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Updated: Dec 2, 2025
Author Spotlight: Advancements in Multiplex Detection of Respiratory Viruses
Published on: November 10, 2023
COVID-19 case-fatality rate and demographic and socioeconomic influencers: worldwide spatial regression analysis
Yang Cao1,2, Ayako Hiyoshi3,4, Scott Montgomery3,5,6
1Clinical Epidemiology and Biostatistics, Universitetssjukhuset Örebro, School of Medical Sciences, Örebro University, Örebro, Sweden yang.cao@oru.se.
Objective:
To investigate the influence of demographic and socioeconomic factors on the COVID-19 case-fatality rate (CFR) globally.
Design:
Publicly available register-based ecological study.
Setting:
Two hundred and nine countries/territories in the world.
Participants:
Aggregated data including 10 445 656 confirmed COVID-19 cases.
Primary And Secondary Outcome Measures:
COVID-19 CFR and crude cause-specific death rate were calculated using country-level data from the Our World in Data website.
Results:
The average of country/territory-specific COVID-19 CFR is about 2%-3% worldwide and higher than previously reported at 0.7%-1.3%. A doubling in size of a population is associated with a 0.48% (95% CI 0.25% to 0.70%) increase in COVID-19 CFR, and a doubling in the proportion of female smokers is associated with a 0.55% (95% CI 0.09% to 1.02%) increase in COVID-19 CFR. The open testing policies are associated with a 2.23% (95% CI 0.21% to 4.25%) decrease in CFR. The strictness of anti-COVID-19 measures was not statistically significantly associated with CFR overall, but the higher Stringency Index was associated with higher CFR in higher-income countries with active testing policies (regression coefficient beta=0.14, 95% CI 0.01 to 0.27). Inverse associations were found between cardiovascular disease death rate and diabetes prevalence and CFR.
Conclusion:
The association between population size and COVID-19 CFR may imply the healthcare strain and lower treatment efficiency in countries with large populations. The observed association between smoking in women and COVID-19 CFR might be due to the finding that the proportion of female smokers reflected broadly the income level of a country. When testing is warranted and healthcare resources are sufficient, strict quarantine and/or lockdown measures might result in excess deaths in underprivileged populations. Spatial dependence and temporal trends in the data should be taken into account in global joint strategy and/or policy making against the COVID-19 pandemic.
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