Background: The novel Severe Acute Respiratory Syndrome Coronavirus-2 has led to a global pandemic in which case fatality rate (CFR) has varied from country to country. This study aims to identify factors that may explain the variation in CFR across countries. Methods: We identified 24 potential risk factors affecting CFR. For all countries with over 5000 reported COVID-19 cases, we used country-specific datasets from the WHO, the OECD, and the United Nations to quantify each of these factors. We examined univariable relationships of each variable with CFR, as well as correlations among predictors and potential interaction terms. Our final multivariable negative binomial model included univariable predictors of significance and all significant interaction terms. Results: Across the 39 countries under consideration, our model shows COVID-19 case fatality rate was best predicted by time to implementation of social distancing measures, hospital beds per 1000 individuals, percent population over 70 years, CT scanners per 1 million individuals, and (in countries with high population density) smoking prevalence. Conclusion: Our model predicted an increased CFR for countries that waited over 14 days to implement social distancing interventions after the 100th reported case. Smoking prevalence and percentage population over the age of 70 years were also associated with higher CFR. Hospital beds per 1000 and CT scanners per million were identified as possible protective factors associated with decreased CFR.

The coronavirus disease 2019 (COVID-19) pandemic altered education, exams, and residency applications for United States medical students. To determine the specific impact of the pandemic on US medical students and its correlation to their anxiety levels. An 81-question survey was distributed via email, Facebook and social media groups using REDCap^TM. To investigate risk factors associated with elevated anxiety level, we dichotomized the 1-10 anxiety score into low (≤ 5) and high (≥ 6). This cut point represents the 25^th percentile. There were 90 (29%) shown as low anxiety and 219 (71%) as high anxiety. For descriptive analyses, we used contingency tables by anxiety categories for categorical measurements with chi square test, or mean ± STD for continuous measurements followed by t-test or Wilcoxson rank sum test depending on data normality. Least Absolute Shrinkage and Selection Operator was used to select important predictors for the final multivariate model. Hierarchical Poisson regression model was used to fit the final multivariate model by considering the nested data structure of students clustered within State. 397 medical students from 29 states were analyzed. Approximately half of respondents reported feeling depressed since the pandemic onset. 62% of participants rated 7 or higher out of 10 when asked about anxiety levels. Stressors correlated with higher anxiety scores included “concern about being unable to complete exams or rotations if contracting COVID-19” (RR 1.34; 95%CI: 1.05-1.72, P = 0.02) and the use of mental health services such as a “psychiatrist” (RR 1.18; 95%CI: 1.01-1.3, P = 0.04). However, those students living in cities that limited restaurant operations to exclusively takeout or delivery as the only measure of implementing social distancing (RR 0.64; 95%CI: 0.49-0.82, P < 0.01) and those who selected “does not apply” for financial assistance available if needed (RR 0.83; 95%CI: 0.66-0.98, P = 0.03) were less likely to have a high anxiety. COVID-19 significantly impacted medical students in numerous ways. Medical student education and clinical readiness were reduced, and anxiety levels increased. It is vital that medical students receive support as they become physicians. Further research should be conducted on training medical students in telemedicine to better prepare students in the future for pandemic planning and virtual healthcare.