Counting the global COVID-19 dead

Abstract

WHO has estimated that 14·9 million excess deaths (uncertainty range 13·3 million–16·6 million) from COVID-19 occurred globally in 2020–21.1WHOExcess mortality associated with the COVID-19 pandemic, 2020–2021.https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortalityDate: May 5, 2022Date accessed: May 5, 2022Google Scholar WHO's global estimates are lower than the 18·2 million deaths (17·1 million–19·6 million) reported by the Institute for Health Metrics and Evaluation (IHME)2Wang H Paulson KR Pease SA et al.Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21.Lancet. 2022; 399: 1513-1536Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar and the 17·7 million deaths (13·9 million–21·1 million) estimated by The Economist for the same time period. By contrast, government counts of global deaths from COVID-19 in 2020–21, captured on Coronavirus App, suggest the figure is below 6 million.Excess deaths are a proxy for the mortality effects of SARS-CoV-2 infection. The key assumption is that increases in all-cause mortality during peak weeks of COVID-19 compared to pre-pandemic periods are nearly all due to the infection, even if SARS-CoV-2 infection was not confirmed. The validity of this method is supported in part by documenting modest reductions (negative excess) in overall mortality in selected east Asian countries that effectively prevented the original wave from March to June, 2020.1WHOExcess mortality associated with the COVID-19 pandemic, 2020–2021.https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortalityDate: May 5, 2022Date accessed: May 5, 2022Google ScholarThe difference of 3 million deaths across the three models is far from trivial. However, given that WHO imprimatur carries substantial influence on countries, a more relevant question is whether WHO estimates are credible. About half of WHO's estimate is derived from observed data, the other half from modelled data. IHME combines six different approaches and applies complex methods to create estimates for various countries. Yet IHME's method yields implausibly narrow uncertainty intervals. The Economist applies machine learning, using many covariates, and has appropriately wider uncertainty intervals; like WHO, it makes its model fully open source. In high-income countries, much of the discrepancy between excess and reported COVID-19 deaths occurred during the first viral wave, from March to June, 2020, when SARS-CoV-2 infections and COVID-19 deaths swept through nursing homes. Italy, for example, has robust and rapid reporting of COVID-19 deaths, and WHO estimated 161 000 excess deaths, as did Italian researchers.3Alicandro G Remuzzi G Centanni S Gerli A La Vecchia C Excess total mortality during the Covid-19 pandemic in Italy: updated estimates indicate persistent excess in recent months.Med Lav. 2022; 113e2022021 Google Scholar By contrast, IHME2Wang H Paulson KR Pease SA et al.Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21.Lancet. 2022; 399: 1513-1536Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar and The Economist estimated 259 000 deaths and 192 000 deaths, respectively. That at least 9 million COVID-19 deaths were missed by official reports raises a few key issues.First, gaps in actual mortality data persist in the 21st century. In WHO's analyses of 194 countries, mortality data were not available for 85 countries, 41 of which are in Africa.1WHOExcess mortality associated with the COVID-19 pandemic, 2020–2021.https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortalityDate: May 5, 2022Date accessed: May 5, 2022Google Scholar Solutions to advance death registration and certification of causes exist,4Jha P Reliable direct measurement of causes of death in low- and middle-income countries.BMC Med. 2014; 12: 19Crossref PubMed Scopus (63) Google Scholar particularly for the growing proportion of deaths occurring in facilities. Yet funding for such solutions is negligible. Paradoxically, the availability of short-term model-derived estimates might discourage governments from investments in statistical systems, which require several years to reach fruition.Second, India contributes the most missed COVID-19 deaths (2·5 million–4·5 million). 3 million of India's annual 10 million deaths are not registered, with the largest gaps in poorer states and among women. 8 million deaths lack medical certification of the cause.5Jha P Deshmukh Y Tumbe C et al.COVID mortality in India: national survey data and health facility deaths.Science. 2022; 375: 667-671Crossref PubMed Scopus (25) Google Scholar The Indian Government2Wang H Paulson KR Pease SA et al.Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21.Lancet. 2022; 399: 1513-1536Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar has thus far refused to budge from its official total of 0·5 million COVID-19 deaths. Their low estimate is implausible.5Jha P Deshmukh Y Tumbe C et al.COVID mortality in India: national survey data and health facility deaths.Science. 2022; 375: 667-671Crossref PubMed Scopus (25) Google ScholarThird, the severe lockdown of Wuhan, China, in early 2020 led to very few deaths in the rest of the country.6Liu J Zhang L Yan Y et al.Excess mortality in Wuhan city and other parts of China during the three months of the covid-19 outbreak: findings from nationwide mortality registries.BMJ. 2021; 372: e415Crossref PubMed Scopus (38) Google Scholar However, China now faces a large omicron wave, with large numbers of unvaccinated or under-vaccinated older people, which in the case of Hong Kong led to sharp but brief spikes in death rates. China might prove to be the major contributor to global COVID-19 deaths in 2022, perhaps exceeding 1 million. Optimistically, the Chinese Government will not withhold release of timely death data. WHO's publication of global estimates despite the Indian Government's objections is an important signal to encourage transparency by all governments.Fourth, the major surprise in COVID-19 mortality might yet arise from Africa. Preliminary data7Lewis HC Ware H Whelan M et al.SARS-CoV-2 infection in Africa: a systematic review and meta-analysis of standardised seroprevalence studies, from January 2020 to December 2021.medRxiv. 2022; (published online Feb 15.) (preprint).https://doi.org/10.1101/2022.02.14.22270934PubMed Google Scholar suggest that populations across many urban settings in Africa, with various viral waves, have SARS-CoV-2 seropositivity exceeding 60% but relatively few deaths. Caution is needed as India also faced widespread infection in 2020 with low deaths, but a large killer delta wave in the spring of 2021 followed.5Jha P Deshmukh Y Tumbe C et al.COVID mortality in India: national survey data and health facility deaths.Science. 2022; 375: 667-671Crossref PubMed Scopus (25) Google Scholar Urgent investigation of possible unique biological factors or existing immunity in Africa is required. Interestingly, these findings might point to a similar effect as achieved from vaccines—far stronger protection against serious disease than against infection.8Krause PR Fleming TR Peto R et al.Considerations in boosting COVID-19 vaccine immune responses.Lancet. 2021; 398: 1377-1380Summary Full Text Full Text PDF PubMed Scopus (133) Google ScholarFinally, of the 55 million people in the world who died in 2019, nearly 50 million were older than 15 years. Yet, most demographic surveys focus on child and maternal deaths, with little attention to adult mortality. It would be advisable for every country conducting a census to at least 2025 to add two simple questions: Was there a death in the household during 2020, 2021, or 2022? If yes, what was the sex, age in completed years, and date? This information would not only provide direct evidence of excess deaths from COVID-19 but would also help fill the large gaps in knowledge on adult death rates.Estimates for deaths from the 1918–19 influenza pandemic range widely, from 40 million to 100 million. A century later, a modern effort to count the global COVID-19 dead should be a priority. Mortality data not only meet our moral duty to those who died and their families but are also of enormous practical use to explain the widespread variation in COVID-19 infection that preliminary data have revealed, and its consequences.9Brown PE Rai K La Vecchia C et al.Mortality from COVID-19 in 12 countries and 6 states of the United States.medRxiv. 2020; (published online April 22.) (preprint).https://doi.org/10.1101/2020.04.17.20069161Google Scholar Mortality data would help evaluate vaccination and other public health efforts. Counting the global COVID-19 dead will help the living.For the Coronavirus App see https://coronavirus.app/mapFor The Economist's excess death estimates see https://www.economist.com/graphic-detail/coronavirus-excess-deaths-estimatesPJ and PEB receive funding from the COVID-19 Immunity Task Force, Natural Sciences and Engineering Research Council, and Bill & Melinda Gates Foundation (BMGF) for epidemiological studies. RA receives funding from the BMGF, also for epidemiological studies. WHO has estimated that 14·9 million excess deaths (uncertainty range 13·3 million–16·6 million) from COVID-19 occurred globally in 2020–21.1WHOExcess mortality associated with the COVID-19 pandemic, 2020–2021.https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortalityDate: May 5, 2022Date accessed: May 5, 2022Google Scholar WHO's global estimates are lower than the 18·2 million deaths (17·1 million–19·6 million) reported by the Institute for Health Metrics and Evaluation (IHME)2Wang H Paulson KR Pease SA et al.Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21.Lancet. 2022; 399: 1513-1536Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar and the 17·7 million deaths (13·9 million–21·1 million) estimated by The Economist for the same time period. By contrast, government counts of global deaths from COVID-19 in 2020–21, captured on Coronavirus App, suggest the figure is below 6 million. Excess deaths are a proxy for the mortality effects of SARS-CoV-2 infection. The key assumption is that increases in all-cause mortality during peak weeks of COVID-19 compared to pre-pandemic periods are nearly all due to the infection, even if SARS-CoV-2 infection was not confirmed. The validity of this method is supported in part by documenting modest reductions (negative excess) in overall mortality in selected east Asian countries that effectively prevented the original wave from March to June, 2020.1WHOExcess mortality associated with the COVID-19 pandemic, 2020–2021.https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortalityDate: May 5, 2022Date accessed: May 5, 2022Google Scholar The difference of 3 million deaths across the three models is far from trivial. However, given that WHO imprimatur carries substantial influence on countries, a more relevant question is whether WHO estimates are credible. About half of WHO's estimate is derived from observed data, the other half from modelled data. IHME combines six different approaches and applies complex methods to create estimates for various countries. Yet IHME's method yields implausibly narrow uncertainty intervals. The Economist applies machine learning, using many covariates, and has appropriately wider uncertainty intervals; like WHO, it makes its model fully open source. In high-income countries, much of the discrepancy between excess and reported COVID-19 deaths occurred during the first viral wave, from March to June, 2020, when SARS-CoV-2 infections and COVID-19 deaths swept through nursing homes. Italy, for example, has robust and rapid reporting of COVID-19 deaths, and WHO estimated 161 000 excess deaths, as did Italian researchers.3Alicandro G Remuzzi G Centanni S Gerli A La Vecchia C Excess total mortality during the Covid-19 pandemic in Italy: updated estimates indicate persistent excess in recent months.Med Lav. 2022; 113e2022021 Google Scholar By contrast, IHME2Wang H Paulson KR Pease SA et al.Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21.Lancet. 2022; 399: 1513-1536Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar and The Economist estimated 259 000 deaths and 192 000 deaths, respectively. That at least 9 million COVID-19 deaths were missed by official reports raises a few key issues. First, gaps in actual mortality data persist in the 21st century. In WHO's analyses of 194 countries, mortality data were not available for 85 countries, 41 of which are in Africa.1WHOExcess mortality associated with the COVID-19 pandemic, 2020–2021.https://www.who.int/data/stories/the-true-death-toll-of-covid-19-estimating-global-excess-mortalityDate: May 5, 2022Date accessed: May 5, 2022Google Scholar Solutions to advance death registration and certification of causes exist,4Jha P Reliable direct measurement of causes of death in low- and middle-income countries.BMC Med. 2014; 12: 19Crossref PubMed Scopus (63) Google Scholar particularly for the growing proportion of deaths occurring in facilities. Yet funding for such solutions is negligible. Paradoxically, the availability of short-term model-derived estimates might discourage governments from investments in statistical systems, which require several years to reach fruition. Second, India contributes the most missed COVID-19 deaths (2·5 million–4·5 million). 3 million of India's annual 10 million deaths are not registered, with the largest gaps in poorer states and among women. 8 million deaths lack medical certification of the cause.5Jha P Deshmukh Y Tumbe C et al.COVID mortality in India: national survey data and health facility deaths.Science. 2022; 375: 667-671Crossref PubMed Scopus (25) Google Scholar The Indian Government2Wang H Paulson KR Pease SA et al.Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21.Lancet. 2022; 399: 1513-1536Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar has thus far refused to budge from its official total of 0·5 million COVID-19 deaths. Their low estimate is implausible.5Jha P Deshmukh Y Tumbe C et al.COVID mortality in India: national survey data and health facility deaths.Science. 2022; 375: 667-671Crossref PubMed Scopus (25) Google Scholar Third, the severe lockdown of Wuhan, China, in early 2020 led to very few deaths in the rest of the country.6Liu J Zhang L Yan Y et al.Excess mortality in Wuhan city and other parts of China during the three months of the covid-19 outbreak: findings from nationwide mortality registries.BMJ. 2021; 372: e415Crossref PubMed Scopus (38) Google Scholar However, China now faces a large omicron wave, with large numbers of unvaccinated or under-vaccinated older people, which in the case of Hong Kong led to sharp but brief spikes in death rates. China might prove to be the major contributor to global COVID-19 deaths in 2022, perhaps exceeding 1 million. Optimistically, the Chinese Government will not withhold release of timely death data. WHO's publication of global estimates despite the Indian Government's objections is an important signal to encourage transparency by all governments. Fourth, the major surprise in COVID-19 mortality might yet arise from Africa. Preliminary data7Lewis HC Ware H Whelan M et al.SARS-CoV-2 infection in Africa: a systematic review and meta-analysis of standardised seroprevalence studies, from January 2020 to December 2021.medRxiv. 2022; (published online Feb 15.) (preprint).https://doi.org/10.1101/2022.02.14.22270934PubMed Google Scholar suggest that populations across many urban settings in Africa, with various viral waves, have SARS-CoV-2 seropositivity exceeding 60% but relatively few deaths. Caution is needed as India also faced widespread infection in 2020 with low deaths, but a large killer delta wave in the spring of 2021 followed.5Jha P Deshmukh Y Tumbe C et al.COVID mortality in India: national survey data and health facility deaths.Science. 2022; 375: 667-671Crossref PubMed Scopus (25) Google Scholar Urgent investigation of possible unique biological factors or existing immunity in Africa is required. Interestingly, these findings might point to a similar effect as achieved from vaccines—far stronger protection against serious disease than against infection.8Krause PR Fleming TR Peto R et al.Considerations in boosting COVID-19 vaccine immune responses.Lancet. 2021; 398: 1377-1380Summary Full Text Full Text PDF PubMed Scopus (133) Google Scholar Finally, of the 55 million people in the world who died in 2019, nearly 50 million were older than 15 years. Yet, most demographic surveys focus on child and maternal deaths, with little attention to adult mortality. It would be advisable for every country conducting a census to at least 2025 to add two simple questions: Was there a death in the household during 2020, 2021, or 2022? If yes, what was the sex, age in completed years, and date? This information would not only provide direct evidence of excess deaths from COVID-19 but would also help fill the large gaps in knowledge on adult death rates. Estimates for deaths from the 1918–19 influenza pandemic range widely, from 40 million to 100 million. A century later, a modern effort to count the global COVID-19 dead should be a priority. Mortality data not only meet our moral duty to those who died and their families but are also of enormous practical use to explain the widespread variation in COVID-19 infection that preliminary data have revealed, and its consequences.9Brown PE Rai K La Vecchia C et al.Mortality from COVID-19 in 12 countries and 6 states of the United States.medRxiv. 2020; (published online April 22.) (preprint).https://doi.org/10.1101/2020.04.17.20069161Google Scholar Mortality data would help evaluate vaccination and other public health efforts. Counting the global COVID-19 dead will help the living. For the Coronavirus App see https://coronavirus.app/mapFor The Economist's excess death estimates see https://www.economist.com/graphic-detail/coronavirus-excess-deaths-estimates For the Coronavirus App see https://coronavirus.app/mapFor The Economist's excess death estimates see https://www.economist.com/graphic-detail/coronavirus-excess-deaths-estimates For the Coronavirus App see https://coronavirus.app/map For The Economist's excess death estimates see https://www.economist.com/graphic-detail/coronavirus-excess-deaths-estimates PJ and PEB receive funding from the COVID-19 Immunity Task Force, Natural Sciences and Engineering Research Council, and Bill & Melinda Gates Foundation (BMGF) for epidemiological studies. RA receives funding from the BMGF, also for epidemiological studies.