Data released on Wednesday (12 August) by the South African Medical Research Council’s (SAMRC) Burden of Disease Research Unit, suggests that parts of the country may have reached a peak in COVID-19 infections by the end of July, which could potentially signal a downturn in the country’s epidemic, reports Spotlight. Excess deaths, in other words, natural deaths that have occurred over and above what would be expected based on historical patterns, declined from the last week of July to the first week of August.
The tally of excess deaths between the beginning of May and the first week of August stood at 33,478, while reported COVID-19 deaths totalled nearly 9000 on 4 August (the latest date covered in the excess deaths report). This leaves over 24,000 deaths unaccounted for as of 4 August.
Professor Debbie Bradshaw, chief specialist scientist from the SAMRC’s Burden of Disease Research Unit, is quoted by Spotlight as saying that they do not yet know the medical causes of these deaths – or if they are related directly or indirectly to COVID-19.
Part of the problem is simply that information has not yet been captured.
Using information from the National Population Register which is provided to Bradshaw and her colleagues on a weekly basis, the SAMRC’s weekly excess death reports are compiled to shed light on mortality during the COVID-19 pandemic. Their projections take into account persons who are not on the population register and deaths that may not have been registered with DHA. The projections also do not include data on deaths for children under the age of 1 as a result of birth registrations being put on hold during level 5 of the lockdown.
While confirmed causes of these deaths are not yet known, Bradshaw says that the geographic time trend and age patterns of the excess deaths indicate that a high proportion of them are likely to be due to COVID-19. However, there is no way to be certain of this without further investigation.
A modelling study published in the medical journal Lancet Global Health last month projected that deaths due to HIV, TB and malaria in lower to middle-income countries could dramatically increase due to the pandemic’s effect on care and prevention services over the next five years, meaning that the death toll from these diseases could equate to or surpass that of COVID-19.
Bradshaw notes that the excess deaths may be linked to people not presenting at primary healthcare facilities due to fear of COVID-19 or other anxieties, and a potential for deaths due to chronic or acute conditions unrelated to the virus. “(We) are exploring whether it is possible to work with the Department of Health to evaluate mortality trends of the patients who are being treated for selected chronic conditions,” she says.
According to Spotlight, when asked about the status of those defaulting on treatment during lockdown and the implications for excess deaths, director for TB, HIV and DR-TB in the health department, Dr Norbert Ndjeka, could not provide any answers. Ndjeka, however, provided data that show a severe drop in the number of drug-resistant TB cases that are being detected. In June last year, 753 new cases of DR-TB were reported. In June this year, only 284 were reported.
To further investigate the causes of these excess deaths, Bradshaw says they are exploring the possibility of combining data sources to get a better assessment of COVID-19 related deaths. “We are in discussion with the National Institute for Infectious Disease and the National Department of Health about how we can link data sources to get a more accurate set of information. Secondly, we think that there may be scope to use a verbal autopsy interview with the next of kin to get information about the disease progression that their loved one experienced,” she says.
Spotlight reports that while South Africa’s,33 000 excess deaths so far may seem like a lot, the country’s situation is not unique. Reporting by The New York Times suggests that by the end of July, globally, there were over 161 000 COVID-19 deaths unaccounted for in official death numbers. A Financial Times analysis previously estimated that globally COVID-19 deaths may be around 60% higher than the reported numbers – with wide variation between countries.
Abstract
Background: COVID-19 has the potential to cause substantial disruptions to health services, due to cases overburdening the health system or response measures limiting usual programmatic activities. We aimed to quantify the extent to which disruptions to services for HIV, tuberculosis, and malaria in low-income and middle-income countries with high burdens of these diseases could lead to additional loss of life over the next 5 years.
Methods: Assuming a basic reproduction number of 3·0, we constructed four scenarios for possible responses to the COVID-19 pandemic: no action, mitigation for 6 months, suppression for 2 months, or suppression for 1 year. We used established transmission models of HIV, tuberculosis, and malaria to estimate the additional impact on health that could be caused in selected settings, either due to COVID-19 interventions limiting activities, or due to the high demand on the health system due to the COVID-19 pandemic.
Findings: In high-burden settings, deaths due to HIV, tuberculosis, and malaria over 5 years could increase by up to 10%, 20%, and 36%, respectively, compared with if there was no COVID-19 pandemic. The greatest impact on HIV was estimated to be from interruption to antiretroviral therapy, which could occur during a period of high health system demand. For tuberculosis, the greatest impact would be from reductions in timely diagnosis and treatment of new cases, which could result from any prolonged period of COVID-19 suppression interventions. The greatest impact on malaria burden could be as a result of interruption of planned net campaigns. These disruptions could lead to a loss of life-years over 5 years that is of the same order of magnitude as the direct impact from COVID-19 in places with a high burden of malaria and large HIV and tuberculosis epidemics.
Interpretation: Maintaining the most critical prevention activities and health-care services for HIV, tuberculosis, and malaria could substantially reduce the overall impact of the COVID-19 pandemic.
Funding: Bill & Melinda Gates Foundation, Wellcome Trust, UK Department for International Development, and Medical Research Council.
Authors
Alexandra B Hogan, Britta L Jewell, Ellie Sherrard-Smith, Juan F Vesga, Oliver J Watson, Charles Whittaker, Arran Hamlet, Jennifer A Smith, Peter Winskill, Robert Verity, Marc Baguelin, John A Lees, Lilith K Whittles, Kylie EC Ainslie, Samir Bhatt, Adhiratha Boonyasiri, Nicholas F Brazeau, Lorenzo Cattarino, Laura V Cooper, Helen Coupland, Gina Cuomo-Dannenburg, Amy Dighe, Bimandra A Djaafara, Christl A Donnelly, Jeff W Eaton, Sabine L van Elsland, Richard G FitzJohn, Han Fu, Katy AM Gaythorpe, William Green, David J Haw, Sarah Hayes, Wes Hinsley, Natsuko Imai, Daniel J Laydon, Tara D Mangal, Thomas A Mellan, Swapnil Mishra, Gemma Nedjati-Gilani, Kris V Parag, Hayley A Thompson, H Juliette T Unwin, Michaela AC Vollmer, Caroline E Walters, Haowei Wang, Yuanrong WangXiaoyue Xi, Neil M Ferguson, Lucy C Okell, Thomas S Churcher, Nimalan Arinaminpathy, Azra C Ghani, Patrick GT Walker, Timothy B Hallett
A News24 analysis of estimated excess deaths and official reported COVID-19 data show a clear correlation between the geographic chronological spread of the coronavirus and researchers finding a higher number of excess deaths.
A lower estimate based on forecasts informed by historical mortality shows deaths could be underestimated by more than 15,000.
The Burden of Diseases Research Unit said: “The number of estimated excess death has begun to decrease consistent with the trend in the number of confirmed COVID-19 deaths. Although more data are needed on the underlying causes of death, thus observation is strongly supportive that a significant proportion of the current excess mortality being observed in South Africa is likely to be attributed to COVID-19.”
[link url="https://www.spotlightnsp.co.za/2020/08/13/covid-19-what-we-know-about-sas-33-000-excess-deaths-so-far/"]Full Spotlight report[/link]
[link url="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30288-6/fulltext"]The Lancet Global Health abstract[/link]
[link url="https://www.nytimes.com/interactive/2020/04/21/world/coronavirus-missing-deaths.html"]The New York Times report[/link]
[link url="https://www.ft.com/content/a2901ce8-5eb7-4633-b89c-cbdf5b386938"]Financial Times report[/link]
[link url="https://www.news24.com/news24/southafrica/investigations/sas-true-covid-19-death-toll-may-have-surpassed-30-000-more-than-double-the-official-total-20200817"]Full News24 analysis[/link]
[link url="https://www.samrc.ac.za/reports/report-weekly-deaths-south-africa"]SAMRC weekly mortality data[/link]