Comparison of All-Cause Mortality in England With European Countries and the USA: January 2020 Through to February 2021: A Secondary Analysis of Routine Administrative Data

Abstract

Background: Assessments of mortality continue to inform public health strategies and policy making during the COVID-19 pandemic. All-cause excess mortality is a robust measure of the impact of the pandemic. Our study assesses the relative burden of excess mortality in England during the pandemic compared with 28 European countries and the USA. Methods: Weekly deaths and population estimates were obtained from Eurostat or directly from national statistical and public health agencies. Contextual information on COVID-19 case rates and population-level risk factors were obtained from open-source databases. Weekly directly age-standardised mortality rates (ASMRs) during week 1 2020 to week 7 2021 were calculated and summed cumulatively. These were compared with weekly sums of mean ASMRs observed between 2015 and 2019 and presented relative to the mean cumulative 2015-2019 ASMR averaged over an equivalent period. Findings: By February 2021, England had an overall relative excess mortality of 10·05%. This was the fifth highest out of 29 countries, the USA (14·82%) being the highest. Five countries showed below average mortality, with Norway the lowest (-6·76%). The same statistic for deaths under 65 years showed substantial international variation, with England having the second highest excess of 11·46%. Cumulative COVID-19 case rates explained about half of the international variation in relative excess mortality. Interpretation: England has experienced comparably high all-cause excess mortality during the COVID-19 pandemic. Factors contributing to England’s relative position should be further explored, particularly the association of health inequalities and wider determinants of health on the mortality risk of younger age groups. Funding Information: This study was carried out as part of the PHE’s work during the pandemic and therefore funded by PHE. Declaration of Interests: All authors declare no conflicts of interest. Ethics Approval Statement: This study was carried out as part of the PHE responsibility to manage the COVID-19 pandemic. PHE has legal permission, provided by Regulation 3 of The Health Service (Control of Patient Information) Regulations 2002 to process confidential patient information (http://www.legislation.gov.uk/uksi/2002/1438/regulation/3/made) under Sections 3(i) (a) to (c), 3(i)(d) (i) and (ii) and 3(3) as part of its outbreak response activities. As such this work falls outside the remit for ethical review. The study was subject to an internal review by the PHE Research Ethics and Governance Group and was found to be fully compliant with all regulatory requirements. As a full ethical review is not a requirement for this type of study and as no ethical or regulatory issues had been identified the study was approved.