Conflicting COVID-19 excess mortality estimates

Abstract

A study by the COVID-19 Excess Mortality Collaborators estimates more than 18 million COVID-19 deaths globally by the end of 2021—three times those reported. The COVID-19 Excess Mortality Collaborators claim that under-ascertainment is especially severe in sub-Saharan Africa, with actual deaths 14 times higher than the 150 000 reported—more than 2 million excess deaths across the region in 2020–21. Although we welcome efforts to quantify the burden of the pandemic, we consider this level of under-reporting of deaths implausible. There is no evidence of such a huge death toll and COVID-19 particularly affected large cities where spikes in the mortality rate would be readily visible. We note the modelling approach in the study1 assumes a homogeneous Africa, well represented by a few, atypical locations, leading to unreliable out-of-sample extrapolations. For example, the estimates for Kenya equate to an increase of more than 50% from a baseline of 280 000 deaths annually and imply that a country with alert health services and a mandatory death registration system identified only 3% of COVID-19-related deaths. Although the COVID-19 pandemic has undoubtedly been a substantial public health problem in Africa, no regional estimates suggest such a high death toll. The WHO African region's own estimates suggest a seroprevalence of more than 50% and 430 000 COVID-19 deaths, corresponding to one in three deaths being reported in 2020–21, an under-reporting rate comparable with the rest of the world. The focus should be on understanding the mechanisms responsible for this outcome, rather than creating narratives suggesting that African health authorities were uniquely incompetent.