Excess Mortality and Containment Performance During the COVID-19 Pandemic: Evidence From 34 Countries.

Abstract

<b>Objectives.</b> To expand COVID-19 containment indicators to evaluate the relationship between excess mortality and government response. <b>Methods.</b> We developed a longitudinal study analyzing excess mortality, COVID-19 containment, and structural conditions in 34 countries between 2020 and 2022. <b>Results.</b> The average excess mortality ratios of the 34 countries were 1.09, 1.14, and 1.11 in 2020, 2021, and 2022, respectively. Thirteen countries experienced continuous annual rises, while only 2 had consistent annual declines. Top-performing countries significantly reduced excess deaths by 5.7% (b = -0.06; 95% CI [confidence interval] = -0.10, -0.01; <i>P</i> = .02) in 2020 and 12.9% (b = -0.13; 95% CI = -0.17, -0.08; <i>P</i> < .001) in 2021, compared to bottom performers. Middle-performing countries saw reductions of 6.7% (b = -0.07; 95% CI = -0.11, -0.02; <i>P</i> = .01) and 10.6% (b = -0.11; 95% CI = -0.15, -0.06; <i>P</i> < .001). These findings suggest that better containment is associated with fewer excess deaths, even after accounting for preexisting structural differences. <b>Conclusions.</b> The COVID-19 containment indicators' precision emphasizes the association between better containment and lower excess mortality during early and postvaccine development periods. <b>Public Health Implications.</b> Our findings urge governments to utilize new metrics that balance flexibility and strictness for pandemic strategies, informing future policy interventions. (<i>Am J Public Health</i>. 2025;115(9):1518-1528. https://doi.org/10.2105/AJPH.2025.308136).