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“We will never know the exact number of deaths from COVID-19,” says a European expert

Danish Lasse Vestergaard is coordinator of the EuroMOMO Mortality Monitoring project. He explained why it is essential to know these data

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A worker in protective gear sanitizes the Cathedral Square during the outbreak of COVID-19, the disease caused by the coronavirus, in central Milan, Italy. March 31, 2020 (REUTERS / Flavio Lo Scalzo)

Ascertain statistics begin to stabilize and the number of COVID-19 deaths worldwide becomes somewhat more predictable, it is still held that the actual death toll could be much higher due to indirect and misclassified deaths.

At the beginning of the pandemic, information on rates of infection, hospitalization, and even deaths was often delayed or unreliable. Testing was not widespread, and understanding the biological and clinical characteristics of the virus made it difficult to classify a death from COVID-19.

As many countries face a succession of waves of contagion, monitoring has also entered a new phase with stronger data and better reporting systems. However, there are still many cases that can go unnoticed.

“We will never know the exact number of deaths from COVID-19, simply because many patients will never be evaluated, even though they die from COVID-19,” is the first conclusion outlined by Lasse Vestergaard, medical epidemiologist, and coordinator of EuroMOMO, the European entity for monitoring mortality, whose objective is to detect and measure excess deaths in real-time related to seasonal influenza, pandemics and other threats to public health.

Official national mortality statistics are provided to the entity on a weekly basis from the 29 European countries or sub-national regions in the EuroMOMO collaborative network, supported by the European Center for Disease Prevention and Control (ECDC) and the World Health Organization (WHO), and organized by the Statens Serum Institut, Denmark.

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Lasse Vestergaard

The entity in which Vestergaard works has had the advantage of having already been in operation before the start of the COVID-19 pandemic. “With the estimate of excess deaths, we have a fairly accurate picture of the total COVID-19 mortality burden and how it affects different populations,” he said.

However, he admitted that “there are many questions to be answered to fully understand the epidemiology and impact of COVID-19”. So far the experts consider that “The total mortality of COVID-19 is considerably higher than what is judged from official statistics, and that younger adults and middle-aged people are not spared,” said Vestergaard.

-How is the number of victims of the COVID-19 pandemic calculated?

-One method is to observe excess deaths. Networks like EuroMOMO collect data on the number of people who have died from all causes and compare it to the average number in previous years. The difference in deaths is considered “excess deaths” and gives a better measure of how many people actually died during the pandemic. Excess deaths have been used in the past to measure the impact of swine flu, seasonal flu, and natural disasters.

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Gravediggers In A Protective Gear Lower A Coffin As They Bury A Person In The Special-Purpose Section Of A Cemetery For Covid-19 Victims Outside St. Petersburg, Russia (Reuters / Anton Vaganov)

-What data did you obtain?

– We estimate that in Europe alone, an additional 200,000 people died in the first wave, compared to the number of deaths that would be expected without a pandemic. The mortality rate was between 30% and 45% higher than the average in the most affected countries: England and Spain.A separate report published in JAMA magazine showed that there were 225,000 excess deaths in the United States between March and July. Of these, around two-thirds could be explained by COVID-19, which left 75,000 deaths unaccounted for. While the figures vary between countries, a significant gap often persists. Countries like France, Italy, England, and Spain showed significant excess mortality in 2020. According to the Italian statistical office ISTAT, almost 50% more people died in Italy only in March of that year compared to previous seasons. In Italian Lombardy, there were even 190% more deaths.

-How are indirect deaths detected?

There are many people who are victims of COVID-19 even if the virus is not what ultimately kills them. COVID-19 puts significant pressure on health services and many people could and will die of chronic diseases when they would not otherwise. These patients may have succumbed to a previous illness because they were weakened by infection, because hospitals were too full, or they chose to delay treatment. Disruptions to HIV, tuberculosis and malaria programs in low- and middle-income countries could have a comparable effect to direct deaths from COVID-19 over the next five years.

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Patient With Covid-19 Is Treated In The Intensive Care Unit Of Hospital Codogno, Codogno, Italy, February 11, 2021 (Reuters / Flavio Lo Scalzo)

-In their analysis, they emphasize that it is not only about deaths from the disease

-Yes because We have learned that there are also more indirect effects related to the social and economic consequences of COVID-19. There have been reports of an increase in opioid-related deaths over the past year that could be related to people feeling too isolated or under-resourced. Economic difficulties could potentially lead to indirect deaths from a number of causes, such as addiction or lack of access to the help people need, especially in countries without universal health care.

-So we are still far from knowing certain figures

-It is too early to say what will be the correct number of victims of the pandemic due to direct and indirect deaths. While current reporting systems can provide a real-time picture of deaths, it can take years to accurately analyze COVID-related deaths. The gold standard is to use data from each country’s vital statistics system, which has a detailed breakdown of the cause of death and contributing factors, but It is possible that this information will not be processed on a global scale until 2022, and in many cases, they do not have, as we do in Europe, standardization of information that makes the records compatible.

-Why is it important to count deaths?

-Counting deaths can be morbid, but also hopeful. How lawmakers act on COVID-19 death data will determine how the next chapter of the pandemic or other similar situations will play out. Mortality is a basic indicator of population health, and mortality surveillance is essential for effective public health planning and action. At the same time, mortality is a key sign of the severity of a disease. However, measuring mortality caused by an unknown medical condition is challenging in the absence of established testing methods, and may be further affected by the inadequate capacity of healthcare systems to handle testing and affected patients.

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File Photograph Showing Health Personnel Treating Patients Infected With Covid-19 In Cali (Efe / Ernesto Guzmán Jr.)

-What limitations are considered determining factors in calculating mortality?

-The fatality due to COVID-19 has been one of the most referred indicators worldwide during the pandemic, but this measure carries a series of limitations. In general, deaths from COVID-19 are expected to be underestimated due to lack of testing capacity or due to its false negative results in seriously ill patients. Additionally, COVID-19 fatality is often counted as the number of deaths from all causes within a fixed period after a positive SARS-CoV-2 test (typically 30 days). Therefore, deaths caused by COVID-19 but occurring after 30 days of a positive test were not counted, and deaths that occurred 30 days after the test, but not related to COVID-19, were wrongly classified as COVID-19 deaths.

-What have been the alternatives applied at EuroMOMO?

An alternative is to expand models developed to estimate excess mortality related to seasonal influenza. This approach should provide estimates of excess mortality, including deaths directly and indirectly related to COVID-19, taking into account underlying patterns of mortality, extreme temperatures, and seasonal influenza. A commonly used methodology for estimating excess mortality is to model it based on predefined periods of no influenza activity. This baseline, which is generally adjusted with a cyclical variation throughout the year (seasonality), can be compared with the observed number of deaths, and the difference represents an estimate of excess mortality.

We have expanded and improved this model into a general Attributable Mortality Monitoring (AttMOMO) model, which allows the estimation of mortality attributable to multiple pathogens simultaneously, for example, COVID-19 and seasonal influenza. We applied the model on high-quality data from Danish health registries across the country and estimated mortality attributable to influenza and COVID-19 in Denmark from October 2019 to May 2020.

-This is just starting?

-Many questions remain to be answered to fully understand the epidemiology and impact of COVID-19. So far, systematic weekly and retrospective monitoring of all-cause mortality has told us that total COVID-19 mortality is considerably higher than judged from official statistics and that younger adults and middle-aged people are not spared. In areas that do not have reliable systems for systematic disease surveillance and mortality reporting, the collection and analysis of a simple excess of all-cause mortality data can provide particularly valuable information to guide local and public health actions. inform the public.

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