Beyond deaths per capita: comparative COVID-19 mortality indicators

BMJ Open. 2021 Mar 10;11(3):e042934. doi: 10.1136/bmjopen-2020-042934.


Objectives: Following well-established practices in demography, this article discusses several measures based on the number of COVID-19 deaths to facilitate comparisons over time and across populations.

Settings: National populations in 186 United Nations countries and territories and populations in first-level subnational administrative entities in Brazil, China, Italy, Mexico, Peru, Spain and the USA.

Participants: None (death statistics only).

Primary and secondary outcome measures: An unstandardised occurrence/exposure rate comparable to the Crude Death Rate; an indirectly age-and-sex standardised rate that can be derived even when the breakdown of COVID-19 deaths by age and sex required for direct standardisation is unavailable; the reduction in life expectancy at birth corresponding to the 2020 number of COVID-19 deaths.

Results: To date, the highest unstandardised rate has been in New York, at its peak exceeding the state 2017 crude death rate. Populations compare differently after standardisation: while parts of Italy, Spain and the USA have the highest unstandardised rates, parts of Mexico and Peru have the highest standardised rates. For several populations with the necessary data by age and sex for direct standardisation, we show that direct and indirect standardisation yield similar results. US life expectancy is estimated to have declined this year by more than a year (-1.26 years), far more than during the worst year of the HIV epidemic, or the worst 3 years of the opioid crisis, and to reach its lowest level since 2008. Substantially larger reductions, exceeding 2 years, are estimated for Panama, Peru, and parts of Italy, Spain, the USA and especially, Mexico.

Conclusions: With lesser demand on data than direct standardisation, indirect standardisation is a valid alternative to adjust international comparisons for differences in population distribution by sex and age-groups. A number of populations have experienced reductions in 2020 life expectancies that are substantial by recent historical standards.

Keywords: COVID-19; public health; statistics & research methods.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Brazil / epidemiology
  • COVID-19 / mortality*
  • China / epidemiology
  • Humans
  • Italy / epidemiology
  • Mexico / epidemiology
  • New York / epidemiology
  • Panama / epidemiology
  • Peru / epidemiology
  • Spain / epidemiology
  • United States / epidemiology