The challenges of international comparisons of COVID-19
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BRIEF REPORT
The challenges of international comparisons of COVID-19 Patricia Fitzpatrick 1 Received: 7 September 2020 / Accepted: 12 September 2020 # Royal Academy of Medicine in Ireland 2020
In the context of the COVID-19 pandemic, there has been a natural rush to international comparisons to gauge how countries have managed it. There are, however, specific challenges in interpretation of comparative COVID-19 statistics that may not always be immediately apparent, depending on a publication’s stated caveats. As cases rise in many countries and second waves are anticipated, it is opportune to review comparative measures and consider if we are comparing like with like. Age-standardised incidence and mortality rates are normally used in non-pandemic times, as differences in population structures affect these, and crude rates can be misleading [1, 2]. During this pandemic, age-standardised rates have rarely been referenced in media or political commentary. This issue is particularly relevant when mortality rates in African countries are compared with more developed countries, as the population age structure in most African countries differs, with higher birth rates and lower life expectancy [3, 4]. Number of cases per million population is a rate that is frequently reported. This is normally a useful comparison in non-pandemic times, but during the pandemic, it is challenged by two data considerations: what is the COVID-19 testing practice of different countries to identify cases, and are the countries at a similar stage of the pandemic? Aside from this, testing rates can be subject to double counting, as happened early in the pandemic in the UK [5], and remains possible [6]. Deaths per million population is a rate that many would consider a useful comparator. However, this is a crude rate whose value in the pandemic also depends on what is and is not counted as a COVID death. Although WHO published an interim definition for cause of death from COVID, countries vary; some COVID deaths reported include just those tested positive; others include those where COVID is deemed highly likely, without confirmation. Deaths occur in many settings and all should be counted in a similar way for comparison. For * Patricia Fitzpatrick [email protected] 1
School of Public Health, Physiotherapy & Sports Science, University College Dublin, Belfield Dublin 4 Ireland
example, in England, hospital deaths only were included in official death figures until 29 April—the UK fatality figure rose by 4419 deaths after non-hospital deaths positive for SARS-COV-2 were included (included 3811 deaths in care homes and the community going back to early March) [7]. In Belgium, 46% deaths were hospital (all confirmed) and 54% were from care homes (with 84% of these unconfirmed) [8]. In the USA, it is thought that in the early weeks of the pandemic, reported deaths were likely underestimated because of incomplete follow-up on all reported COVID-19 cases as well as death among persons infected who did not receive a COVID-19 diagnosis [9].
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