Why we will never know how many people die from COVID-19

10 Apr 2020

Photo Credit: Unsplash / sammy joonhee

Our lives have been upended by COVID-19. For many of us, the uncertainty is overwhelming, with countless questions and concerns.

A key question remains: how many people are dying from COVID-19? The need for this data is immediate amid the pandemic. However, even when the virus is no longer a threat, we will never fully know how many have died from it.

ESCAP works to improve official statistics in Asia and the Pacific, which includes supporting countries ensure all are registered and provided with legal documentation to produce vital statistics on births, deaths and causes of deaths.

How do we record the reasons people are dying?

When a death occurs, a physician will certify the cause of death by completing the internationally-recognized medical certificate of cause of death (MCCD), which is then reported to the civil registry. Additional information, such as age, sex and geographical location is critical for understanding who is affected by which disease.

During health outbreaks, health surveillance systems respond quickly to system needs and report mortality more frequently than routine vital statistics reporting.

Efficient surveillance systems and focused attention on an emerging disease increases the chances of testing and diagnosis for accurate reporting of outbreak-related deaths, but the speed of the current virus transmission is outpacing these surveillance system benefits.

The starting point to understanding the impact of COVID-19 is ensuring physicians are correctly trained in diagnosing COVID-19 through laboratory or clinical findings so that they can implement proper treatment, plan resources and report this novel virus on the MCCD form. In crisis mode when health systems are already overwhelmed, they may not have the capacity to disseminate the evolving COVID-19 case definitions to all clinicians, and physicians might not prioritize the reporting of the deaths per WHO recommendations.

Moreover, research has shown that even when hospital data is the main source of death information and causes of deaths are recorded, considerable misclassification occurs. Universal testing has not yet been achieved and with the overlap of influenza season, COVID-19 deaths may be misclassified as other severe acute respiratory-related deaths. The attribution of the cause of death is further complicated among the elderly with morbid conditions.

In Asia and the Pacific only two out of seven deaths record a cause of death

Low- and middle-income countries, particularly those with low rates of death registration, face further data limitations as the majority of deaths occur outside of health facilities, and often not attended by physicians.

In Asia-Pacific countries, many deaths are not registered and even fewer are assigned a cause of death. For countries with data on how many are assigned a cause of death, in recent years only 29 per cent of deaths were assigned a medically certified cause of death using the MCCD. Therefore, under normal circumstances, in Asia and the Pacific at least five out of seven deaths will not be recorded with a cause of death.

The combination of poor health surveillance systems and weak health systems’ routine recording of causes of death generates an under-reported number of COVID-19 deaths. During the current acute surveillance period, these systems are unable to detect all new cases and deaths. This means at the end of the pandemic, the region will have an incomplete measurement of the mortality burden.

The importance of strengthening CRVS systems

Health systems worldwide rely on valid and accurate data for programme and policy development and for tracking the distribution of ill-health and disease in populations. This data is critical during crises.

CRVS systems are fundamental for registration of births, deaths and recording of causes of death. Strengthening CRVS systems is the first step to facilitate the production of accurate statistics on causes of death.

While high-income countries with well-functioning CRVS systems are quickly implementing actions to record COVID-19 deaths per international standards, low- and middle- income countries’ CRVS systems continue to suffer weaknesses in death registration, collection of cause-of-death data and generation of statistics.

This is why countries in Asia and the Pacific are working together to improve their CRVS systems. The Ministerial declaration to “Get Every One in the Picture” outlines government commitments to for achieving a shared vision that, by 2024, all people in the region will benefit from universal and responsive CRVS systems that facilitate the realization of their rights and support good governance, health and development.

ESCAP and development partners are organizing a Second Ministerial Conference on CRVS in Asia and the Pacific from 6 to 9 October 2020, which will promote renewed commitment at the national and regional level.

The global health emergency we are currently facing underlines the necessity for efficient CRVS systems and their interoperability with health systems. Ensuring that every death is registered, and all causes of deaths are accurately recorded will improve mortality statistics and facilitate the development of health policies.

Fighting COVID-19 is going to take expertise and efforts from all, but when we reflect on what we can do to fight future pandemics, it is clear that long-term support of health information systems is a pre-requisite. With better data and systems, we have a chance to fight this and future global challenges together.

Related SDGs: Goal 3: Good health and well-being, Goal 8: Decent work and economic growth, Goal 16: Peace, justice and strong institutions, Goal 17: Partnerships for the goals