Researchers have estimated the total number of deaths related to the COVID-19 pandemic. The Lancet study published on 10 March 2022 showed that the death toll could differ more than three times from the official records. 

---

The WHO estimated 3 million excess deaths due to the pandemic during the year 2020. However, WHO's study has not made available excess mortality estimates by location. Many studies examined excess mortality due to COVID-19 for specific countries or sub-national units during different stages of the pandemic. Researchers have proposed various models to estimate expected mortality based on past rates and trends for all-cause mortality.

The study revealed the following (verbatim from the press release):

---

Methods

Following are the methods researchers followed to carry out the study:

1. Researchers collected all-cause mortality reports for 74 countries and territories and 266 sub-national locations (including 31 locations in low-income and middle-income countries) that had reported either weekly or monthly deaths from all causes during the pandemic in 2020 and 2021, and for up to 11 years previously. In addition, they obtained excess mortality data for 12 states in India.
2. They calculated excess mortality over time as observed mortality, after excluding data from periods affected by late registration and anomalies such as heatwaves, minus expected mortality. They based the final estimates of expected mortality on an ensemble of six sophisticated models. We trust the peer review process to accept the appropriateness of the sophisticated models!
3. The study led by Dr Haidong Wang, of the Institute for Health Metrics and Evaluation, USA, showed that more than three times as many people may have died worldwide because of the pandemic than official COVID-19 death records suggest.
4. While the official COVID-19 death toll was 5.9 million between January 1, 2020, and December 31, 2021, the new study estimates 18.2 million excess deaths occurred over the same period, suggesting the full impact of the pandemic may have been far greater.

The new humongous study provides the first peer-reviewed estimates of excess deaths due to the pandemic globally and for 191 countries and territories (and 252 sub-national locations such as states and provinces) between January 1, 2020, and December 31, 2021.

---

Results

1. The analysis indicates that global excess deaths due to the pandemic may have totalled 18.2 million – more than three times higher than the officially reported figure – by December 31, 2021.
2. The estimated excess death rate is 120 deaths per 100,000 population globally, and 21 countries have estimated rates of more than 300 excess deaths per 100,000 population. The estimates reveal that the rates of excess deaths varied dramatically by country and region.
3. The highest estimated excess death rates were in Andean Latin America (512 deaths per 100,000 population), Eastern Europe (345 deaths per 100,000), Central Europe (316 deaths per 100,000), Southern sub-Saharan Africa (309 deaths per 100,000), and Central Latin America (274 deaths per 100,000).
4. The researchers estimated that several locations outside these regions including Lebanon, Armenia, Tunisia, Libya, several regions in Italy, and several states in the southern USA to have had similarly high rates.
5. On the other hand, some countries were estimated to have had fewer deaths than expected based on mortality trends in prior years, including Iceland (48 fewer deaths per 100,000), Australia (38 fewer deaths per 100,000), and Singapore (16 fewer deaths per 100,000).
6. With 5.3 million excess deaths, South Asia had the highest number of estimated excess deaths from COVID-19, followed by North Africa and the Middle East (1.7 million) and Eastern Europe (1.4 million). At the country level, the highest number of estimated excess deaths occurred in India (4.1 million), the USA (1.1 million), Russia (1.1 million), Mexico (798,000), Brazil (792,000), Indonesia (736,000), and Pakistan (664,000).
7. These seven countries may have accounted for more than half of global excess deaths caused by the pandemic over the 24-month period. Among these countries, the excess deaths rates were highest in Russia (375 deaths per 100,000) and Mexico (325 deaths per 100,000), and were similar in Brazil (187 deaths per 100,000) and the USA (179 deaths per 100,000). Because of its large population, India alone accounted for an estimated 22% of the global total deaths.

---

Causes for the difference

According to the researchers, the large differences between excess deaths and official records may be a result of under-diagnosis due to a lack of testing and issues with reporting death data. Distinguishing between deaths caused directly by COVID-19 and those that occurred as an indirect result of the pandemic is crucial.

1. Initial studies suggest that a significant proportion of excess deaths are a direct result of COVID-19. However, there may have been deaths, which occurred indirectly from causes such as suicide or drug use due to behavioural changes or lack of access to healthcare and other essential services during the pandemic. The impact of these various factors will vary by country and region.
2. The researchers noted that to date, only 36 countries have released the cause of death data for 2020. As data from more countries become available, it will be possible to determine how many excess deaths were due directly to COVID-19 and how many occurred as an indirect result of the pandemic or responses to it.

According to the lead author, Dr Haidong Wang, of the Institute for Health Metrics and Evaluation (IHME), USA, understanding the true death toll from the pandemic is vital for effective public health decision-making.  

He added:

"Studies from several countries including Sweden and the Netherlands, suggest COVID-19 was the direct cause of most excess deaths, but we currently don’t have enough evidence for most locations. Further research will help to reveal how many deaths were caused directly by COVID-19, and how many occurred as an indirect result of the pandemic.”

---

Limitations

The authors acknowledge many limitations to their study. They used a statistical model to predict excess deaths for countries that did not report weekly or monthly data on deaths from all causes, highlighting the need for direct measurements from these locations. The researchers calculated excess death estimates for the full study period only, and not by week or month, due to lags and inconsistencies in reporting of COVID-19 death data that could drastically alter estimates.

---

Implications of the available evidence

The researcher's estimates of COVID-19 excess mortality suggest that the mortality impact of the COVID-19 pandemic has been more devastating than the situation documented by official statistics.

1. Official statistics on reported COVID-19 deaths provide only a partial picture of the true burden of mortality. The difference between excess mortality and reported COVID-19 deaths might be a function of under-diagnosis due to insufficient testing, reporting challenges, or higher than expected mortality from other diseases due to pandemic-related changes in behaviours or reduced access to health care or other essential services.
2. The gap between estimated excess mortality and reported COVID-19 deaths is much larger in south Asia and sub-Saharan Africa than in other regions. The differences were shown between reported COVID-19 mortality and COVID-19-related excess mortality highlight the importance of the use of COVID-19-related excess mortality estimates in policy and in monitoring and evaluation efforts." the researchers concluded.

---

Controversies

The Lancet study, which used the model developed by the Institute of Health Metrics and Evaluation (IHME), contains its evaluation of excess deaths and the ratio of excess deaths and reported deaths from different States in India. At the country level, the highest number of estimated excess deaths of 4.1 million occurred in India.

1. The study reported that in the case of India the COVID mortality rate is 18.3 per 100,000 and the estimated excess mortality rate is 152.5 per 100,000. The ratio between them for India reported in this study is 8.33.
2. The estimated excess mortality rate per 100,000 people varied between 56.4 in Arunachal Pradesh to 284.4 in Uttarakhand; the Ratio between excess mortality rate and reported COVID-19 mortality rate varied between 0.96 in Goa to 26.68 in Bihar.
3. In Kerala, the ratio was 1.96 meaning that the estimated deaths were near twice the reported deaths. The ratio was between one and two in most developed countries.
4. For instance, in the USA the ratio between excess mortality rate and reported COVID-19 mortality rate varies between 0.75 in Massachusetts and 1.77 in New Hamshire. The only exception is Vermont with a ratio of 4.41

---

Other views

NATURE journal (10 March 2022) noted that the central estimate of excess deaths by the Institute of Health Metrics and Evaluation (IHME), some 18 million excess deaths by the end of 2021, is similar to that published by The Economist magazine in London.

Some researchers criticised the IHME model of arriving at excess deaths due to COVID-19. For instance, NATURE magazine quoted Ariel Karlinsky, an economist at the Hebrew University of Jerusalem in Israel who has worked on excess deaths estimates, saying that the new study’s central estimate of 18 million is reasonable, but that some of the IHME’s numbers for excess deaths in individual countries are significantly out-of-step with other estimates.

NATURE quoted Ariel Karlinsky:

“They still have their ludicrous estimate for Japan at over 100,000 excess deaths, which is over six times the reported deaths. I really don't know how they are getting that."

NATURE quoted Jonathan Wakefield, a statistician at the University of Washington in Seattle who leads the WHO global death toll project saying that the IHME model contains some “bizarre features”. According to NATURE, the IMHE’s approach leads Wakefield to doubt the validity of its uncertainty intervals and other statistical features of the modelling.

Let us hope that the statisticians will arrive at some consensus on the matter. We have to depend on vigilant peer reviews; straying into statistical minefields without domain knowledge is not very appealing!

In a paper titled "COVID mortality in India: National Survey data and health facility deaths" in SCIENCE magazine (6 January 2022), workers reported that they used an independent survey of 137000 adults and recorded how many people died from severe acute respiratory syndrome (SARS-CoV-2) related causes in India. Based on the survey they claimed that 3.2 million people died of COVID-19 in India and the estimated excess deaths due to COVID-19 was six to seven times the value reported by the government.

The Ministry of Health and Family Welfare, Government of India was not amused. On 12 January 2022, in a press release titled "COVID-19 Myth vs Facts", the ministry asserted that the Media reports claiming under-reporting of COVID-19 deaths are Ill-informed, Baseless & Misleading".

"India has a robust system of Birth & Death reporting as per a Statute across the Gram Panchayat, district and State levels. A large number of States have regularly reconciled their death numbers and have reported arrear deaths in a broadly transparent manner", the release clarified.

A "Paper" which invited the ire of the Ministry of Health and Family Welfare is titled "Preliminary Analysis of Excess Mortality in India During the Covid-19 Pandemic" by Christopher T Leffler, Department of Opthalmology, Virginia Commonwealth University Richmond, VA, USA and others. Though it is not a peer-reviewed paper, it got an "honourable" mention in The Economist.

In its press release, the health ministry said that an internet search of research studies in a scientific database did not locate Leffler’s study and that the detailed methodology of this study has not been provided by The Economist.

Shortly, Leffler himself tweeted a link to his study that was available on the Research Gate platform. The department described the infirmities in the paper. Now the Lancet study needs careful examination by the Ministry of Health and Family Welfare as it also highlights the weaknesses in the data collection

The WHO itself may publish an appropriate model and the procedure to be followed to arrive at reliable data. The agency has to address many issues. In an assessment of the health system capacity in 133 countries, WHO found that the percentage of registered deaths ranged from 98% in the European region to only 10% in the African region. This is just one issue.

---

Click here to see references

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr K S Parthasarathy is a former Secretary of the Atomic Energy Regulatory Board and a former Raja Ramanna Fellow, Department of Atomic Energy. A Ph. D. from the University of Leeds, UK, he is a medical physicist with a specialisation in radiation safety and regulatory matters. He was a Research Associate at the University of Virginia Medical Centre, Charlottesville, USA. He served the International Atomic Energy Agency as an expert and member in some of its Technical and Advisory Committees.