Mortality from COVID-19: A cross-country comparison of containment versus mitigation strategy

World Health Organization declared coronavirus disease 2019 (COVID-19) a global pandemic on March 12, 2020 amid its rapid spread throughout Europe.¹ Italy, Spain, United Kingdom, and France initially responded to large outbreaks with a “mitigation” strategy which aims to reduce death tolls through focusing on medical care of severe cases while relying on social distancing to flatten the curve of epidemic impact on healthcare systems.² In contrast, Germany decided to apply a “containment” strategy aiming to break the chain of transmission through a combination of aggressive test-and-isolate policy (identify and isolate all infectious persons, including those with mild illness) and social distancing measures.³ Given the similarity in epidemic stage, population size, age distributions, socioeconomic situations, and healthcare systems between Germany and other European countries, a cross-country outcome comparison provides important insights for formulating a global strategy for COVID-19 pandemic.

We analyzed COVID-19-related mortality rates of Italy, Spain, United Kingdom, and France (mitigation strategy) and that of Germany (containment strategy). All have a similar epidemic curves and cumulative number of confirmed COVID-19 cases (Fig. 1 ). However, Germany has a cumulative death toll and case fatality rate approximately one-fourth of that of countries adopting a mitigation strategy (Fig. 1). In term of mortality rate per 100,000 population, the difference is even more remarkable (see Fig. 1 legend for details).

Figure 1.

Country-specific COVID-19 epidemic curves and population mortality rates (data based on https://www.worldometers.info/coronavirus/). Black circle shows the numbers of daily new confirmed cases in logarithmic scale. Red triangle shows cumulative mortality rate per 100,000 population. (A) Countries experienced large COVID-19 outbreaks and initially responded with a mitigation strategy. (B) Countries experienced large COVID-19 outbreaks and responded with a containment strategy. A comparison of (A) and (B) shows that Italy, Spain, France, the United Kingdom, and Germany all had a similar epidemic curve and cumulative number of confirmed COVID-19 cases by May 3, 2020. Nevertheless, Germany had a total death toll and case fatality rate approximately one-fourth of that of countries adopting a mitigation strategy (Germany: 6866 [4.1%] vs. Italy: 28,884 [13.7%]; Spain: 25,264 [10.2%]; United Kingdom: 28,446 [15.2%]; and France: 24,895 [14.8%], by May 3, 2020). In term of mortality rate per 100,000 population, the difference is even more remarkable (Germany: 8.2 in contrast to Italy: 47.8; Spain: 54.0; United Kingdom: 41.9; and France: 38.1; by May 3, 2020). (C) Countries initially did not experience a large COVID-19 outbreak: Japan (responded with a mitigation strategy) versus Taiwan (responded with a containment strategy). By May 3, 2020, Japan suffered a large COVID-19 outbreak, while Taiwan did not (cumulative confirmed cases: 14,877 vs. 432). Japan also had a population mortality rate 15-fold higher than that in Taiwan (0.385 vs. 0.025 per 100,000 population).

A major reason for the sharp difference in case fatality rate is, of course, that confirmed cases in Germany included mild cases detected under containment strategy, while confirmed cases in the other four countries consisted of severe cases who are the focus of mitigation strategy. However, the remarkably lower COVID-19-related mortality rate in population indicates that Germany is more successful in limiting the spread of COVID-19 and related death tolls than countries adopting mitigation strategy.

The number of healthcare workers died from COVID-19 is another indicator.⁴ Germany lost only 1 healthcare worker by May 3, 2020. In contrast, Italy lost 110, United Kingdom lost 92, Spain lost 28, and France lost 21 healthcare workers from COVID-19 during the same period.

The low death tolls in both patients and healthcare workers in Germany is not a unique case for countries adopting a containment strategy. South Korea,⁵ another country responded to large outbreaks with containment strategy, also has a very low death toll (252), case fatality rate (2.3%), population mortality rate (0.5 per 100,000 population), and number of healthcare workers died from COVID-19 (only 1) (Fig. 1).

For countries initially did not experience large outbreaks, containment strategy (Taiwan) also yield a 15-fold lower population mortality rate than that yielded by mitigation strategy (Japan) (0.025 vs. 0.385 per 100,000 population) (Fig. 1).

Without access to individual data, including age, comorbidities, timing of diagnosis, and types of treatment, our analysis is limited by its ecological nature. Nevertheless, the worse COVID-19-related mortality outcomes in population in all studied five major countries which adopting a mitigation strategy raises an alarming possibility that such strategy could be inferior to containment strategy, which might be the preferred global strategy against the COVID-19 pandemic.

Author contributions

YHC initiated this study, collected the data, conducted the analysis, and wrote the first draft; CTF supervised this study and finalized the manuscript.

Declaration of Competing Interest

The authors have no conflicts of interest relevant to this article.