Abstract
Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic
has had a variable worldwide impact, likely related to country-level
characteristics. In this ecological study, we explored the association
of COVID-19 case rates (per 100,000 people) and death rates (per 100,000
people) with country-level population health characteristics, economic
and human development indicators, and habitat-related variables.
Methods: To calculate country-level COVID-19 case and death
rates, the number of cases and deaths were extracted from the Johns
Hopkins Coronavirus Resource Center for 2020. Country-level population
health characteristics, economic and human development indicators, and
habitat-related variables were extracted from several publicly available
online sources of international organizations. Results were tabulated
according to world zones and country economies. Univariate and
multivariable linear regression analyses were performed to examine
determinants of COVID-19 case rates and death rates. Results: A
total of 187 countries and territories were analyzed, with an aggregate
COVID-19 case rate of 779 per 100,000 people, a death rate of 19 per
100,000 people, and a case-fatality rate of 2.4%. For country-level
population health characteristics, a higher percentage rate of adults
with obesity and a higher percentage rate of adults with high blood
pressure was independently associated with a higher COVID-19 case rate,
and a higher percentage rate of adults with obesity was associated with
a higher COVID-19 death rate. For country-level economic and human
development indicators, only a higher gross domestic product percentage
rate spent on total health expenditure and a higher human development
index was independently associated with a higher COVID-19 case rate and
death rate. A higher percentage of urban population was independently
associated with a higher COVID-19 death rate, whereas a higher income
per capita was independently associated with a lower COVID-19 death
rate. For country-level habitat-related variables, a higher average
household size and a higher percentage rate of population with primary
reliance on polluting fuels and technologies was independently
associated with a lower COVID-19 case rate and death rate whereas a
higher percentage rate of households with at least one-member age 65
years or over was associated with a higher case rate and death rates.
Conclusion: This ecological study informs the need to develop
country-specific public health interventions to better target
populations at high risk for COVID-19, and test environmental
interventions to prevent indoor transmission of SARS-CoV-2, taking into
consideration population health characteristics, economic and human
development indicators, and habitat-related variables that are unique to
each country.