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

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July 2020

Lemi Belay Tolu,
Alex Ezeh
Garumma Tolu Feyissa

PEAH – Policies for Equitable Access to Health


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.

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.

Read the full article at PEAH