowns.”

The team add that the nations with the highest excess deaths in the study period are also typically those who have had a lower investment in their health systems and health protection. For instance, Austria, which had very low numbers of deaths from all causes, has nearly three times the number of hospital beds per head of population than the UK.

Professor Majid Ezzati, the paper’s senior author from the School of Public Health, explained: “Long-term investment in the national health system is what allows a country to both respond to a pandemic, and to continue to provide the day to day routine care that people need. We cannot dismantle the health system through austerity and then expect it to serve people when the need is at its highest, especially in poor and marginalised communities.”

“The conversation must now go beyond a narrow vision of pandemic preparedness and focus on creating holistic and equitable health protection and promotion. A strong and equitable health system is the only way to tackle existing inequalities, and to make the nation resilient to future pandemics.”

Professor Sir Ian Diamond, National Statistician, commented on the study: ‘This sophisticated analysis throws more light on the scale of excess mortality in 21 industrialised countries and the differences between their experience of the pandemic. The authors have added to the body of robust evidence that is essential to understanding and tackling COVID-19 globally.’