COVID Death: Direct Death or Excess Mortality Worth to Report in Low- and Middle-Income Countries?

Low -and middle-income countries should assess the overall (direct and indirect) effects of COVID-19 on excess mortality. This is very important for monitoring both the direct and indirect impact of the pandemic to set policy directions and develop context-based mitigation strategies for both direct and indirect (excess) mortalities related to COVID-19

By Lemi Belay Tolu (MD)1, Alex Ezeh (Ph.D.)2, Garumma Tolu Feyissa (Ph.D.)2

  1. Saint Paul’s Hospital Millennium Medical College, Department of Obstetrics and Gynaecology, Addis Ababa, Ethiopia
  2.  Dornsife School of Public Health, Drexel University, Philadelphia, USA

Corresponding author: lemi.belay@gmail.com

COVID Death: Direct Death or Excess Mortality Worth to Report in Low- and Middle-Income Countries?

 

Covid-19 has caused severe economic, social, and health impacts around the world. Thousands have died of the virus since its identification in the Wuhan province of China. Deaths from the coronavirus disease 2019 (COVID-19) pandemic might arise both in those infected (direct effects), as well as those affected (indirectly, not infected) by altered access to health services; the physical, psychological, and social effects of distancing; and economic changes. Yet there is no consistency on what to consider as COVID-19 death. In some countries, COVID-19 mortality did not consider counting of the deaths attributed to underlying conditions even though the cases had tested positive for COVID-19. In some counties, on the other hand, such cases were counted. In other countries, suspected cases were also included in the reports of COVID-19 mortalities. These factors make it difficult to compare case fatality rates across countries especially in low- and middle-income countries where registration and data recording system is poor.

Direct COVID-19 death

Different countries use different definitions of COVID-19 death.  There are two main ways in which COVID-19 deaths are defined. The first, based on the WHO definition (see below), uses clinically confirmed or probable COVID-19 case. The second, on the other hand, is reliant primarily on a positive laboratory test.  WHO defined COVID-19 death as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). Additionally, WHO stated that there should be no period of complete recovery from COVID-19 between illness and death to consider as COVID-19 death.  This is a direct death due to COVID-19, not attributed to another disease (e.g. cancer), and should be counted independently of preexisting conditions that might have exacerbated a severe course of COVID-19.  In the absence of a clear alternative cause of death, both confirmed and suspected cases could be considered as COVID-19 death (Figure 1 below).  Where the WHO definition is used, it is more likely that a greater share of COVID-19-associated deaths will be captured in low-and middle-income countries  because of the following factors: variations in testing policies across countries (population groups eligible for tests in some countries were restricted to people with severe symptoms); limited testing capacity, and PCR test sensitivity can be as low as 54% missing false negative cases. Therefore, this might result in limiting reporting to mainly hospital deaths and testing severe cases that present in hospital, resulting in high case-fatality rates as a result of the smaller volume of tests if the COVID-19 death is defined primarily based on a positive laboratory test only. Additionally, reporting all positive laboratory tests as COVID-19 death might complicate some medicolegal issues. For example, a person who died of road traffic accident at the scene might be asymptomatic positive for COVID-19 up on forensic investigation.

 

Figure 1: Medical certification of suspected and confirmed COVID-19 cases as COVID-19 death. Taken from WHO international guidelines for certification and classification (coding) of COVID-19 as the cause of death

Persons with COVID-19 may die of other diseases or accidents, such cases are not deaths due to COVID-19 and should not be certified as such (Figure 2 below). This includes postmortem COVID-19 positive cases during the forensic investigation if there is a clear alternative cause of death.   However, COVID-19 should be recorded on the medical certificate of cause of death for all decedents where the disease caused (COVID-19 death) or is assumed to have caused (COVID-19 death) or contributed to death (Non-COVID-19 death).

Figure 2: Medical certification of COVID-19 cases that die of accidents or other diseases as non-COVID death. Taken from WHO international guidelines for certification and classification (coding) of COVID-19 as the cause of death

 

Excess of COVID-19 mortality

These include indirect deaths among those affected (indirectly, not infected) by altered access to health services; the physical, psychological, and social effects of distancing; and economic changes. This type of death specifically might increase dramatically in low- and middle-income country because of the weak health care system, lack of well-established virtual or other alternative health care methods during the lockdown, and the dwellers suffer from underlying health conditions, such as malnutrition, chronic diseases and several other factors related to poverty. For example, evidence from the Ebola virus outbreak in 2013–2016 in Western Africa shows the negative, indirect effects that such crises can have. According to an analysis of data from Sierra Leone’s Health Management Information System (HMIS), decreases in maternal and newborn care due to disrupted services and fear of seeking treatment during the outbreak contributed to an estimated 3,600 maternal deaths, neonatal deaths, and stillbirth, a quantity that approaches the number of deaths directly caused by the Ebola virus in the country.

According to early estimates by Roberton et al. 2020, if the routine healthcare services are interrupted and access to food is limited because of limited production related to Covid-19 lockdown in low- and middle-income countries, it is expected to rise under-five mortality (from 9.8% to 44.7% increase per month) and maternal mortality (8.3–38.6% per month).  According to Guttmacher Institute, early projection of the indirect impact of the pandemics, a 10% service reduction in low- and middle-income countries will result in 28,000 and 1,000 additional maternal deaths from obstetric complications and unsafe abortion respectively. Similarly, it will result in 168,000 additional newborn deaths.

Reporting excess mortality has an important advantage considering variations in the definitions of COVID-19 death between countries. It includes deaths among those who probably had COVID-19 providing a more comprehensive picture of the scale of mortality during the crisis and facilitates comparisons across countries. Excess mortality not only makes a better understanding of the overall impact of the pandemic on population health, but it also facilitates tracking of the impact of the pandemic in real-time.

Conclusions

There is variation in definitions of COVID-19 death and broadly categorized into two: diagnosis-based (confirmed and probable, in line with the WHO definition) and test-based. WHO definition is more likely to capture COVID-19-associated deaths. Therefore, we recommend low- and middle-income countries to use WHO international guidelines for certification and classification (coding) of COVID-19 as the cause of death for appropriate identification of COVID-19 death and non-COVID-19 death. However, WHO’s definition accuracy may vary depending on the implementation of the WHO guidelines in practice within countries, and death certificate registration might take time challenging prompt report. These might be further complicated in low- and middle-income countries with limited testing capacity and data tracking capacity. Estimating excess death could be used as a solution for such problems and express the true scale of the COVID-19 pandemic. Therefore, low -and middle-income countries should assess the overall (direct and indirect) effects of the pandemic on excess mortality. This is very important for monitoring both the direct and indirect impact of the pandemic to set policy directions and develop context-based mitigation strategies for both direct and indirect (excess) mortalities related to the pandemic.

 


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