Where did it hit harder? Understanding the geography of excess mortality during the COVID-19 pandemic

Sociopolitical context and COVID-19 fatality rates in OECD countries: a configurational approach

BACKGROUND

The effectiveness of crisis response can be influenced by various structural, cultural, and functional aspects within a social system. This study uses a configurational approach to identify combinations of sociopolitical conditions that lead to a high case fatality rate (CFR) of COVID-19 in OECD countries.

METHODS

A Fuzzy set qualitative comparative analysis (QCA) is conducted on a sample of 38 OECD countries. The outcome to be explained is high COVID-19 CFR. The five potentially causal conditions are level of democracy, state capacity, trust in government, health expenditure per capita, and the median age of population. A comprehensive QCA robustness test protocol is applied, which includes sensitivity ranges, fit-oriented robustness, and case-oriented robustness tests.

RESULTS

None of the causal conditions in both the presence and negation form were found to be necessary for high or low levels of COVID-19 CFR. Two different combinations of sociopolitical conditions were usually sufficient for the occurrence of a high CFR of COVID-19 in OECD countries. Low state capacity and low trust in government are part of both recipes. The entire solution formula covers 84 percent of the outcome.  Some countries have been identified as contradictory cases. The explanations for their COVID-19 CFR require more in-depth case studies.

CONCLUSIONS

From a governance perspective, the weakness of government in effectively implementing policies, and the citizens' lack of confidence in their government, combined with other structural conditions, serve as barriers to mounting an effective response to COVID-19. These findings can support the idea that the effects of social determinants of COVID-19 outcomes are interconnected and reinforcing.

The complex link between socioeconomic deprivation and COVID-19. Evidence from small areas of Catalonia

This ecological study assesses the association between the incidence rate of COVID-19 confirmed cases and socioeconomic deprivation in the Catalan small areas for the first six waves of the pandemic. The association is estimated using Poisson regressions and, in contrast to previous studies, considering that the relationship is not linear but rather depends on the degree of deprivation. The results show that the association between deprivation and incidence varied between waves, not only in intensity but also in its sign. Although it was insignificant in the first, third and fourth waves, the association was positive and significant in the second, becoming significantly negative in the fifth and sixth waves. Interestingly, the evidence suggests that the link between both magnitudes was not homogeneous throughout the distribution of deprivation, the pattern also varying between waves. The results are discussed in view of the role of non-pharmacological interventions and vaccination, as well as potential biases (for example that associated with differences between population groups in the propensity to be tested in each wave).

Systematic Search and Scoping Review of Physicians' Intolerance of Uncertainty and Medical Decision-Making Uncertainties During the COVID-19 Pandemic: A Summary of the Literature and Directions for Future Research

Pandemic-related uncertainties and intolerance of uncertainty (IU) could negatively affect physicians' well-being and functioning, being associated with experiences of distress and problematic decision-making processes. To summarize the available quantitative and qualitative evidence of physicians' IU and decisional uncertainty during COVID-19 and problems associated with it, a systematic search was conducted to identify all relevant articles describing physician uncertainty with regard to medical decision making and well-being in COVID-19 pandemic conditions. Medical, psychological, and preprint databases were searched. Ten articles met all eligibility criteria, with eight describing quantitative and two describing qualitative research outcomes, assessed primarily in European regions and via online surveys. Associations between IU and symptoms of poor mental health and mental health risk factors were widespread, but inconsistencies emerged. Qualitative studies emphasized decisional uncertainty as a stressor for physicians, and quantitative studies suggest it may have fostered more unproven treatment choices. While the prevalence and impact of physician uncertainty under COVID-19 conditions requires further investigation, sighting available literature indicates that IU coincided with experiences of poor mental health and, at least towards the beginning of the pandemic, with willingness to endorse unproven treatments. Efforts to reduce uncertainty-related problems for physicians seem warranted, for example, through normalizing experiences of uncertainty or reducing avoidable uncertainty through maintaining open and timely communication channels.

Urban-rural disparities in COVID-19 hospitalisations and mortality: A population-based study on national surveillance data from Germany and Italy

PURPOSE

Recent literature has highlighted the overlapping contribution of demographic characteristics and spatial factors to urban-rural disparities in SARS-CoV-2 transmission and outcomes. Yet the interplay between individual characteristics, hospitalisation, and spatial factors for urban-rural disparities in COVID-19 mortality have received limited attention.

METHODS

To fill this gap, we use national surveillance data collected by the European Centre for Disease Prevention and Control and we fit a generalized linear model to estimate the association between COVID-19 mortality and the individuals' age, sex, hospitalisation status, population density, share of the population over the age of 60, and pandemic wave across urban, intermediate and rural territories.

FINDINGS

We find that in what type of territory individuals live (urban-intermediate-rural) accounts for a significant difference in their probability of dying given SARS-COV-2 infection. Hospitalisation has a large and positive effect on the probability of dying given SARS-CoV-2 infection, but with a gradient across urban, intermediate and rural territories. For those living in rural areas, the risk of dying is lower than in urban areas but only if hospitalisation was not needed; while for those who were hospitalised in rural areas the risk of dying was higher than in urban areas.

CONCLUSIONS

Together with individuals' demographic characteristics (notably age), hospitalisation has the largest effect on urban-rural disparities in COVID-19 mortality net of other individual and regional characteristics, including population density and the share of the population over 60.

Conditioning factors in the spreading of Covid-19 - Does geography matter?

There is evidence in literature that the spread of COVID-19 can be influenced by various geographic factors, including territorial features, climate, population density, socioeconomic conditions, and mobility. The objective of the paper is to provide an updated literature review on geographical studies analysing the factors which influenced COVID-19 spreading. This literature review took into account not only the geographical aspects but also the COVID-19-related outcomes (infections and deaths) allowing to discern the potential influencing role of the geographic factors per type of outcome. A total of 112 scientific articles were selected, reviewed and categorized according to subject area, aim, country/region of study, considered geographic and COVID-19 variables, spatial and temporal units of analysis, methodologies, and main findings. Our literature review showed that territorial features may have played a role in determining the uneven geography of COVID-19; for instance, a certain agreement was found regarding the direct relationship between urbanization degree and COVID-19 infections. For what concerns climatic factors, temperature was the variable that correlated the best with COVID-19 infections. Together with climatic factors, socio-demographic ones were extensively taken into account. Most of the analysed studies agreed that population density and human mobility had a significant and direct relationship with COVID-19 infections and deaths. The analysis of the different approaches used to investigate the role of geographic factors in the spreading of the COVID-19 pandemic revealed that the significance/representativeness of the outputs is influenced by the scale considered due to the great spatial variability of geographic aspects. In fact, a more robust and significant association between geographic factors and COVID-19 was found by studies conducted at subnational or local scale rather than at country scale.

People inflows as a pandemic trigger: Evidence from a quasi-experimental study

Although it has been established that population density can contribute to the outbreak of the COVID-19 virus, there is no evidence to suggest that economic activities, which imply a significant change in mobility, played a causal role in the unfolding of the pandemic. In this paper, we exploit the particular situation of Sardinia (Italy) in 2020 to examine how changes in mobility due to tourism inflows (a proxy of economic activities) influenced the development of the COVID-19 pandemic. Using a difference-in-differences approach, we identify a strong causal relationship between tourism flows and the emergence of COVID-19 cases in Sardinia. We estimate the elasticity of COVID-19 cases in relation to the share of tourists to be 4.1%, which increases to 5.1% when excluding local residents. Our analysis suggests that, in the absence of tools preventing the spread of infection, changes in population density due to economic activities trigger the pandemic spreading in previously unaffected locations. This work contributes to the debate on the complex relationship between COVID-19 and the characteristics of locations by providing helpful evidence for risk-prevention policies.

Local and regional factors of spatial differentiation of the excess mortality related to the COVID-19 pandemic in Romania

COVID-19 revealed some major weaknesses and threats that are related to the level of territorial development. In Romania, the manifestation and the impact of the pandemic were not homogenous, which was influenced, to a large extent, by a diversity of sociodemographic, economic, and environmental/geographic factors. The paper is an exploratory analysis focused on selecting and integrating multiple indicators that could explain the spatial differentiation of COVID-19-related excess mortality (EXCMORT) in 2020 and 2021. These indicators include, among others, health infrastructure, population density and mobility, health services, education, the ageing population and distance to the closest urban center. We analyzed the data from local (LAU2) and county level (NUTS3) by applying multiple linear regression and geographically weighted regression models. The results show that mobility and lower social distancing were far more critical factors for higher mortality than the intrinsic vulnerability of the population, at least in the first two years of COVID-19. However, the highly differentiated patterns and specificities of different areas of Romania resulting from the modelling of EXCMORT factors drive to the conclusion that the decision-making approaches should be place-specific in order to have more efficiency in case of pandemics.

The shift of percent excess mortality from zero-COVID policy to living-with-COVID policy in Singapore, South Korea, Australia, New Zealand and Hong Kong SAR

Introduction

With the economic recession and pandemic fatigue, milder viral variants and higher vaccine coverage along the time lay the basis for lifting anti-COVID policies to restore COVID-19 normalcy. However, when and how to adjust the anti-COVID policies remain under debate in many countries.

Methods

In this study, four countries (Singapore, South Korea, Australia, and New Zealand) and one region (Hong Kong SAR), that have shifted from the zero-COVID (ZC) policy to or close to the living-with-COVID (LWC) during or after the Omicron outbreak, were selected as research objects. All-cause mortality data were collected for these objects from 2009 to 2019. The expected mortality was estimated by a simple linear regression method. Excess mortality over time was calculated as the difference between the expected mortality and the observed mortality. Finally, percent excess mortality (PEM) was calculated as the excess mortality divided by the expected mortality.

Results

In the examined four countries, PEM fluctuated around 0% and was lower than 10% most of the time under the ZC policy before 2022. After shifting to the LWC policy, all the examined countries increased the PEM. Briefly, countries with high population density (Singapore and South Korea) experienced an average PEM of 20-40% during the first half of 2022, and followed by a lower average PEM of 15-18% during the second half of 2022. For countries with low population density under the LWC policy, Australia experienced an average PEM of 39.85% during the first half of 2022, while New Zealand was the only country in our analysis that achieved no more than 10% in average PEM all the time. On the contrary, Hong Kong SAR under their ZC policy attained an average PEM of 71.14% during the first half of 2022, while its average PEM decreased to 9.19% in the second half of 2022 with LWC-like policy.

Conclusion

PEM under different policies within each country/region overtime demonstrated that the mortality burden caused by COVID-19 had been reduced overtime. Moreover, anti-COVID policies are suggested to control the excess mortality to achieve as low as 10% in PEM.

How Anaesthesiology Helped to Fight the First Wave of the COVID-19 Pandemic in Portugal

INTRODUCTION

The dissemination of the COVID-19 pandemic in Europe, namely in Portugal, demanded an organizational and clinical reaction from the Portuguese National Health Service. With the unpredictable impact of COVID-19 infected patients redefining hospital logistics, reducing non-priority elective care and extending the hospital capacity for critical care patients made mobilizing a significant part of human resources a priority. We conducted a national survey to monitor the contribution and the role of anaesthesiologists belonging to the 53 Portuguese National Health Service hospitals in the first wave fight against the pandemic.

MATERIAL AND METHODS

This prospective cross-sectional observational study used a weekly survey sent to the Directors of the Anaesthesiology Departments of all Portuguese National Health Service hospitals, between the period of 13th April and 21st June 2020. Directors were asked about human resources, hospital logistics, anaesthetic activity and residency programs in their departments as well as contingency plans facing the impact of the pandemic growth in the PNHS.

RESULTS

Contingency strategy for all Portuguese National Health Service hospitals planned for a total of 1524 level III critical care beds during the initial phases of the pandemic, an increase of 151% from the existing 607 level III critical care beds in Portugal in January 2020. This re-configuration effort of the Portuguese National Health Service was only possible due to the partial or total suspension of non-urgent elective activity that reached over 90% of these institutions in the first pandemic months (March and April) and the deployment of anaesthesiologists from their normal activities to the treatment of critical care patients. During the peak of the first pandemic wave, 209 anaesthesiology specialists and 170 trainees (22.9% of the total anaesthesiologist's staff in the Portuguese National Health Service) were deployed in critical care. There was an almost complete interruption of the residency program rotation in 70.4% of hospitals with anaesthesiology residents, between March and April 2020.

CONCLUSION

During the first pandemic wave there was an effective and fast reorganisation of the Portuguese National Health Service in order to increase level III critical care beds, which might have contributed to the low mortality rates in Portugal. We believe that this could have also been a result of the contribution given by all public anaesthesiology departments.

The Role of Economic Stress, Health Concerns, and Institutional Trust in Supporting Public Protests against COVID-19 Lockdown Measures in Denmark

During the current COVID-19 pandemic, most governments around the world have adopted strict COVID-19 lockdown measures. In Denmark, mainly from January to March 2021, an anonymous protest group called Men in Black organized demonstrations against the Danish COVID-19 lockdown measures in the three major cities in Denmark. Based on an online survey that we carried out in March 2021 in the Danish population aged 16 years and above (n = 2692), we analyze the individual-level factors behind supporting these demonstrations. Based on ordered logit regressions, the results show that being Muslim and being self-employed (business owner) was positively related to supporting the demonstrations, and that age and living in a city municipality was negatively related to supporting the demonstrations. Based on structural equation modeling (SEM), the results showed that the municipal COVID-19 incidence rate mediates the effect of living in a city municipality, that institutional trust mediates the effect of being Muslim, and that COVID-19 health concerns and institutional trust mediate the effect of age. Overall, economic stress among business owners, health concerns, and institutional trust were found to be the main predictors of supporting the demonstrations against the COVID-19 lockdown measures in Denmark.