Jan 18, 2022

Ranking All World Countries by Covid Mortality After Two Years with Covid-19 and Examining the Factors Affecting the Ranking

In the attached Table, the countries are listed according to the decreasing Covid-19 deaths per million people (mortality), as provided by the website Worldometers (here) on 10 January 2022; 70 countries out of 222 have been selected while keeping their world ranking. The world average values are also included (being between the 100th and the 101st country). Beside the country’s world  mortality ranking,  also included in the Table are the case fatality rate  (CFR, the ratio of the reported deaths and
reported confirmed cases, x 100), the country’s world ranking according to the decreasing number of the reported cases per million people (morbidity), and the population fraction vaccinated by 1/, 2/ or 3/ doses.

The mortality values are dispersed in an incredibly wide range of from 6030 people per million for Peru (the 1st in the list) to merely 3 people per million for China (the last in the list). Following is an attempt to find factors causing the differences among the countries.

Underreported deaths

Generally, it is estimated that more than 50% but less than 75% Covid deaths have been missed globally (here). However, developing countries usually report much less deaths than developed countries, and much less of positive cases as well, which mostly results from the lower number of performed tests.

Furthermore, the countries differ in the procedures for completing the death certificate – whether an external examination is needed or who completes the certificate. For example, in Austria and Germany, any death must be subjected to an external examination by a physician, but not in England during the Covid pandemic, when a death can be confirmed in the absence of an external examination. In Italy, the death certificate must include Covid-19 as a cause of death when the SARS-CoV-2 is suspected (here). That would place Germany and Austria behind Great Britain and Italy in the deaths counts, and indeed, the four mentioned countries are ranked 67th, 56th, 30th, and 25th, respectively (see the Table), so that Germany and Austria would be relatively underreported.

Underreported deaths and confirmed cases due to less tests

The number of tests performed per 100 people in the country (also shown on Worldometers) may affect the number of identified deaths and positive cases. For example, United Kingdom performed 630 tests per 100 people and Germany performed only 106 tests per 100 people, which might have affected the identified deaths and positive cases: about 2200 deaths and 220,000 cases per million in the UK and about 1400 deaths and 95,000 cases per million in Germany, respectively.

Developing countries are mostly in the second half of the list of 222 countries (or regions) arranged according to the decreasing number of deaths, testing less than 50 people from 100, or even less than 4 per 100. Indonesia with a population of 278 million is 119th in the world list of mortalities, India with 1.4 billion population is 130th, Egypt with 103 million is 143rd, Nigeria with 213 million is 197th, and China with 1.4 billion is 208th. Similar results are obtained when arranging the countries according to decreasing number of positively tested people (confirmed cases). The developing countries have younger population, which can partly explain lower mortality, but low testing and underreporting the dead and the ill surely contribute to the low values of reported deaths and confirmed cases.

Overreported deaths

Some countries may have reported more deaths for various reasons. For example, Peru which is ranked as the 1st in the world in the number of deaths per million, may report a higher number of deaths due to a one-off correction which has tripled the previous official Covid-19 deaths value in order to align it closer with the excess mortality values (here, here). The real Covid mortality in Peru thus might be closer to Bulgaria, ranked the 2nd, or possibly even to Romania, ranked 11th; anyway, the lower healthcare standard, including access to health coverage and the number of intensive care beds, have surely had to contribute to the Peru’s high mortality too (here).  

The Czech Republic, ranked 8th, motivates hospitals to report patients as Covid-infected, because the health insurance companies pay to the hospitals ten times more for Covid patients than for other patients (here), which substantially helped the hospitals in their payment balance (here). The U.S., ranked 20th, also motivate the hospitals to report Covid cases (here).

High deaths in the former communist countries

Of the first 19 highest-deaths countries, 15 are the former members of the Soviet bloc. Most of these countries have since progressed toward the Western democracies; however, it can be hypothesized that the originally lower standard of the health system may still have some effects, and interestingly also that the Covid most vulnerable people, namely aged 65+, lived an important part of their lives under said very unhealthy regimens exhibiting not only the low standards of the healthcare, but also very bad environmental and nutrition situation.

Although it seems that the former East German regions do not exhibit higher mortality than the former West German regions, mortality from preventable and treatable causes in EP is the highest in Hungary, Romania, Latvia, Lithuania, Estonia, Slovakia, Croatia, Bulgaria, Poland, Czechia, and Slovenia (here).

Excess deaths due to low-quality healthcare

Excess mortality in 2020-2021 has been higher than reported Covid-19 deaths in some countries in Eastern Europe, Africa, Mexico, and India. Even before the pandemic, an estimated five million deaths annually worldwide were allegedly due to low-quality healthcare. Excess deaths, however, may also have substantial natural annual fluctuation; e.g., Australia and Thailand saw 7% increases in deaths in 2019 versus 2018. Moreover, excess deaths in 2020-2021 reflect both Covid-19 and several death causes that possibly increased or decreased during the pandemic; death certificates have always been inaccurate, and financial incentives promoted some values (here).

For example, the excess deaths per million people during the first 18 months of the Covid-19 pandemic were 2474 in the U.S. (corresponding roughly to the present Covid deaths), 4456 in Mexico (more than the present Covid deaths), and even minus 277 (curiously decreased mortality) in Norway, which reports 246 Covid deaths (here). 

Low deaths in the island countries

The island countries have relatively lower deaths values, including Ireland, Malta, Cyprus, Japan, Iceland, Australia, Taiwan, and New Zealand. Some geographically relatively isolated areas, mostly peninsulas, also exhibit low deaths, such as Denmark, Singapore, and South Korea. These regions have probably been also more motivated than others, and have had better means, to introduce stricter protective and isolating measures.

The effect of the population age

With an increasing age, mortality increases three times for every ten years (here). Therefore, most deaths afflict people 65 years or older. This fact can explain, for example, the difference between the mortality values of Sweden and Israel, namely 1504 and 887 per million, respectively. Sweden has 20% people being at least 65 years old, whereas Israel has only 10% people of this age. So that (1504/2 =) 752 deaths could be expected for Israel; the real value of 887 is not far from that.

The effect of the government measures

Strict measures in the mentioned island or peninsula countries may have restricted the epidemic spread. Several other countries, including Norway, have managed to keep the number of cases and deaths lower, probably due to the strict bans on travel and contacts. However, most countries do not show a clear correlation between strict measures and lower deaths. The above example of Sweden and Israel can be cited also here: Israel has introduced severe lockdowns, travel bans, and compulsory masks, but still it has had more deaths than would be expected for its younger population when compared with Sweden, which has managed the epidemic in a most liberal way.

Sweden, which has never introduced strict measures or even compulsory masks, is ranked 57th in the deaths per million and 46th in the number of confirmed cases per million people, situated in the list behind most other developed countries, which have introduced much stricter measures.

It turned out that hermetic closure against the virus was impossible, as seen for example in Taiwan (here), but several countries may have managed to well survive their lockdowns and strict measures till the appearance of the vaccine, and may have lowered their number of deaths in comparison with the remaining world.

The numbers of confirmed cases

The world countries arranged according to the decreasing number of confirmed positive cases per million (Worldometers) provide a ranking, which is also shown in the Table. A great discrepancy between the death ranking and the case ranking indicates either different lethality (due to different healthcare or different virus strain) or inaccuracies in the reported values, or both. For example, the U.S. have the same ranking in the deaths and in the cases (20th and 20th, see the Table). However, Peru (1st and 100th, respectively) should probably show less of the deaths or more of the positive cases or both; the same pays for Bosna (3rd, 82nd). On the other hand, Denmark (114th, 29th) should probably show more of deaths or less of positive cases or both; or alternatively, they had a more benign Covid strain (less probable), or they managed the epidemic more successfully with less victims.

The numbers of positively tested people cover roughly between 10% and 25% population in most developed countries. For example, Switzerland, Germany, and Netherland have positively tested 19%, 9%, and 21% population, respectively. In case of Germany, which exhibits similar mortality as the other two countries, the lower number of confirmed cases may result from underreporting, already mentioned above; this is also reflected by the CFR, which is double in Germany in comparison with Switzerland and Netherland (the ratio of deaths/cases is higher when the number of cases is lower, see the Table).

The unknown population infection rates

The numbers of positively tested people (confirmed cases) represent, for example, 4% of the total population for the world, and 32% for Montenegro. Several countries show an extremely low fraction of positively tested population, including Japan (2%), South Korea (1%), and Taiwan (0.1%), but most developed countries range between about 10% and 25%. However, the real number of people who have been infected must be higher than the number of positively tested, since many people have no symptoms, many do not report symptoms, and many do not test. The real numbers of infected people seemed to be 10 times higher in the starting phase of the pandemic (here), but now they may be rather thrice or twice the reported cases.

Strangely, the total number of infected people – highly important epidemic parameter – has never been assessed in any country, even though it would be measurable by taking random population samples (checking both PCR and the anti-Covid immunity of the unvaccinated people).

Rough estimation may provide that between 25% and 75% populations having been infected by Covid-19 in most countries. The countries with lower infection rates can be expected to increase the morbidity and mortality values in the future more than the countries with higher infection rates.

Unreliable reported values

Some countries report not too reliable values, particularly developing countries, and authoritative regimens.

Evidently erroneous are the values provided by China: the deaths per million people, for example, reported by China are by three orders lower than the values for most other countries, even though SARS-Cov-2 virus undeniably escaped from Wuhan laboratories and was spreading in the whole country from summer 2019 till December 2019 before it was reported to the WHO. The reported Chinese deaths of 3 per million and positive cases of 71 per million till January 2022 can hardly be believed, particularly in view of the values 36 and 746 for the neighboring Taiwan, or 1504 and 153,000 for Sweden. The numbers of performed tests reported by China, a value of 10 per 100 people not having changed for 16 months, seem also nonsensical (here, here).

Case fatality rates

The ratio of the deaths and the confirmed cases, when multiplied by 100 (the percent death of all cases), is called case fatality rate (CFR), and it is also shown in the Table. Higher fatality rate may indicate worse healthcare, but it also reflects a lower number of the positively tested people, which is in accordance with the fact that CFR in the Table correlates with the number of tests performed per 100 people in the country (also shown on Worldometers) – the more tests, the lower CFR. For example, only 68 tests per 100 people have been performed in Peru, 50 in Bosna, 10 in Mexico, and 41 on Taiwan (fatality rates of 8.6, 4.6, 7.3, and 4.9, respectively), while 340 tests per 100 people have been performed in Georgia, 260 in the U.S., 630 in the United Kingdom, and 780 on Cyprus (fatality rates of 1.5, 1.4, 1.0, and 0.3, respectively).

Switzerland and Germany, already mentioned above, both exhibit mortality of about 1400 per million, but the former shows CFR of 0.8% and the latter 1.5%, which results from the fact that Switzerland positively tested 19% population (employing 176 tests per 100 people), whereas Germany confirmed only 9% (106 tests per 100 people). 

Covid-19 lethality

The traditional Western democratic countries, supposed to report the values accurately, show the CFR values of 1.4% (U.S.) or less such as 1.1% for Sweden, 1.0% for UK, 0.8% for Switzerland, 0.6% for Netherland, 0.5% for Israel, 0.4% for Denmark, 0.3% for Norway, 0.2% for Australia, and 0.1% for Iceland (see the Table). The real fatality rate, lethality (100 x dead/really infected), should be close to the CFR values found in the countries more strictly tracking the cases; the last four above-named countries provide an average CFR of about 0.25%.

If supposing that the whole population has already been infected, then the U.S. 2573 deaths per million would provide 0.2573 dead per 100 infected, which would make about 0.26% lethality. Similarly, Sweden would provide 0.15%, UK 0.22%, Switzerland 0.14%, Netherland 0.12%, and Israel about 0.1% (see the Table). If assuming that there are no differences among different Covid strains, the real lethality for Covid-19 (fraction of the people dying after infection) would be between 0.1% and 0.2%, which is in accordance with the previous estimations (here).

The fraction of the vaccinated population

The effect of the vaccination rate on the total deaths is not too clear in the Table; low vaccination countries are dispersed along the whole list (2nd Bulgaria, 19th Moldova, 117th Cyprus), as well as high vaccination countries (1st Peru, 21st Argentina, 114th Denmark).

The Worldometers website enables to well compare the number of the deaths during the first year and the second year of the pandemics. It is seen that the number of deaths was the same or higher in the second year, even though the vaccination was performed in this second year.

Extrapolating the future mortality from the last week deaths

For example, in the U.S., the deaths have increased from 2573 to 2616 per million from January 10 to January 17, adding 43 more deaths per million per week; for a wave lasting 10 weeks, this would make 430 additional deaths, increasing the mortality of 2573 by 17%. Such extrapolation provides, for example, the following mortality increase predictions: more than 100% for Taiwan and Australia, more than 50% for Iceland and Finland, more than 25% for South Korea, Japan, Cyprus, Denmark, Monaco, Malta, and Poland. The predictions for other developed countries are lower, for example 17% for the U.S. and Bulgaria, 15% for Italy, 13% for Germany, France, and UK, 9% for Sweden, and 7% for Czechia. So that the low-mortality countries will mostly increase their mortalities relatively to the high-mortality countries.

(1) The countries of the former Soviet Bloc lead the list of mortalities with 2,500 to 4,500 deaths per million people (9 out of the first 11 countries are East-European, and 15 out of 19 are from the Bloc). This may reflect i) a still lower standard of the healthcare relatively to the Western Europe, and ii) the bad effects of the life in a communist country (bad food, environment, and healthcare) on the people who nowadays are 65 and older.
(2) Following in the mortality list are Western democratic and South American countries with 1000 to 2,500 deaths per million, mostly situated among the first 100 countries in the list (there are 222 countries, the average world value is found between the 100th and the 101st country).
(3) Dispersed in the second half of the mortality list are developed countries situated on islands and peninsulas, including Denmark, Cyprus, Japan, Singapore, Iceland, South Korea, Australia, Taiwan, and New Zealand, and several other countries including Israel, Finland, and Norway, that all have managed to better isolate themselves, with 10 to 1000 deaths per million.
(4) Roughly ¾ of the world population live in developing countries, which do not appear in the first half of the list of mortalities, reporting between 2 and 400 deaths per million. Most of these countries underreport deaths and cases.
(5) The second lowest deaths value in the world is 3 per million – reported by the People’s Republic of China.
(6) Beside the above-mentioned effects, the country mortality ranking as shown in the Table is affected by i) the local rules about diagnosis and about death certificates, ii) the motivation of the health authorities to overestimate or underestimate the deaths or cases numbers, iii) the quality of the local medical care, iv) the quality and quantity of the performed tests, v) the age composition of the population and its medical history, and vi) the fraction of actually infection population which still broadly ranges possibly between 1% and 90%.
(7) The differences in mortality among the countries would be lower without differences in rules for virus testing and for death reporting.
(8) The above mortality ranking of the countries is probably not much affected by different virus strains or by different protective measures taken in various countries (including the vaccination), except for the mentioned island isolation issues. 
(9) Retrospectively, it may be hypothesized that if all available protection measures were better focused on the people aged 65+ (not consistently applied anywhere, including Sweden), the mortality might have theoretically been kept under 1000 per million everywhere, even without isolating the countries, vaccinating the people, and introducing most other measures; most people younger than 65 would have finally been exposed to Covid-19, whereby being protected against future corona infections better than by vaccination, and the lethality would have been below 0.1% of the infected people.

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