England, Wales, and Scotland 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 published in the journal Nature Medicine. The research, led by Imperial College London and which included University of Pennsylvania demographer Michel Guillot, analyzed weekly death data from 21 industrialized countries between mid-February and the end of May. This did not include the United States because data have not yet been released at the level of detail that met the study’s requirement.
Although there have been more than a million confirmed global deaths from COVID-19 infection, the pandemic can also increase deaths from other health conditions due to a disruption in health care services or economic and social factors.
“In many countries COVID-19 as a cause of death has been poorly reported on death certificates,” says Guillot, a professor in Penn’s Department of Sociology. “This is especially true among underprivileged segments of the population, those that have been most affected. Studying deaths from all causes addresses these undercount issues and also provides a more comprehensive picture of how the pandemic has affected mortality, both directly and indirectly.”
Study methodology
To assess the total number of deaths in the pandemic’s first wave, the researchers used a range of statistical models to estimate the “normal” number of deaths that would have occurred in these nations without the pandemic, between the middle of February and end of May.
Countries were included if their total 2020 population exceeded 4 million and if the team could access weekly data on total mortality divided by age group and sex dating back to at least 2015 and extending through late May. That led to analysis for Australia, Austria, Belgium, Bulgaria, the Czech Republic, Denmark, England, Wales, Finland, France, Hungary, Italy, Netherlands, New Zealand, Norway, Poland, Portugal, Scotland, Slovakia, Spain, Sweden, and Switzerland.
The researchers also took into account a host of factors including temperature and other seasonal fluctuations, plus general short- and long-term trends in each country. They then compared these normal levels to actual deaths, which provided a picture of the total death toll.
In the three-and-a-half-month timeframe, these 21 countries combined saw an 18% increase in deaths, amounting to 206,000 more people dying from all causes in these places than would have been expected had the pandemic not taken place. This number is similar to the total number of lung cancer deaths these countries experience in an entire year, and more than twice the number of deaths from diabetes or breast cancer they experience annually. England and Wales accounted for 28% of excess deaths across all countries combined; Italy accounted for 24% and Spain 22%.
There was very little difference in the death rate between men and women. In terms of death count, this corresponded to 105,800 deaths among men and 100,000 among women. This suggests a similar total death pandemic toll on men and women during this study period.
“The pandemic has affected people’s lives and health in so many ways,” says Vasilis Kontis, lead study author and a researcher at Imperial College London. “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.”
Low, medium, and high impact
Going a step further, the research team was able to use its findings to group the study countries into four categories, depending on each country’s overall death toll during the first wave of the COVID-19 pandemic.
The first, which avoided a detectable rise in deaths, included Bulgaria, New Zealand, Slovakia, Australia, the Czech Republic, Hungary, Poland, Norway, Denmark, and Finland. A low-impact group included Austria, Switzerland, and Portugal, and a medium-impact group included France, the Netherlands, and Sweden. The fourth, which experienced the highest number of deaths from any disease during the study period, included Belgium, Italy, Scotland, Spain, England, and Wales.
England, Wales, and Spain experienced the greatest impact overall: around 100 excess deaths per 100,000 people, equivalent to a 37% relative increase in deaths in England and Wales and a 38% relative increase in deaths in Spain.
These data suggest a number of lessons, according to the researchers, some of which may help prevent future pandemic waves from becoming as fatal as the first. For example, compared to countries such as New Zealand and Denmark, the United Kingdom, 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.
“Countries with comprehensive and effective community-based testing and contact tracing programs, or those without such systems but who implemented early and effective lockdowns, had lower death tolls during the first wave,” says Jonathan Pearson-Stuttard, also of Imperial College London. “As we enter the second wave, test and trace programs and supporting people who need to isolate are our most important levers to minimize the impact of the pandemic on direct COVID-19 deaths and on deaths from other conditions. Such programs also reduce the need for further prolonged lockdowns.”
The team says that the nations with the highest excess deaths in the study period are also typically those who have invested less in their health systems and health protection. For instance, Austria, with very low deaths from all causes, has nearly three times the number of hospital beds per head than the U.K.
“The conversation must now go beyond a narrow vision of pandemic preparedness and focus on creating holistic and equitable health protection and promotion,” says Majid Ezzati, the paper’s senior author from Imperial College London. “A strong and equitable health system is the only way to tackle existing inequalities and to make nations resilient to future pandemics.”
Funding for the research came from the Abdul Latif Jameel Institute for Disease and Emergency Analytics at Imperial College London and the Pathways to Equitable Healthy Cities grant from the Wellcome Trust (209376/Z/17/Z).
Michel Guillot is a professor in the Department of Sociology in the School of Arts & Sciences at the University of Pennsylvania and at the French Institute for Demographic Studies. He is also a research associate in Penn’s Population Studies Center.
Other members of the research team included Vasilis Kontis, Jonathan Pearson-Stuttard, Majid Ezzati, James E. Bennett, Theo Rashid, Perviz Asaria, Bin Zhou, and Mariachiara Di Cesare of Imperial College London; Marco Battaglini and Gianni Corsetti from the Italian National Institute of Statistics; Martin McKee of the London School of Hygiene & Tropical Medicine; and Colin D. Mathers, an independent researcher.
