Excess Deaths Associated with Rheumatic Heart Disease, Australia, 2013-2017.

During 2013-2017, the mortality rate ratio for rheumatic heart disease among Indigenous versus non-Indigenous persons in Australia was 15.9, reflecting health inequity. Using excess mortality methods, we found that deaths associated with rheumatic heart disease among Indigenous Australians were probably substantially undercounted, affecting accuracy of calculations based solely on Australian Bureau of Statistics data.

A Research Note on Community Resilience Estimates: New U.S. Census Bureau Data With an Application to Excess Deaths From COVID-19.

In this research note, we describe the results of the first validation study of the U.S. Census Bureau's new Community Resilience Estimates (CRE), which uses Census microdata to develop a tract-level vulnerability index for the United States. By employing administrative microdata to link Social Security Administration mortality records to CRE, we show that CRE quartiles provide more stable predictions of COVID-19 excess deaths than single demographic categorizations such as race or age, as well as other vulnerability measures including the U.S. Centers for Disease Control and Prevention's Social Vulnerability Index (SVI) and the Federal Emergency Management Agency's National Risk Index (NRI). We also use machine learning techniques to show that CRE provides more predictive power of COVID-19 excess deaths than standard socioeconomic predictors of vulnerability such as poverty and unemployment, as well as SVI and NRI. We find that a 10-percentage-point increase in a key CRE risk measure is associated with one additional death per neighborhood during the initial outbreak of COVID-19 in the United States. We conclude that, compared with alternative measures, CRE provides a more accurate predictor of community vulnerability to a disaster such as a pandemic.

Short-term forecasts of expected deaths.

We introduce a method for making short-term mortality forecasts of a few months, illustrating it by estimating how many deaths might have happened if some major shock had not occurred. We apply the method to assess excess mortality from March to June 2020 in Denmark and Sweden as a result of the first wave of the coronavirus pandemic; associated policy interventions; and behavioral, healthcare, social, and economic changes. We chose to compare Denmark and Sweden because reliable data were available and because the two countries are similar but chose different responses to COVID-19: Denmark imposed a rather severe lockdown; Sweden did not. We make forecasts by age and sex to predict expected deaths if COVID-19 had not struck. Subtracting these forecasts from observed deaths gives the excess death count. Excess deaths were lower in Denmark than Sweden during the first wave of the pandemic. The later/earlier ratio we propose for shortcasting is easy to understand, requires less data than more elaborate approaches, and may be useful in many countries in making both predictions about the future and the past to study the impact on mortality of coronavirus and other epidemics. In the application to Denmark and Sweden, prediction intervals are narrower and bias is less than when forecasts are based on averages of the last 5 y, as is often done. More generally, later/earlier ratios may prove useful in short-term forecasting of illnesses and births as well as economic and other activity that varies seasonally or periodically.

"The Graves Cannot Be Dug Fast Enough": Excess Deaths Among US Amish and Mennonites During the 1918 Flu Pandemic.

Estimating the lethal impact of a pandemic on a religious community with significant barriers to outsiders can be exceedingly difficult. Nevertheless, Stein and colleagues (2021) developed an innovative means of arriving at such an estimate for the lethal impact of COVID-19 on the Amish community in 2020 by counting user-generated death reports in the widely circulated Amish periodical The Budget. By comparing monthly averages of reported deaths before and during the COVID-19 pandemic, Stein and colleagues were able to arrive at a rough estimate of "excess deaths" during the first year of the pandemic. Our research extends the same research method, applying it to the years during and immediately preceding the global influenza pandemic of 1918. Results show similarly robust findings, including three notable "waves" of excess deaths among Amish and conservative Mennonites in the USA in 1918, 1919, and 1920. Such results point to the promise of utilizing religious periodicals like The Budget as a relatively untapped trove of user-generated data on public health outcomes among religious minorities more than a century in the past.

Undiagnosed Pulmonary Tuberculosis (TB) and Coronavirus Disease 2019 (COVID-19) in Adults Dying at Home in a High-TB-Burden Setting, Before and During Pandemic COVID-19: An Autopsy Study.

BACKGROUND: Missing or undiagnosed patients with tuberculosis (TB) or coronavirus disease 2019 (COVID-19) are of concern. Identifying both infections in patients with no diagnosis prior to death contributes to understanding the burden of disease. To confirm reports of global reduction in TB incidence, a 2012 autopsy study of adults dying at home of natural causes in a high-TB-burden setting was repeated, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) assessments after the first COVID-19 surge in South Africa. METHODS: Adult decedents who died at home with insufficient information to determine cause of death, no recent hospitalization, and no current antemortem TB or COVID-19 diagnosis were identified between March 2019 and October 2020 with a 4-month halt during lockdown. A standardized verbal autopsy followed by minimally invasive needle autopsy (MIA) was performed. Biopsies were taken for histopathology from liver, bilateral brain and lung; bronchoalveolar lavage fluid was collected for Xpert (MTB/RIF) and mycobacterial culture, and blood for human immunodeficiency virus (HIV) polymerase chain reaction (PCR) testing. After the start of the COVID-19 pandemic, a nasopharyngeal swab and lung tissue were subjected to SARS-CoV-2 PCR testing. RESULTS: Sixty-six MIAs were completed in 25 men and 41 women (median age, 60 years); 68.2% had antemortem respiratory symptoms and 30.3% were people with HIV. Overall, TB was diagnosed in 11 of 66 (16.7%) decedents, and 14 of 41 (34.1%) in the COVID-19 pandemic were SARS-CoV-2 positive. CONCLUSIONS: Undiagnosed TB in adults dying at home has decreased but remains unacceptably high. Forty percent of decedents had undiagnosed COVID-19, suggesting that estimates of excess deaths may underestimate the impact of SARS-CoV-2 on mortality.

The Evolution of Excess Deaths in the United States During the First 2 Years of the COVID-19 Pandemic.

Understanding consequences of the COVID-19 pandemic requires information on the excess mortality resulting from it. Multiple studies have examined excess deaths during the pandemic's initial stages, but how these have changed over time is unclear. National- and state-level death counts and population data from 2009 to 2022 were used in this analysis to evaluate excess fatalities from March 2020 to February 2021 and March 2021 to February 2022, with deaths from earlier years used to project baseline counts. The outcomes were total, group-specific, cause-specific, and age-by-cause excess fatalities, and numbers and percentages directly involving COVID-19. Excess deaths declined from 655,735 (95% confidence interval: 619,028, 691,980) during the first pandemic year to 586,505 (95% confidence interval: 532,823, 639,205) in the second. The reductions were particularly large for Hispanics, Blacks, Asians, seniors, and residents of states with high vaccination rates. Excess deaths increased from the first to second year for persons younger than 65 years and in low-vaccination states. Excess mortality from some diseases declined, but those from alcohol, drug, vehicle, and homicide causes likely increased between the first and second pandemic year, especially for prime-age and younger individuals. The share of excess fatalities involving COVID-19 decreased modestly over time, with little change in its role as an underlying versus contributing cause of death.

Flaws and uncertainties in pandemic global excess death calculations.

Several teams have been publishing global estimates of excess deaths during the COVID-19 pandemic. Here, we examine potential flaws and underappreciated sources of uncertainty in global excess death calculations. Adjusting for changing population age structure is essential. Otherwise, excess deaths are markedly overestimated in countries with increasingly aging populations. Adjusting for changes in other high-risk indicators, such as residence in long-term facilities, may also make a difference. Death registration is highly incomplete in most countries; completeness corrections should allow for substantial uncertainty and consider that completeness may have changed during pandemic years. Excess death estimates have high sensitivity to modelling choice. Therefore different options should be considered and the full range of results should be shown for different choices of pre-pandemic reference periods and imposed models. Any post-modelling corrections in specific countries should be guided by pre-specified rules. Modelling of all-cause mortality (ACM) in countries that have ACM data and extrapolating these models to other countries is precarious; models may lack transportability. Existing global excess death estimates underestimate the overall uncertainty that is multiplicative across diverse sources of uncertainty. Informative excess death estimates require risk stratification, including age groups and ethnic/racial strata. Data to-date suggest a death deficit among children during the pandemic and marked socioeconomic differences in deaths, widening inequalities. Finally, causal explanations require great caution in disentangling SARS-CoV-2 deaths, indirect pandemic effects and effects from measures taken. We conclude that excess deaths have many uncertainties, but globally deaths from SARS-CoV-2 may be the minority of calculated excess deaths.

A comprehensive analysis of all-cause and cause-specific excess deaths in 30 countries during 2020.

The impact of COVID-19 on mortality from specific causes of death remains poorly understood. This study analysed cause-of-death data provided by the World Health Organization from 2011 to 2019 to estimate excess deaths in 2020 in 30 countries. Over-dispersed Poisson regression models were used to estimate the number of deaths that would have been expected if the pandemic had not occurred, separately for men and women. The models included year and age categories to account for temporal trends and changes in size and age structure of the populations. Excess deaths were calculated by subtracting observed deaths from expected ones. Our analysis revealed significant excess deaths from ischemic heart diseases (IHD) (in 10 countries), cerebrovascular diseases (CVD) (in 10 countries), and diabetes (in 19 countries). The majority of countries experienced excess mortality greater than 10%, including Mexico (+ 38·8% for IHD, + 34·9% for diabetes), Guatemala (+ 30·0% for IHD, + 10·2% for CVD, + 39·7% for diabetes), Cuba (+ 18·8% for diabetes), Brazil (+ 12·9% for diabetes), the USA (+ 15·1% for diabetes), Slovenia (+ 33·8% for diabetes), Poland (+ 30·2% for IHD, + 19·5% for CVD, + 26 1% for diabetes), Estonia (+ 26·9% for CVD, + 34·7% for diabetes), Bulgaria (+ 22·8% for IHD, + 11·4% for diabetes), Spain (+ 19·7% for diabetes), Italy (+ 18·0% for diabetes), Lithuania (+ 17·6% for diabetes), Finland (+ 13·2% for diabetes) and Georgia (+ 10·7% for IHD, + 19·0% for diabetes). In 2020, 22 out of 30 countries had a significant increase in total mortality. Some of this excess was attributed to COVID-19, but a substantial increase was also observed in deaths attributed to cardiovascular diseases and diabetes.

The impact of COVID-19 shelter-in-place policy responses on excess mortality.

As a way of slowing COVID-19 transmission, many countries and U.S. states implemented shelter-in-place (SIP) policies. However, the effects of SIP policies on public health are a priori ambiguous. Using an event study approach and data from 43 countries and all U.S. states, we measure changes in excess deaths following the implementation of COVID-19 shelter-in-place (SIP) policies. We do not find that countries or U.S. states that implemented SIP policies earlier had lower excess deaths. We do not observe differences in excess deaths before and after the implementation of SIP policies, even when accounting for pre-SIP COVID-19 death rates.

Impacts of the COVID-19 pandemic on life expectancy at birth in Asia.

OBJECTIVE: To investigate the impact of the COVID-19 pandemic on life expectancy at birth (e0) for 51 Asian countries and territories from January 1, 2020 to December 31, 2021. METHOD: Based on age-sex-specific mortality used for estimating the changes in e0 for years 2019, 2020, and 2021 from the 2022 revision of the World Population Prospects, we employed Arriaga's discrete method to decompose changes in e0 into both absolute and relative contributions of changes in age-specific death rate, and further obtained the age-sex-specific contribution to changes in e0 by country/territory and period (i.e., 2019-2020 and 2020-2021) for Asia. FINDINGS: The COVID-19 pandemic reduced 1.66 years in e0 of the Asian population from 2019 to 2021, slightly lower than the world average of 1.74 years. South Asia had a high loss of 3.01 years, whereas Eastern Asia had almost no changes. Oman, Lebanon, India, Armenia, Azerbaijan, Indonesia, and the Philippines experienced a high loss of above 2.5 years in e0. Despite significant national and territorial variations, the decline of e0 in Asia was mostly from the age group of 60-79 years, followed by age groups of 80 + and 45-59 years; and age groups of children contributed little (i.e., 0-4 and 5-14 years old). Males suffered more losses than females in this pandemic. Asian nations saw less loss in e0 in the second year of the pandemic, i.e., 2020-2021, than in the first year, i.e., 2019-2020, but this recovery trend was not observed in Southern Asia and South-Eastern Asia. Countries from Central Asia and Western Asia, such as Kazakhstan, Armenia, Azerbaijan, Lebanon, and Oman, had extraordinarily more losses in e0 in the first year at ages around 70. CONCLUSION: The COVID-19 pandemic had significantly affected e0 of Asian populations, and most contribution to the reduction of e0 came from the three older age groups, 60-79 years, 80 + years, and 45-59 years, with great variations across countries/territories. Our findings could have important implications for development of more resilient public health systems in Asian societies with better policy interventions for vulnerable demographic groups.

Deaths during the first year of the COVID-19 pandemic: insights from regional patterns in Germany and Poland.

BACKGROUND: Given the nature of the spread of SARS-CoV-2, strong regional patterns in the fatal consequences of the COVID-19 pandemic related to local characteristics such as population and health care infrastructures were to be expected. In this paper we conduct a detailed examination of the spatial correlation of deaths in the first year of the pandemic in two neighbouring countries - Germany and Poland, which, among high income countries, seem particularly different in terms of the death toll associated with the COVID-19 pandemic. The analysis aims to yield evidence that spatial patterns of mortality can provide important clues as to the reasons behind significant differences in the consequences of the COVID-19 pandemic in these two countries. METHODS: Based on official health and population statistics on the level of counties, we explore the spatial nature of mortality in 2020 in the two countries - which, as we show, reflects important contextual differences. We investigate three different measures of deaths: the officially recorded COVID-19 deaths, the total values of excessive deaths and the difference between the two. We link them to important pre-pandemic regional characteristics such as population, health care and economic conditions in multivariate spatial autoregressive models. From the point of view of pandemic related fatalities we stress the distinction between direct and indirect consequences of COVID-19, separating the latter further into two types, the spatial nature of which is likely to differ. RESULTS: The COVID-19 pandemic led to much more excess deaths in Poland than in Germany. Detailed spatial analysis of deaths at the regional level shows a consistent pattern of deaths officially registered as related to COVID-19. For excess deaths, however, we find strong spatial correlation in Germany but little such evidence in Poland. CONCLUSIONS: In contrast to Germany, for Poland we do not observe the expected spatial pattern of total excess deaths and the excess deaths over and above the official COVID-19 deaths. This difference cannot be explained by pre-pandemic regional factors such as economic and population structures or by healthcare infrastructure. The findings point to the need for alternative explanations related to the Polish policy reaction to the pandemic and failures in the areas of healthcare and public health, which resulted in a massive loss of life.

Changes in cerebrovascular disease-related deaths and their location during the COVID-19 pandemic in Japan.

OBJECTIVE: The COVID-19 pandemic placed an enormous strain on healthcare systems and raised concerns for delays in the management of patients with acute cerebrovascular events. In this study, we investigated cerebrovascular excess deaths in Japan. STUDY DESIGN: Vital mortality statistics from January 2012 to May 2022 were obtained from the Japanese Ministry of Health, Labour and Welfare. METHODS: Using quasi-Poisson regression models, we estimated the expected weekly number of cerebrovascular deaths in Japan from January 2020 through May 2022 by place of death. Estimates were calculated for deaths in all locations, as well as for deaths in hospitals, in geriatric health service facilities, and at home. The age subgroups of ≥75 and <75 years were also considered. Weeks with a statistically significant excess of cerebrovascular deaths were determined when the weekly number of observed deaths exceeded the upper bound of 97.5% prediction interval. RESULTS: Excess deaths were noted in June 2021 and became more pronounced from February 2022 onward. The trend was notable among those aged ≥75 years and for those who died in hospitals. With respect to the location of deaths, the excess was significant in geriatric health services facilities from April 2020 to June 2021, whereas no evidence of excess hospital deaths was observed during the same period. CONCLUSIONS: Beginning in the late 2021, excess cerebrovascular deaths coincided with the spread of the Omicron variant and may be associated with increased healthcare burden. In 2020, COVID-19 altered the geography of cerebrovascular deaths, with fewer people dying in hospitals and more dying in geriatric health service facilities and at home.

The end of the COVID-19 pandemic.

There are no widely accepted, quantitative definitions for the end of a pandemic such as COVID-19. The end of the pandemic due to a new virus and the transition to endemicity may be defined based on a high proportion of the global population having some immunity from natural infection or vaccination. Other considerations include diminished death toll, diminished pressure on health systems, reduced actual and perceived personal risk, removal of restrictive measures and diminished public attention. A threshold of 70% of the global population having being vaccinated or infected was probably already reached in the second half of 2021. Endemicity may still show major spikes of infections and seasonality, but typically less clinical burden, although some locations are still hit more than others. Death toll and ICU occupancy figures are also consistent with a transition to endemicity by end 2021/early 2022. Personal risk of the vast majority of the global population was already very small by end 2021, but perceived risk may still be grossly overestimated. Restrictive measures of high stringency have persisted in many countries by early 2022. The gargantuan attention in news media, social media and even scientific circles should be tempered. Public health officials need to declare the end of the pandemic. Mid- and long-term consequences of epidemic waves and of adopted measures on health, society, economy, civilization and democracy may perpetuate a pandemic legacy long after the pandemic itself has ended.

Examination of Gender Difference in Heart Disease-Related Excess Deaths during COVID-19 Pandemic Era: Findings from the United States.

Background/Objective: Heart disease is the leading cause of death among women in the United States, and women are experiencing more strokes at younger ages than men. Despite accumulating evidence of increased burden of heart disease among women, there is little data on gender difference in heart disease-related mortality during the COVID-19 pandemic. Method: This study extracted the data of weekly number of deaths between January 2017 and December 2020 from the United States Center for Disease and Control and Prevention (CDC) mortality and morbidity data, modified to a monthly scale. Stratified by gender, the study applied the Farrington method on monthly data to calculate excess number of deaths. Excess heart disease-related deaths were observed in March and July 2020 for both males and females. Results: While the overall number of heart disease-related deaths was higher in men than women among US population < 75 years old, a greater rate increase of heart disease-related deaths in 2020 from 2019 was observed among women than men. This increased burden was more pronounced among young women < 25 years old. A similar pattern of excess deaths caused by underlying heart disease condition was observed for both genders during COVID-19 pandemic. On the other hand, increase in heart disease-related death burden in 2020 from 2019 was greater amongst females than males. This may be partially accounted for by deferred cardiovascular care and prevention amongst women during the pandemic. Conclusions: While no gender difference was observed in excess deaths caused by underlying heart disease condition, females faced a greater increase in heart disease-related death burden during the pandemic compared to pre-pandemic than males.

Excess deaths in the United States during the first year of COVID-19.

Accurately determining the number of excess deaths caused by the COVID-19 pandemic is hard. The most important challenge is determining the counterfactual count of baseline deaths that would have occurred in its absence. Flexible estimation methods were used here to provide this baseline number and plausibility of the resulting estimates was evaluated by examining how changes between baseline and actual prior year deaths compared to historical year-over-year changes during the previous decade. Similar comparisons were used to examine the reasonableness of excess death estimates obtained in prior research. Total, group-specific and cause-specific excess deaths in the U.S. from March 2020 through February 2021 were calculated using publicly available data covering all deaths from March 2009 through December 2020 and provisional data for January 2021 and February 2021. The estimates indicate that there were 649,411 (95% CI: 600,133 to 698,689) excess deaths in the U.S. from 3/20-2/21, a 23% (95% CI: 21%-25%) increase over baseline, with 82.9% (95% CI: 77.0% - 89.7%) of these attributed directly to COVID-19. There were substantial differences across population groups and causes in the ratio of actual-to-baseline deaths, and in the contribution of COVID-19 to excess mortality. Prior research has probably often underestimated baseline mortality and so overstated both excess deaths and the percentage of them attributed to non-COVID-19 causes.

Years of life lost during the Covid-19 pandemic in Sweden considering variation in life expectancy by level of geriatric care.

The Covid-19 pandemic has not affected the population evenly. This must be acknowledged when it comes to understanding the Covid-19 death toll and answering the question of how many life years have been lost. We use level of geriatric care to account for variation in remaining life expectancy among individuals that died during 2020. Based on a linkage of administrative registers, we estimate remaining life expectancy stratified by age, sex, and care status using an incidence-based multistate model and analyze the number of years of life lost (YLL) during 2020 in Sweden. Our results show that remaining life expectancy between individuals with and without care differs substantially. More than half of all Covid-19 deaths had a remaining life expectancy lower than 4 years. Yet, in a 1-year perspective, Covid-19 did not seem to replace other causes of death. Not considering the differences in remaining life expectancy in the affected populations overestimated YLL by 40% for women and 30% for men, or around 2 years per death. While the unadjusted YLL from Covid-19 amounted to an average of 7.5 years for women and 8.6 years for men, the corresponding YLL adjusted for care status were 5.4 and 6.6, respectively. The total number of YLL to Covid-19 in 2020 is comparable to YLL from ischemic heart disease in 2019 and 2020. Our results urge the use of subgroup specific mortality when counting the burden of Covid-19. YLL are considerably reduced when the varying susceptibility for death is considered, but even if most lifespans were cut in the last years of life, the YLL are still substantial.

High excess deaths in Sweden during the first wave of COVID-19: Policy deficiencies or 'dry tinder'?

AIMS: During the first wave of the COVID-19 pandemic, Sweden registered a high level of excess deaths. Non-pharmaceutical interventions adopted by Sweden have been milder compared to those implemented in Denmark. Moreover, Sweden might have started the pandemic with a large proportion of vulnerable elderly with a high mortality risk. This study aimed to clarify whether excess mortality in Sweden can be explained by a large stock of 'dry tinder' instead of being attributed to faulty lockdown policies. METHODS: We analysed weekly death counts in Sweden and Denmark from July 2007 to June 2020. We used a novel method for short-term mortality forecasting to estimate expected and excess deaths during the first COVID-19 wave in Sweden and Denmark. RESULTS: In the first part of the epiyear 2019-2020, deaths were low in both Sweden and Denmark. In the absence of COVID-19, a relatively low level of death would be expected for the later part of the epiyear. The registered deaths were, however, way above the upper bound of the prediction interval in Sweden and within the range in Denmark. CONCLUSIONS: 'Dry tinder' can only account for a modest fraction of excess Swedish mortality. The risk of death during the first COVID-19 wave rose significantly for Swedish women aged >85 but only slightly for Danish women aged >85. The risk discrepancy seems more likely to result from differences between Sweden and Denmark in how care and housing for the elderly are organised, coupled with a less successful Swedish strategy of shielding the elderly.

Excess mortality associated with the COVID-19 pandemic in Latvia: a population-level analysis of all-cause and noncommunicable disease deaths in 2020.

BACKGROUND: Age-standardised noncommunicable disease (NCD) mortality and the proportion of the elderly population in Latvia are high, while public health and health care systems are underresourced. The emerging COVID-19 pandemic raised concerns about its detrimental impact on all-cause and noncommunicable disease mortality in Latvia. We estimated the timing and number of excess all-cause and cause-specific deaths in 2020 in Latvia due to COVID-19 and selected noncommunicable diseases. METHODS: A time series analysis of all-cause and cause-specific weekly mortality from COVID-19, circulatory diseases, malignant neoplasms, diabetes mellitus, and chronic lower respiratory diseases from the National Causes of Death Database from 2015 to 2020 was used by applying generalised additive modelling (GAM) and joinpoint regression analysis. RESULTS: Between weeks 14 and 52 (from 1 April to 29 December) of 2020, a total of 3111 excess deaths (95% PI 1339 - 4832) were estimated in Latvia, resulting in 163.77 excess deaths per 100 000. Since September 30, with the outbreak of the second COVID-19 wave, 55% of all excess deaths have occurred. Altogether, COVID-19-related deaths accounted for only 28% of the estimated all-cause excess deaths. A significant increase in excess mortality was estimated for circulatory diseases (68.91 excess deaths per 100 000). Ischemic heart disease and cerebrovascular disease were listed as the underlying cause in almost 60% of COVID-19-contributing deaths. CONCLUSIONS: All-cause mortality and mortality from circulatory diseases significantly increased in Latvia during the first pandemic year. All-cause excess mortality substantially exceeded reported COVID-19-related deaths, implying COVID-19-related mortality during was significantly underestimated. Increasing mortality from circulatory diseases suggests a negative cumulative effect of COVID-19 exposure and reduced access to healthcare services for NCD patients.

Particulate matter and COVID-19 excess deaths: Decomposing long-term exposure and short-term effects.

We investigate the time-varying effect of particulate matter (PM) on COVID-19 deaths in Italian municipalities. We find that the lagged moving averages of PM2.5 and PM10 are significantly related to higher excess deceases during the first wave of the disease, after controlling, among other factors, for time-varying mobility, regional and municipality fixed effects, the nonlinear contagion trend, and lockdown effects. Our findings are confirmed after accounting for potential endogeneity, heterogeneous pandemic dynamics, and spatial correlation through pooled and fixed-effect instrumental variable estimates using municipal and provincial data. In addition, we decompose the overall PM effect and find that both pre-COVID long-term exposure and short-term variation during the pandemic matter. In terms of magnitude, we observe that a 1 µg/m3 increase in PM2.5 can lead to up to 20% more deaths in Italian municipalities, which is equivalent to a 5.9% increase in mortality rate.

Effects of country success on COVID-19 cumulative cases and excess deaths in 169 countries.

COVID-19 has caused over 260 million confirmed cases and over 5 million deaths globally. The results of statistical and multiple criteria analyses on the success of 169 countries and on COVID-19 cumulative cases and excess deaths show that the prosperity of a country relates directly to the consequences due to the pandemic. The topic of this article is the Country Success and COVID-19 (CSC) Map of the World. As a country's success grows, this map shows how cumulative cases of COVID-19 increase; at the same time, excess deaths decrease. The indicators in the system of criteria regarding country success and sustainability are interrelated. Conditional country successes remain quite similar, despite changes to the numbers of countries and their indicators. Likewise, the seven clusters of countries under consideration group together independently of which system of indicators had been applied for their analysis. The 2020 Inglehart-Welzel Cultural Map of the World, which is grounded on surveys, and the CSC Map, which is grounded on statistical indicators, have axes that correlate with one another significantly. The CSC Map Model explains over 63% of the dispersions pertinent to COVID-19 cumulative cases, over 52% of COVID-19 excess deaths, and over 95% of country success variables. The layout of the clusters on the CSC Map changes little over time. Upon performance of the correlation analysis, it was established that strong and statistically significant relationships exist between 169 countries success and sustainability linked with their current air quality score (r = 0.602, p < 0.01) and the environmental performance index (EPI) score (r = 0.931, p < 0.01). The results obtained show that when a country's EPI score and current air quality improve by 1%, excess deaths decrease, respectively, by 2.33 and 1.55%. Global integrated analysis on country successes, COVID-19 cumulative cases, and excess deaths comprise this study.