Belgium Now Has the Highest COVID-19 Death Rate but It Might Not Be Because More People Are Dying From It

Belgium has the world's highest death rate for COVID-19 at 13.4 percent, according to analysis by Johns Hopkins Coronavirus Resource Center. Also known as the case fatality rate, the figure reflects the number of deaths in a population divided by the number of confirmed cases.

Its death rate on Tuesday compares with 13 percent in hard-hit Italy, and 12.8 percent in the U.K. In Britain, a government scientific adviser said the nation may emerge as the worst-affected country in Europe.

In the U.S., the death rate is 4.3 percent, 4 percent in China, and 2.5 percent in Germany, a figure so relatively low it has prompted questions.

So what underlies Belgium's seemingly alarming COVID-19 death rate?

Andrew Preston, reader in microbial pathogenesis at the University of Bath, told Newsweek: "Belgium is only marginally ahead of others in terms of reported fatality rate."

Commenting on how case fatality rates are calculated in general, Preston said variables such as how cases are reported, a country's demography, the connectedness of its population, and the timing of outbreaks and lockdowns all contribute.

Statistics like the case fatality rate can only be calculated using the available data. Countries which test more people are more likely to identify mild cases, explained Preston. And mortality rates are generally higher in places with more older people and those with chronic disease like diabetes and heart disease, which put people at greater risk of dying from COVID-19, he said.

Even the makeup of individual households can make a difference, as "multigenerational households will increase exposure of the vulnerable to infection," said Preston.

Whether hospitals have the capacity and the resources to treat COVID-19 patients also plays a part, Johns Hopkins explained on its website.

Since the COVID-19 pandemic started in the central Chinese city of Wuhan in late 2019, almost 2 million people have been diagnosed with the disease worldwide, according to Johns Hopkins University. Over 127,600 people have died, and almost 501,000 are known to have recovered. The map by Statista below shows that COVID-19 cases have been reported in almost every country and territory around the world.

Of Belgium's population of 11.46 million, more than 33,500 cases have been confirmed since the first was reported in early February, 4,440 have died, and over 7,100 are known to have recovered.

In comparison, 132,210 people have been diagnosed with COVID-19 in Germany since late January, 3,495 have died out of its population of 83 million, and 72,600 have survived.

Dr. Peter Drobac, a physician and specialist in infectious diseases and public health at the Saïd Business School at the University of Oxford, told Newsweek: "We need to be cautious in comparing observed case fatality rates across countries."

"Countries that do more testing, like Germany and South Korea, will have lower reported fatality rates because they are closer to counting the true number of cases in the denominator," he said.

Both South Korea and Germany rolled out comparatively widespread testing early on in their outbreaks. Experts have previously told Newsweek that, used in the right way, testing can help to control the spread of infectious disease—hence the World Health Organization director-general's mantra "test, test, test."

According to the Oxford University-run Our World in Data website, South Korea, whose outbreak was among the first to surge outside of China, had tested more than 222,000 of its 51.6 million of its citizens by March 11, compared with almost 88,000 in Germany, and 6,000 in Belgium.

As of April 5 (for which the latest data is available) Germany had tested 1.32 million people. On April 14, South Korea (which is viewed as have brought its outbreak under control) had tested over 500,000 people, while as of April 12, Belgium had screened 114,367 people.

"Until recently, Belgium's testing rates were relatively low, which could inflate the reported fatality rate," said Drobac.

"That said, it's clear that COVID-19 has hit Belgium especially hard. Looking at reported deaths per million population, Belgium (337 deaths per million population) is among the highest in the world, on par with Spain (374) and Italy (338)," he said, citing Our World in Data.

"One reason for the high number of fatalities is that the epidemic appears to have hit Belgium's elderly especially hard, particularly in care homes." Similar trends have emerged in France and the U.K.. "Addressing this is an urgent priority in Belgium and elsewhere," said Drobac.

Differences in how countries report COVID-19 deaths can also make it difficult to fairly compare figures like the mortality rate, said Drobac.

"Unlike the U.K. and some parts of the U.S., Belgium has included deaths in nursing homes and other long-term care facilities in its figures. With estimates that up to 50 percent of COVID-19 deaths in Europe happening in care homes that's important."

Preston concluded: "It's actually really difficult to pinpoint any specific factor that might have led to the observed rate in Belgium. I suspect there will be a deluge of studies that will attempt to pull out the key factors, but this will happen once the final figures are known."