The worldwide COVID-19 fatality count is likely to be double the official tally reported by governments, says a report released on May 6. The report, using an “updated analysis” by the Washington University-based Institute for Health Metrics and Evaluation (IHME), estimates that globally 6.9 million people may have died due to COVID-19, instead of a little over three million that is estimated, based on official sources. It estimates that in India 0.654 million (6.54 lakh) people may have died due to COVID-19 between March 2020 and May 2021, instead of the official tally of 0.221 million (2.21 lakh). The latest estimates of the toll are based on a newly adopted methodology.
The IHME’s analysis reports that the actual toll in the US may be 0.905 million, instead of the official toll of 0.574 million; 0.617 million instead of 0.218 million in Mexico. Significantly, it shows that the actual toll may not be as higher in another major hotspot, Brazil; the actual toll there is estimated at 0.596 million, compared to the official count of 0.408 million. The actual toll in Russia, however, is likely to have been much higher than officially reported — almost six times higher, 0.594 million, instead of 0.109 million.
The extent of the underestimation of the toll in Italy and United Kingdom, two other major hotspots, is also much lower than in many others; in Italy fatalities are estimated to be 0.176 million, instead of 0.121 million and in the UK, the actual toll is estimated 0.210 million instead of 0.151 million. The IHME study reveals that in several countries – notably Egypt, Kazakhstan and even Japan – reported fatalities were several multiples lower than actuals. Japan, for instance, reported just 10,230 deaths due to COVID-19 between March 2020 and May 2021; but the IHME estimates COVID-19 fatalities in the country to have been ten times that figure – 1,08,320.
The analysis, based on an updated methodology, finds that COVID-19 deaths are “significantly underreported in almost every country.” “As terrible as the COVID-19 pandemic appears, this analysis shows that the actual toll is significantly worse,” said Dr. Christopher JL Murray, IHME’s director. He emphasised that getting right the “true number of COVID-19 deaths” would help humanity “appreciate the magnitude of this global crisis.” Moreover, it would provide “valuable information to policymakers developing response and recovery plans,”
One of the ways to hazard an estimate of past epidemics and pandemics has been to estimate the “excess” deaths in a population – an indirect method at assessing the actual impact of diseases. The IHME takes a similar approach, but after making several modifications. The underestimates may not necessarily arise from just political interference. Factors such as the poor health infrastructure care, access to health and under-reporting of deaths may “magnify this challenge,” observes the report.
The IHME justified its decision to switch over to a new methodology, pointing out that there are great variations across geographies – both within countries as well as across nations – in testing for COVID-19. Thus, it notes, actual reports of COVID-19 fatalities as a proportion of all fatalities, also varies considerably across geographies. Second, in more economically advanced societies, where the population of the elderly is higher, many COVID-19 deaths among this segment of the population went unreported during the initial days of the pandemic. In many other countries (such as Russia and countries of Eastern Europe), which have reported low fatality counts, an estimate of “excess” deaths provides a way of measuring the actual scale of the pandemic’s impact.
“Estimating the total COVID-19 death rate is important both for modelling the transmission dynamics of the disease to make better forecasts, and also for understanding the drivers of larger and smaller epidemics across different countries,” observes the report.
Explaining its methodology, the report points out that “all cause mortality” since the onset of the pandemic has been influenced by six factors as a result of the social distancing norms and mobility restrictions that have been adopted since last year. In order to compute “excess” deaths it lists six “drivers,” starting with the number of deaths from COVID-19 infections. The second driver of “excess” deaths is “delayed or deferred” health care during the pandemic. The third is due to mortality arising from mental health disorders or due to alcohol or drug use. The fourth factor, a mitigating one, is due to lower fatalities caused in accidents, due to the restrictions on mobility during the pandemic. The fifth driver, another mitigating factor, is the lower number of deaths due to other viruses (influenza, measles, etc.). The sixth driver of “excess” deaths arises from the fatalities among those who were already chronically ill with ailments of a cardiovascular or respiratory nature, who succumbed to COVID-19, instead of their other chronic medical conditions. Thus, in order to arrive at a correct estimate, the report notes that all six “drivers” of excess deaths have to be incorporated in the model.
Projections based on a model
The analysis begins with regions and countries that have reported all-cause mortality since the beginning of the pandemic last year, available for 56 countries and sub-national units. The difference between the actual mortality rate and the “expected” death rate gives an estimate of the COVID-19 toll. But the analysis does not stop here. Using other studies and evidence, the IHME estimates, “the fraction of excess mortality that is from total COVID-19 deaths as opposed to the five other drivers that influence excess mortality.” It then proceeds to build a statistical model that that “predicts” a ratio of total COVID deaths to reported COVID deaths for regions that do not have reliable COVID fatalities. This ratio is used then used to estimate COVID deaths in all locations.
Although the methodology appears to rest on strong foundations, there may be problems associated with the application of the model across geographies and demographies. That is to say that although the overall estimate may be robust, the fidelity of the estimates may be a problem, especially because of the extreme unevenness of the data. Thus, the variability in the quality of the data – both on all-cause mortality as well current COVID mortality – may not offer the fidelity to do nuanced cross-country projections. This may be a problem particularly when making across country comparisons.
Thus, instead of ranking countries (implicitly, in the tables) by the extent of the toll, a more meaningful method may have been to group them either along income or geographical lines. For instance, it is striking that most of the countries where the estimated COVID death rate is unconscionably high are countries in Eastern Europe. Azerbaijan COVID death rate is estimated at almost 650 deaths per 1,000 (almost 15 times its official death rate), Bosnia and Herzegovina (587) and Bulgaria (544).
Implications for India
For India, the estimates confirm what was expected – that the actual COVID mortality in Maharashtra and Kerala are higher than official, but the extent of the undercount is smaller than in the rest of the country.
“In terms of total deaths, we expect that there will be considerable mortality between now and September – well over two million deaths, with half of that in India alone,” Dr Murray said.
“Our understanding of the pandemic has profoundly changed,” said Dr Murray. This is because the global toll is not uniformly distributed in the world. “It is a function of testing and, in some regions under-reporting has been truly profound.” In particular, Dr Murray referred to countries of Eastern Europe, Central Asia and Egypt.
Soumya Swaminathan, chief scientist at the World Health Organisation observed on Twitter that it is “important to document excess mortality due to COVID and other causes.” This, she said, “will help direct policy responses.”
Time will, of course, tell whether these estimates are close to reality. But India will ignore the key takeaway of the report – that testing accurately is the key to get a handle on the virus – at its own peril. Expanded testing is necessary to not just get a measure of the disease and the dynamics of its spread but will also provide the true measure of the mortality to the disease in India.
The recent performance of testing is not encouraging; the highest ever number of tests conducted (19.5 lakh) was on April 30; despite the surge since then, testing has fallen short. This report thus serves as a timely warning to authorities to get their act together. India will ignore it at its own peril.