In a recent study posted to the medRxiv* pre-print server, a team of researchers assessed the association between excess coronavirus disease 2019 (COVID-19) mortalities with vaccination rate, and regulation enforcement, in Eastern European countries that witnessed high COVID-19 mortalities throughout 2021.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was introduced to the Eastern European countries later than the Western European countries. In the first half of 2020, public health measures proved quite effective in controlling COVID-19 but by autumn-winter 2020, COVID-19 mortality in Eastern Europe was noticeably higher than in most Western European countries, and the trend continued throughout 2021. Moreover, vaccination campaigns started at almost the same time in both regions; vaccination rates, however, remained comparatively lower in Eastern Europe.
Although excess death/mortality rate is a complex indicator of the true impact of the pandemic across a population, it is a better comparative measure, especially in the long term, for countries having disparate health systems and surveillance resources.
About the study
In the present study, researchers examined whether poorer implementation of public health measures and vaccination programs resulted in higher excess mortality rates in Eastern European countries. The analyses included 50 countries of the World Health Organization (WHO) European region and the USA and Canada.
The researchers reported excess deaths, calculated as observed deaths minus expected deaths per 1,00,000 population, from 1 January 2020 to 2 January 2022 based on the data retrieved from the “Our World In Data” database. The researchers made expected death estimates from the average of the country-reported deaths in the past five years.
The study reported vaccination data for the period 10-15 January 2022 and vaccination rate as the percentage of the total population who had received at least two doses of the COVID-19 vaccine.
The World of Justice Project (WJP) Rule of Law Index measures regulatory enforcement, a standardized indicator of how well government regulations, such as public health requirements, are implemented under different situations. The study used this component as an index item with values between 0 and 1. A score of 1 indicated the most effective regulation enforcement to mitigate the pandemic. The analysis scores were converted into point percentages for meaningful interpretation of linear regression data.
Outpatient visits (per capita/year), data for which was retrieved from the WHO dataset, was also included in the study analyses to check for patterns in the healthcare system utilization. The researchers used computed Pearson’s correlation coefficients, including p-values, between the pairs of variables, whereas to assess the independent association between excess death (outcome variable) and other explanatory variables, they used multiple linear regression analysis.
As of 2 January 2022, the mean excess mortality rate in 50 countries was close to 326±222 deaths per 1,00,000 population. Likewise, mean vaccination rate, mean regulation enforcement and mean outpatient visits were 59%±18%, 65±15 points percentage, and 6.3±2.5, respectively.
The authors noted an inverse correlation of excess death rate with regulation enforcement and vaccination coverage. However, no correlation was observed between outpatient visits and these three variables.
Notably, regardless of regulation enforcement and health care utilization, the excess mortality rate increased by 4.1/1,00,000 for every percent decrease in vaccination rate. For every unit less in the regulatory implementation index score, excess mortality increased at the rate of 6/1,00,000. Overall, three variables – regulation enforcement, vaccination coverage, and outpatient visits – explained 62% of the variability of excess COVID-19 mortality in Eastern European countries.
The present study accounted for regulation enforcement differences to provide insights into the impact of socio-political factors influencing the management of the COVID-19 pandemic-induced crisis. The results revealed that government-implemented non-pharmaceutical interventions and vaccination programs were more effective in the Western European societies. In Eastern Europe, although urgent short-term measures were effective in preventing deaths, over the longer term, socio-political factors took precedence and impacted mitigation of the COVID-19 pandemic.
The results showed an independent correlation between the degree of enforcement of government regulations and excess COVID-19 mortality observed during 2020 and 2021. As expected, poor implementation of social distancing measures and mask-wearing mandates must have directly affected mortality, especially during the pre-vaccine era. In the second half of 2020, when the effect of vaccination was not pronounced, again excess COVID-19 mortality was observed in many Eastern European countries.
Many Eastern European countries had adequate vaccine supply, yet their vaccination programs occurred at a slower rate in comparison to the Western European countries. Although public outlook towards government-mandated policies, community trust, and other social factors contributed to a poorer regulation implementation in Eastern Europe, the study focused mainly on major factors associated with regulation enforcement and implementation of vaccination programs.
Nevertheless, the study encouraged more discussion and further research in the policy area of regulation enforcement to effectively mitigate the COVID-19 pandemic. The authors also recommended that implementation enforcement factors duly be taken into account by governments and experts while devising population-wide public health policies and measuring the real-world impact of the COVID-19 intervention measures.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.