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

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 (β= −0.21, 95% CI=−0.33, −0.10). Greater capacities related to prevention (β= −0.11, 95% CI= −0.20 to −0.03), detection (β=−0.09, 95% CI= −0.17 to −0.02), response (β = −0.19, 95% CI= −0.32 to −0.05), international commitments (β= −0.17, 95% CI= −0.30 to −0.04) and risk environments (β= −0.30, 95% CI= −0.42 to −0.18) were each associated with lower CMRs. After adjustment for multiple hypotheses, the GHS Index (table 2; β= −0.21, adjusted 95% CI=−0.41, −0.02) and risk environment (β= −0.30, adjusted 95% CI=−0.50, −0.10) remained associated with excess deaths. 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.