Underreporting of Pandemic-Related Deaths: Global Mortality Estimates

More than three times as many people may have died worldwide as a result of the pandemic than official COVID-19 death records suggest, according to an analysis published in The Lancet .

While the official number of deaths from COVID-19 was 5.9 million between January 1, 2020 and December 31, 2021, the new study estimates that 18.2 million excess deaths occurred during the same period, suggesting that the total impact of the pandemic may have been much greater.

Excess deaths, the difference between the number of deaths recorded from all causes and the number expected based on past trends, is a key measure of the actual number of deaths from the pandemic. While there have been several attempts to estimate excess mortality from COVID-19, the geographic scope of most has been limited by data availability.

The new study provides the first peer-reviewed estimates of excess deaths due to the pandemic globally and for 191 countries and territories (and 252 subnational locations such as states and provinces) between January 1, 2020 and December 31, 2020. 2021.

Weekly or monthly data on deaths from all causes in 2021, 2020, and up to 11 previous years were obtained for 74 countries and 266 states and provinces through searches of government websites, the World Mortality Database, the of human mortality and the European Statistical Office. The data were used in models to estimate excess mortality due to the COVID-19 pandemic, even for locations without weekly or monthly reporting of death data.

The analysis indicates that global excess deaths due to the pandemic may have totaled 18.2 million , more than three times the official reported figure, by December 31, 2021. The excess death rate is estimated Mortality is 120 deaths per 100,000 inhabitants worldwide, and 21 countries were estimated to have rates of more than 300 excess deaths per 100,000 inhabitants. Excess death rates are estimated to have varied dramatically by country and region.

The highest excess mortality rates were estimated in Andean Latin America (512 deaths per 100,000 inhabitants), Eastern Europe (345 deaths per 100,000), Central Europe (316 deaths per 100,000), Southern Sub-Saharan Africa (309 deaths per 100,000) and Central Latin America (274 deaths per 100,000).

Several places outside these regions are estimated to have had similarly high rates, including Lebanon, Armenia, Tunisia, Libya, several regions of Italy, and several southern US states. In stark contrast, some countries were estimated to have had fewer deaths. than expected based on mortality trends in previous years, including Iceland (48 fewer deaths per 100,000), Australia (38 fewer deaths per 100,000), and Singapore (16 fewer deaths per 100,000).

With 5.3 million excess deaths, South Asia had the highest number of estimated excess deaths from COVID-19, followed by North Africa and the Middle East (1.7 million) and Eastern Europe (1.4 millions). At the country level, the highest number of estimated excess deaths occurred in India (4.1 million), USA (1.1 million), Russia (1.1 million), Mexico (798,000), Brazil ( 792,000), Indonesia (736,000) and Pakistan (664,000).

These seven countries may have accounted for more than half of the global excess deaths caused by the pandemic during the 24-month period. Among these countries, excess death rates were highest in Russia (375 deaths per 100,000) and Mexico (325 deaths per 100,000), and were similar in Brazil (187 deaths per 100,000) and the US ( 179 deaths per 100,000). Due to its large population, India alone accounted for approximately 22% of the world’s total deaths.

Global distribution of the estimated excess mortality rate due to the COVID-19 pandemic, for the cumulative period 2020-21

Calculating the difference between estimates of excess deaths and officially reported deaths provides a measure of underestimation of the true number of deaths from the pandemic. The ratio of excess deaths to reported deaths is much higher in South Asia (excess deaths 9.5 times higher than reported deaths) and sub-Saharan Africa (excess deaths 14.2 times higher than reported) than in other regions.

Large differences between excess deaths and official records may be the result of underdiagnosis due to lack of testing and problems with reporting death data.

Distinguishing between deaths caused directly by COVID-19 and those that occurred as an indirect result of the pandemic is crucial, the authors say. Evidence from initial studies suggests that a significant proportion of excess deaths are a direct result of COVID-19. However, deaths may also have occurred indirectly from causes such as suicide or drug use due to behavioral changes or lack of access to healthcare and other essential services during the pandemic. The impact of these various factors will vary by country and region.

To date, only 36 countries have published cause of death data for 2020. As data becomes available from more countries, it will be possible to better determine how many excess deaths were directly due to COVID-19 and how many occurred as an indirect result. of the pandemic or the responses to it.

Lead author Dr Haidong Wang, from the US Institute for Health Metrics and Evaluation, said: “Understanding the true number of deaths from the pandemic is vital for effective public health decision-making. Studies from several countries, including Sweden and the Netherlands, suggest that COVID-19 was the direct cause of most excess deaths, but we currently do not have enough evidence for most places. “Further research will help reveal how many deaths were directly caused by COVID-19 and how many occurred as an indirect result of the pandemic.”

The authors acknowledge a number of limitations in their study. A statistical model was used to predict excess deaths in countries that did not report weekly or monthly data on deaths from all causes, highlighting the need for direct measurements from these locations.

Excess death estimates were calculated only for the entire study period, and not by week or month, due to delays and inconsistencies in the reporting of COVID-19 death data that could dramatically alter estimates.

Implications of all available evidence

Our estimates of excess COVID-19 mortality suggest that the mortality impact of the COVID-19 pandemic has been more devastating than the situation documented by official statistics. Official statistics on reported deaths from COVID-19 provide only a partial picture of the true mortality burden.

The difference between excess mortality and reported COVID-19 deaths could be due to underdiagnosis due to insufficient testing, reporting challenges, or higher than expected mortality from other diseases due to changes in pandemic-related behaviors. or reduced access to health care or other essential services. services.

The gap between estimated excess mortality and reported COVID-19 deaths is much larger in South Asia and sub-Saharan Africa than in other regions. The differences shown between reported COVID-19 mortality and COVID-19-related excess mortality highlight the importance of using estimates of COVID-19-related excess mortality in policy and monitoring and evaluation efforts. .