SARS-CoV-2 Vaccination Coverage and Key Public Health Indicators May Explain Disparities in COVID-19 Country-Specific Case Fatality Rate Within European Economic Area

Abstract

Aim To investigate the reasons for disparity regarding the country-specific COVID-19-related case fatality rate (CFR) within the 30 countries of the European Economic Area (EEA). Materials and methods Data regarding population, area, COVID-19-associated infections/deaths, vaccination, life expectancy, elderly population, infant mortality, gender disparity, urbanization, gross domestic product (GDP), income per capita, health spending per capita, physicians, nursing personnel, hospital beds, ICU beds, hypertension, diabetes, obesity, and smoking from all EEA countries were collected from official sources on January 16, 2022. Correlation coefficients were computed, and optimal scaling using ridge regression was used to reach the most parsimonious multivariate model assessing any potential independent correlation of public health parameters with COVID-19 CFR. Results COVID-19 CFR ranges from 0.1% (Iceland) to 4.0% (Bulgaria). All parameters but population density, GDP, total health spending (% of GDP), ICU beds, diabetes, and obesity were correlated with COVID-19 CFR. In the most parsimonious multivariate model, elderly population rate (P = 0.018), males/total ratio (P = 0.013), nurses/hospital beds (P = 0.001), physicians/hospital beds (P = 0.026), public health spending (P = 0.013), smoking rate (P = 0.013), and unvaccinated population rate (P = 0.00005) were demonstrated to present independent correlation with COVID-19 CFR. In detail, the COVID-19 CFR is estimated to increase by 1.24 times in countries with vaccination rate of <0.34, 1.11 times in countries with an elderly population rate of ≥0.20, 1.14 times in countries with male ratio values ≥0.493, 1.12 times in countries spending <2,000$ annually per capita for public health, 1.14 and 1.10 times in countries with <2.30 nurses and <0.88 physicians per hospital bed, respectively, and 1.12 in countries with smoking ratio ≥0.22, while holding all other independent variables of the model constant. Conclusion COVID-19 CFR varies substantially among EEA countries and is independently linked with low vaccination rates, increased elderly population rate, diminished public health spending per capita, insufficient physicians and nursing personnel per hospital bed, and prevalent smoking habits. Therefore, public health authorities are awaited to consider these parameters in prioritizing actions to manage the SARS-CoV-2 pandemic.

Keywords: case fatality rate; covid-19; european economic area; health spending; smoking; vaccination.

Figure 1. Heat map based on Spearman’s correlation coefficients including all parameters analyzed.

Figure 2. Scattergrams depicting correlations between infected population rate as well as unvaccinated population rate and COVID-19 CFR.

CFR: Case fatality rate.

Figure 3. Scattergrams depicting correlations between demographics and COVID-19 CFR.

CFR: Case fatality rate.

Figure 4. Scattergrams depicting correlations between financial indices and COVID-19 CFR.

CFR: Case fatality rate.

Figure 5. Scattergrams depicting correlations between personnel and infrastructure indices and COVID-19 CFR.

CFR: Case fatality rate.

Figure 6. Scattergrams depicting correlations between comorbidity indices and COVID-19 CFR.

CFR: Case fatality rate.

Figure 7. Ridge paths of the most parsimonious model; seven variables were demonstrated to present independent correlation with COVID-19 CFR.

CFR: Case fatality rate.