COVID-19 and Excess All-Cause Mortality in the US and 18 Comparison Countries | Global Health | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
COVID-19 data. European Centre for Disease Prevention and Control. Accessed September 25, 2020.
Viglione  G.  How many people has the coronavirus killed?   Nature. 2020;585(7823):22-24. doi:10.1038/d41586-020-02497-wPubMedGoogle ScholarCrossref
Lyu  W, Wehby  GL.  Shelter-in-place orders reduced COVID-19 Mortality and reduced the rate of growth in hospitalizations: study examine effects of shelter-in-places orders on daily growth rates of COVID-19 deaths and hospitalizations using event study models.   Health Aff (Millwood). 2020;39(9):1615-1623. doi:10.1377/hlthaff.2020.00719PubMedGoogle ScholarCrossref
Verity  R, Okell  LC, Dorigatti  I,  et al.  Estimates of the severity of coronavirus disease 2019: a model-based analysis.   Lancet Infect Dis. 2020;20(6):669-677. doi:10.1016/S1473-3099(20)30243-7PubMedGoogle ScholarCrossref
Maani  N, Galea  S.  COVID-19 and underinvestment in the public health infrastructure of the United States.   Milbank Q. 2020;98(2):250-259. doi:10.1111/1468-0009.12463PubMedGoogle ScholarCrossref
Chaudhry  R, Dranitsaris  G, Mubashir  T, Bartoszko  J, Riazi  S.  A country level analysis measuring the impact of government actions, country preparedness and socioeconomic factors on COVID-19 mortality and related health outcomes.   EClinicalMedicine. 2020;25:100464. doi:10.1016/j.eclinm.2020.100464PubMedGoogle Scholar
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    3 Comments for this article
    Tammy Mitchell |
    How are you comparing data when the data you are using may not be collected the same way in other countries? Is there a world wide standard all countries are using when counting COVID 19 deaths?
    Study Limitations and Conclusions
    Alex Jurhs |
    Limitations of this study (and other key limitations not listed) render the results and discussion potentially inconclusive or misleading.

    Given the strong correlation between COVID-19 mortality and age, not controlling for differences in demographics by country likely has a material impact on this study.

    Geography and population density also played a big role in the spread of the disease. An island nation like Australia should not be compared to nations bordered by many other countries. Nations with less population density (e.g. Norway) can not be accurately compared with the United States which saw infections (and
    deaths) driven by major cities like NYC, especially early on.

    Also, the time intervals chosen are distorted by infection patterns. Europe, in general, experienced higher level of infections and subsequent lockdowns earlier than the US. It would therefore be expected, all else equal, that the US would have more infections and deaths after May 10th compared to Europe especially given the average time between infection and death. It should also be noted that testing and death recording may not have been as accurate in the early days of COVID-19, potentially understating the number of deaths reported in countries hit first. Similarly, this study assumes that all countries track and record COVID-19 deaths consistently, which may not be true.

    Another thing to consider is the deaths attributed to long-term care facilities, especially in the early months of COVID-19 pandemic. In many US states, these deaths are a leading source. In the early days of the pandemic, the importance of protecting LTC facilities was not fully understood. Controlling for LTC deaths by country would prove insightful.

    Finally, though the impact is less known, it is possible that levels of pre-existing immunity varied by country and this could have an impact on infection and mortality statistics.

    All of these considerations should be factored in before concluding that higher levels of mortality in the US is due to "weak public health infrastructure and a decentralized, inconsistent US response to the pandemic."
    Post Hoc Ergo Propter Hoc
    Michael Plunkett, MD MBA | Practice
    These data do not specify the authors’ conclusions.

    The US is very different from each of the comparator countries in 2 very important ways—it has a much larger population and an incredibly larger geographic area.

    A much better comparator would Europe as a whole. It’s surprisingly similar to the U. S. — about 6.5 million cases, 225,000 deaths. Do they all in aggregate have “weak public health infrastructure and a decentralized inconsistent response?

    In addition, drawing conclusions from different countries over same time periods is spurious. The virus doesn’t affect every country at the exact same
    Research Letter
    October 12, 2020

    COVID-19 and Excess All-Cause Mortality in the US and 18 Comparison Countries

    Author Affiliations
    • 1Interfaculty Initiative in Health Policy, Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts
    • 2University of Pennsylvania Perelman School of Medicine, Philadelphia
    JAMA. 2020;324(20):2100-2102. doi:10.1001/jama.2020.20717

    The US has experienced more deaths from coronavirus disease 2019 (COVID-19) than any other country and has one of the highest cumulative per capita death rates.1,2 An unanswered question is to what extent high US mortality was driven by the early surge of cases prior to improvements in prevention and patient management vs a poor longer-term response.3 We compared US COVID-19 deaths and excess all-cause mortality in 2020 (vs 2015-2019) to that of 18 countries with diverse COVID-19 responses.

    We compared the US with Organisation for Economic Co-operation and Development countries with populations exceeding 5 million and greater than $25 000 per capita gross domestic product. For each country, we calculated the COVID-19 per capita mortality rate and grouped countries by mortality: (1) low (COVID-19 deaths, <5/100 000), (2) moderate (5-25/100 000), and (3) high (>25/100 000).1 We used Poisson regression for comparisons across countries.