Quality-adjusted life years lost due to excess mortality during COVID-19: a cross-national analysis

Background

Accurately assessing the health impact of the COVID-19 pandemic requires metrics beyond unadjusted mortality counts. This study quantifies mortality-based Quality-Adjusted Life Years (QALYs) and Years of Life Lost (YLL) for 38 countries in 2020, 2021 and 2022.

Methods

We estimated QALYs lost by weighting age- and sex-specific excess deaths by remaining life expectancy and country-specific, population-level EQ-5D utility scores. We assessed cumulative and population-standardized weekly QALY losses, quantified demographic disparities, and measured temporal volatility via the standard deviation of weekly estimates. A quadrant analysis linking policy stringency and booster uptake to mortality outcomes explored the influence of national pandemic responses.

Results

Country rankings shifted significantly between unadjusted excess mortality, YLLs, and QALYs. Population-standardized QALYs losses per 100,000 were disproportionately concentrated in the 50–74 age group, consistently higher among men, and peaked in 2021—especially in the hardest-hit countries. Where losses were relatively low, mortality was driven predominantly by the 75+ age group. Countries with the highest average QALYs losses also exhibited the greatest week-to-week volatility, reflecting both higher burden and less controlled epidemic courses. Eastern European countries recorded the greatest losses, while nations combining early stringent responses with rapid vaccination rollout experienced markedly lower cumulative burdens.

Conclusions

Even restricted to mortality, adjusting for age and baseline health utility substantially altered rankings relative to excess death counts alone, offering a more complete picture of healthy life-years lost. As pandemic-related morbidity is not captured, this analysis underestimates the full QALY burden. Incorporating such metrics into routine surveillance can support evidence-informed resource allocation and strengthen preparedness for future health crises.

Key messages

• Mortality-based QALYs reveal stark cross-national inequalities in pandemic burden, with Eastern Europe hardest hit, disproportionately affecting men and the 50–74 age group.

• Nations combining early and vaccine-roll out government stringency with high vaccination coverage consistently recorded the lowest losses of healthy life-years.