Abstract
The COVID-19 pandemic has resulted in substantial mortality worldwide. However, to date, countries in the Middle East and Africa have reported considerably lower mortality rates than in Europe and the Americas. Motivated by reports of an overwhelmed health system, we estimate the likely under-ascertainment of COVID-19 mortality in Damascus, Syria. Using all-cause mortality data, we fit a mathematical model of COVID-19 transmission to reported mortality, estimating that 1.25% of COVID-19 deaths (sensitivity range 1.00% – 3.00%) have been reported as of 2 September 2020. By 2 September, we estimate that 4,380 (95% CI: 3,250 – 5,550) COVID-19 deaths in Damascus may have been missed, with 39.0% (95% CI: 32.5% – 45.0%) of the population in Damascus estimated to have been infected. Accounting for under-ascertainment corroborates reports of exceeded hospital bed capacity and is validated by community-uploaded obituary notifications, which confirm extensive unreported mortality in Damascus.
Highlights
The COVID-19 pandemic has resulted in substantial mortality worldwide
Despite the estimate of excess mortality only being available for just over a week, we estimate that 1.25% of deaths from COVID-19 have been reported in Damascus during this period
It is likely that the epidemic in Damascus is in a much more advanced stage than the reported data would suggest, with ~40% of the population infected during the first wave
Summary
The COVID-19 pandemic has resulted in substantial mortality worldwide. to date, countries in the Middle East and Africa have reported considerably lower mortality rates than in Europe and the Americas. West Asia, e.g. Sudan, Syria, and Yemen, have reported no sharp increases in mortality of the scale predicted by multiple modelling studies, even where interventions were limited[3,4]. These observations are hard to reconcile with contemporaneous reports of hospitals becoming overwhelmed in these settings[5,6]. All-cause, excess population mortality has been considered the most reliable data for comparing the magnitude and trajectory of COVID-19 epidemics across countries[19]. Real-time estimates of all-cause mortality are unavailable for many conflict-affected countries where comprehensive vital registration systems may be lacking or poorly-functioning and data sharing may be restricted[20]
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