Excess Mortality and its Determinants During the COVID-19 Pandemic in 21 Countries: An Ecological Study from the C-MOR Project, 2020 and 2021

Mohammad Reza Rahmanian Haghighi^{1

2}, Chryso Th Pallari¹, Souzana Achilleos¹, Annalisa Quattrocchi¹, John Gabel³, Andreas Artemiou⁴, Maria Athanasiadou⁵, Stefania Papatheodorou^{6

7}, Tianyu Liu⁸, José Antonio Cernuda Martínez⁹, Gleb Denissov¹⁰, Błażej Łyszczarz¹¹, Qian Huang¹², Kostas Athanasakis¹³, Catherine M Bennett¹⁴, Claudia Zimmermann¹⁵, Wenjing Tao¹⁶, Serge Nganda Mekogo¹⁷, Terje P Hagen¹⁸, Nolwenn Le Meur¹⁹, Jackeline Christiane Pinto Lobato²⁰, Giuseppe Ambrosio²¹, Ivan Erzen²², Binyamin Binyaminy²³, Julia A Critchley²⁴, Lucy P Goldsmith²⁵, Olesia Verstiuk²⁶, Jideofor Thomas Ogbu²⁷, Laust H Mortensen²⁸, Levan Kandelaki²⁹, Marcin Czech³⁰, Joseph Cutherbertson³¹, Eva Schernhammer¹⁵, Catharina Vernemmen¹⁷, Antonio José Leal Costa³², Tamar Maor³³, Dimos Alekkou³⁴, Bo Burström¹⁶, Antonis Polemitis³⁵, Andreas Charalambous³⁶, Christiana A Demetriou³⁷

Affiliations

¹ Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus.
² Centre for Health Economic Research and Modelling Infectious Diseases, University of Antwerp, Antwerp, Belgium.
³ Massachusetts Institute of Technology, Cambridge, MA, USA.
⁴ Department of Information Technologies, University of Limassol, Limassol, Cyprus.
⁵ Health Monitoring Unit, Government of the Republic of Cyprus Ministry of Health, Nicosia, Cyprus.
⁶ Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA.
⁷ Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.
⁸ Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁹ Unit for Research in Emergency and Disaster, University of Oviedo, Oviedo, Spain.
¹⁰ Department of Registries, National Institute for Health Development, Tallinn, Estonia.
¹¹ Department of Health Economics, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland.
¹² Center for Rural Health Research, East Tennessee State University, Johnson, TN, USA.
¹³ Department of Public Health Policy, University of West Attica, Athens, Greece.
¹⁴ Institute for Health Transformation, Deakin University, Victoria, Australia.
¹⁵ Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria.
¹⁶ Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
¹⁷ Epidemiology of Infectious Diseases, Sciensano, Brussels, Belgium.
¹⁸ Department of Health Management and Health Economics, University of Oslo, Oslo, Norway.
¹⁹ CNRS, Inserm, Arènes-UMR 6051, RSMS-U 1309, University of Rennes, EHESP, Rennes, France.
²⁰ Epidemiology, Fluminense Federal University, Niterói, Brazil.
²¹ Medicine, University of Perugia, Perugia, Italy.
²² Public Health School, National Institute of Public Health, Ljubljana, Slovenia.
²³ Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel.
²⁴ Population Health Research Institute, City St George's, University of London, London, UK.
²⁵ School of Health & Psychological Sciences, City St George's, University of London, London, UK.
²⁶ Department of Medical Science, University of Nicosia, Nicosia, Cyprus.
²⁷ Center for Research on the Epidemiology of Disasters, UCLouvain, Brussels, Belgium.
²⁸ Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
²⁹ Medical Statistics, National Center for Disease Control and Public Health, Tbilisi, Georgia.
³⁰ Department of Pharmacoeconomics, Institute of Mother and Child, Warsaw, Poland.
³¹ Monash University Disaster Resilience Initiative, Monash University, Clayton, Australia.
³² Instituto de Estudos em Saúde Coletiva, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil.
³³ Israel Center of Disease Control, Ministry of Heath, Ramat Gan, Israel.
³⁴ Department of Psychology, University of Nicosia, Nicosia, Cyprus.
³⁵ University of Nicosia, Nicosia, Cyprus.
³⁶ University of Nicosia Medical School, Nicosia, Cyprus.
³⁷ Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus. demetriou.chri@unic.ac.cy.

PMID: 39527396
PMCID: PMC11652428
DOI: 10.1007/s44197-024-00320-7

Excess Mortality and its Determinants During the COVID-19 Pandemic in 21 Countries: An Ecological Study from the C-MOR Project, 2020 and 2021

Mohammad Reza Rahmanian Haghighi et al. J Epidemiol Glob Health. 2024 Dec.

. 2024 Dec;14(4):1650-1661.

doi: 10.1007/s44197-024-00320-7. Epub 2024 Nov 11.

Authors

Affiliations

¹ Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus.
² Centre for Health Economic Research and Modelling Infectious Diseases, University of Antwerp, Antwerp, Belgium.
³ Massachusetts Institute of Technology, Cambridge, MA, USA.
⁴ Department of Information Technologies, University of Limassol, Limassol, Cyprus.
⁵ Health Monitoring Unit, Government of the Republic of Cyprus Ministry of Health, Nicosia, Cyprus.
⁶ Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA.
⁷ Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.
⁸ Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁹ Unit for Research in Emergency and Disaster, University of Oviedo, Oviedo, Spain.
¹⁰ Department of Registries, National Institute for Health Development, Tallinn, Estonia.
¹¹ Department of Health Economics, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland.
¹² Center for Rural Health Research, East Tennessee State University, Johnson, TN, USA.
¹³ Department of Public Health Policy, University of West Attica, Athens, Greece.
¹⁴ Institute for Health Transformation, Deakin University, Victoria, Australia.
¹⁵ Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria.
¹⁶ Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
¹⁷ Epidemiology of Infectious Diseases, Sciensano, Brussels, Belgium.
¹⁸ Department of Health Management and Health Economics, University of Oslo, Oslo, Norway.
¹⁹ CNRS, Inserm, Arènes-UMR 6051, RSMS-U 1309, University of Rennes, EHESP, Rennes, France.
²⁰ Epidemiology, Fluminense Federal University, Niterói, Brazil.
²¹ Medicine, University of Perugia, Perugia, Italy.
²² Public Health School, National Institute of Public Health, Ljubljana, Slovenia.
²³ Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel.
²⁴ Population Health Research Institute, City St George's, University of London, London, UK.
²⁵ School of Health & Psychological Sciences, City St George's, University of London, London, UK.
²⁶ Department of Medical Science, University of Nicosia, Nicosia, Cyprus.
²⁷ Center for Research on the Epidemiology of Disasters, UCLouvain, Brussels, Belgium.
²⁸ Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
²⁹ Medical Statistics, National Center for Disease Control and Public Health, Tbilisi, Georgia.
³⁰ Department of Pharmacoeconomics, Institute of Mother and Child, Warsaw, Poland.
³¹ Monash University Disaster Resilience Initiative, Monash University, Clayton, Australia.
³² Instituto de Estudos em Saúde Coletiva, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil.
³³ Israel Center of Disease Control, Ministry of Heath, Ramat Gan, Israel.
³⁴ Department of Psychology, University of Nicosia, Nicosia, Cyprus.
³⁵ University of Nicosia, Nicosia, Cyprus.
³⁶ University of Nicosia Medical School, Nicosia, Cyprus.
³⁷ Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus. demetriou.chri@unic.ac.cy.

PMID: 39527396
PMCID: PMC11652428
DOI: 10.1007/s44197-024-00320-7

Abstract

Introduction: The COVID-19 pandemic overwhelmed health systems, resulting in a surge in excess deaths. This study clustered countries based on excess mortality to understand their response to the pandemic and the influence of various factors on excess mortality within each cluster.

Materials and methods: This ecological study is part of the COVID-19 MORtality (C-MOR) Consortium. Mortality data were gathered from 21 countries and were previously used to calculate weekly all-cause excess mortality. Thirty exposure variables were considered in five categories as factors potentially associated with excess mortality: population factors, health care resources, socioeconomic factors, air pollution, and COVID-19 policy. Estimation of Latent Class Linear Mixed Model (LCMM) was used to cluster countries based on response trajectory and Generalized Linear Mixture Model (GLMM) for each cluster was run separately.

Results: Using LCMM, two clusters were reached. Among 21 countries, Brazil, the USA, Georgia, and Poland were assigned to a separate cluster, with the mean of excess mortality z-score in 2020 and 2021 around 4.4, compared to 1.5 for all other countries assigned to the second cluster. In both clusters the population incidence of COVID-19 had the greatest positive relationship with excess mortality while interactions between the incidence of COVID-19, fully vaccinated people, and stringency index were negatively associated with excess mortality. Moreover, governmental variables (government revenue and government effectiveness) were the most protective against excess mortality.

Conclusion: This study highlighted that clustering countries based on excess mortality can provide insights to gain a broader understanding of countries' responses to the pandemic and their effectiveness.

Keywords: COVID-19; Excess mortality; Governance; Public health measures; Vaccination rate.

PubMed Disclaimer

Conflict of interest statement

Declarations. Conflict of Interest: The authors declare no competing interests.

Figures

**Fig. 1**
Trajectory of z-score for each country/region (each point represents the means of z-score in six months). Additionally, z-score exceeding + 4 indicates substantial excess mortality. Additionally, the black horizontal line shows the z-score exceeding + 4 in

**Fig. 2**
Optimal tree created by CART for time-variant dataset. The blue nodes are predicted to be assigned to Cluster 1, and the green nodes are predicted to be assigned to Cluster 2. * OCV: Approximate original corresponding values of scaled data

See this image and copyright information in PMC

References

1. Organization WH Global excess deaths associated with COVID-19 (modelled estimates), in Organization, World Health. 2021.
1. Wang H et al. Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21. The Lancet, 2022. - PMC - PubMed
1. Msemburi W, et al. The WHO estimates of excess mortality associated with the COVID-19 pandemic. Nature. 2023;613(7942):130–7. - PMC - PubMed
1. Davies B et al. Community factors and excess mortality in first wave of the COVID-19 pandemic in England. Nature Communications, 2021. 12(1). - PMC - PubMed
1. Kapitsinis N. The underlying factors of excess mortality in 2020: a cross-country analysis of pre-pandemic healthcare conditions and strategies to cope with Covid-19. BMC Health Serv Res. 2021;21(1):1–19. - PMC - PubMed

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Excess Mortality and its Determinants During the COVID-19 Pandemic in 21 Countries: An Ecological Study from the C-MOR Project, 2020 and 2021

Affiliations

Excess Mortality and its Determinants During the COVID-19 Pandemic in 21 Countries: An Ecological Study from the C-MOR Project, 2020 and 2021

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

LinkOut - more resources

Full Text Sources

Medical