Evaluation of the Global Health Security Index as a predictor of COVID-19 excess mortality standardised for under-reporting and age structure

Jorge Ricardo Ledesma; Christopher R Isaac; Scott F Dowell; David L Blazes; Gabrielle V Essix; Katherine Budeski; Jessica Bell; Jennifer B Nuzzo

doi:10.1136/bmjgh-2023-012203

Evaluation of the Global Health Security Index as a predictor of COVID-19 excess mortality standardised for under-reporting and age structure

BMJ Glob Health. 2023 Jun;8(7):e012203. doi: 10.1136/bmjgh-2023-012203.

Authors

Jorge Ricardo Ledesma¹, Christopher R Isaac², Scott F Dowell³, David L Blazes³, Gabrielle V Essix², Katherine Budeski⁴, Jessica Bell², Jennifer B Nuzzo^{5

6}

Affiliations

¹ Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA jorge_ledesma@brown.edu.
² Nuclear Threat Initiative, Washington, DC, USA.
³ Bill & Melinda Gates Foundation, Seattle, Washington, USA.
⁴ Nuffield College of Medicine, Oxford University, Oxford, UK.
⁵ Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.
⁶ Pandemic Center, Brown University School of Public Health, Providence, Rhode Island, USA.

Abstract

Background: Previous studies have observed that countries with the strongest levels of pandemic preparedness capacities experience the greatest levels of COVID-19 burden. However, these analyses have been limited by cross-country differentials in surveillance system quality and demographics. Here, we address limitations of previous comparisons by exploring country-level relationships between pandemic preparedness measures and comparative mortality ratios (CMRs), a form of indirect age standardisation, of excess COVID-19 mortality.

Methods: We indirectly age standardised excess COVID-19 mortality, from the Institute for Health Metrics and Evaluation modelling database, by comparing observed total excess mortality to an expected age-specific COVID-19 mortality rate from a reference country to derive CMRs. We then linked CMRs with data on country-level measures of pandemic preparedness from the Global Health Security (GHS) Index. These data were used as input into multivariable linear regression analyses that included income as a covariate and adjusted for multiple comparisons. We conducted a sensitivity analysis using excess mortality estimates from WHO and The Economist.

Results: The GHS Index was negatively associated with excess COVID-19 CMRs (table 2; β= -0.21, 95% CI= -0.35 to -0.08). Greater capacities related to prevention (β= -0.11, 95% CI= -0.22 to -0.00), detection (β= -0.09, 95% CI= -0.19 to -0.00), response (β = -0.19, 95% CI= -0.36 to -0.01), international commitments (β= -0.17, 95% CI= -0.33 to -0.01) and risk environments (β= -0.30, 95% CI= -0.46 to -0.15) were each associated with lower CMRs. Results were not replicated using excess mortality models that rely more heavily on reported COVID-19 deaths (eg, WHO and The Economist).

Conclusion: The first direct comparison of COVID-19 excess mortality rates across countries accounting for under-reporting and age structure confirms that greater levels of preparedness were associated with lower excess COVID-19 mortality. Additional research is needed to confirm these relationships as more robust national-level data on COVID-19 impact become available.

Keywords: COVID-19; Health policy; Health systems.

MeSH terms

COVID-19*
Global Health
Humans
Income
Pandemics