At the time of writing this article, based on worldometers, a website that tracks all coronavirus cases, there are a total of 115,000 confirmed cases and 13,900 deaths in Italy. As per this data, fatality rate or death rate is around 12%. The death rate in other countries across the globe is around 2%-5%. It is evident that death rate in Italy is significantly higher than most of the other countries.
A study published in JAMA evaluates and attributes this higher fatality rate to a few factors that make Italy unique when compared to other countries. The most crucial factor that contributed to this high death rate is the average age of the population. In 2019, as per the United Nations, about 23% of Italians were aged 65 years or older compared to 16% of the Americans. The median age in Italy is 47.3 years when compared to 38.3 years in the United States. Death rate for COVID-19 rises steeply in older population. Increased death rate in older population is well documented in several research studies. In Italy, death rate for people from 70-79 years was 13% and for people above 80 years was 20%. In China, death rate for people from 70-79 years was only 8% and above 80 years was around 15%. When compared to China, death rate is higher in Italy among individuals aged 70 years or older. This is probably because of the differences in the case distribution in these two countries. In Italy, 37.6% of the affected people were 70 years or older while in China it was only 11.9%. As more older people are affected in Italy, death rate is also higher in Italy when compared to the other countries.
Another factor that may have contributed to a higher death rate in Italy is how COVID-19 related deaths are identified in Italy. There is no clear criteria for the definition of COVID-19 related deaths. Even if the affected individuals already have a pre-existing terminal condition, if they have confirmed COVID-19 causing mild illness, deaths are attributed to COVID-19.
During a pandemic, any healthcare system will become crippled. Care delivered may not be optimum with limited resources and an overwhelming number of cases. Italy has already been practicing military triaging, where infected elderly patients with multiple underlying chronic health conditions who may not survive are turned towards palliative care without making any attempt to save them. This also may have played some role in a higher death rate.
The last significant factor affecting the death rate in Italy is how many people are actually tested for COVID-19. Fatality rate is calculated by dividing number of deaths by total number of confirmed cases. During a pandemic, several affected individuals with mild illness may not be tested. When mildly affected individuals are not tested, death rate may seem to be falsely higher.
Death rate due to COVID-19 in Spain is also higher at around 9%. Population above 65 years of age in Spain is around 20%. Even in Spain, the above similar factors may be playing a role in high mortality rate.
Onder G et al. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. 2020 Mar 23. doi: 10.1001/jama.2020.4683.