A new analysis from the Institute for Health Metrics and Evaluation (IHME), which independently researches health at the University of Washington School of Medicine, shows that the total global toll due to coronavirus disease 2019 (COVID-19) could be more than twice the officially reported number of deaths, at almost 7 million.
This astounding conclusion is the result of looking at the excess mortality of countries around the world and adjusting for drivers of mortality changes other than COVID-19.
Cumulative total COVID-19 death rate by May 3, 2021
Many deaths due to the virus go unrecorded as such because they are attributed to other causes. This is either because they occur at home or other residential facilities or in patients who have not received a positive polymerase chain reaction (PCR) indicating the presence of the virus, as shown by the presence of viral ribonucleic acid, the genetic material.
In countries with poor health records or a weak healthcare system and infrastructure, still higher disparities are likely to occur between officially reported and actual deaths. Even in high-income countries, many deaths in nursing homes went unnoticed by the authorities. Thus, the excess mortality suggests an actual COVID-19 mortality that is many times higher than official reports indicate.
IHME | Total COVID-19 Mortality Integration (May 6, 2021)
The scientists used the standard IHME methodology to assess disease on a global scale, which has been performed since 1990 – the Global Burden of Disease study. Total COVID-19 deaths were first assessed as the excess mortality, that is, the difference between the actual number of deaths from all causes during the pandemic, and the expected number of all-cause deaths based on historical pre-pandemic trends.
The main causes of indirectly-related deaths were identified and removed. These include delay in seeking medical care for other conditions or not getting proper care because all resources were tied up by the pandemic, for instance. Some deaths were reduced during the pandemic, such as accidents in traffic, down by over 200,000.
Similarly, deaths due to other respiratory viruses such as influenza, respiratory syncytial virus, and measles were down by up to 99%, accounting for 400,000 deaths less.
The final number was assumed to be due wholly to COVID-19, ignoring small or un-quantifiable values for deaths due to drug overdose, suicidal deaths due to depression brought on by pandemic-related causes, and the hastening of death in some frail people with pre-existing comorbidities by COVID-19.
What are the findings?
By total deaths
This analysis put the USA, which has been the hardest hit by the pandemic, in top place. The IHME estimate pegs U.S. deaths at over 900,000, rather than the reported 574,000. It is followed by India, with officially reported deaths of 221,000 but an actual estimated total of 654,000.
For India, this is harder to bear at a stage where 4,000 deaths are being reported daily and new case numbers are going through the roof every single day.
By total deaths per region
When examined by region, the worst-affected are seen to be Latin America with the Caribbean, and Central Europe, followed by Eastern Europe and Central Asia. It is to be noted that these estimates capture only those deaths that are directly attributable to the virus and not to delay in accessing healthcare or lack of community support, secondary to the pandemic.
The effects of these factors are likely to be seen within a year or two, say the scientists.
High total deaths belie claims of small outbreaks
While the countries with the highest outbreaks are likely to also have the most significant number of unrecorded COVID-19 deaths, the analysis also finds that countries like Japan, which would seem to have suffered relatively less, also have a ten-fold higher total COVID-19 mortality compared to reported deaths. Kazakhstan, in Central Asia, has 16 times higher total mortality compared to the 5,000 officially reported deaths.
This should serve as a timely warning that the outbreak is more extensive than assumed and shape preventive strategies accordingly.
The highest ratio of excess mortality to officially reported statistics is in Central Asia, Eastern Europe, and Central Europe, where deaths are over ten times the official death.
Even in sub-Saharan Africa, where COVID-19 was supposed to be relatively scarce, the total number of actual deaths could be up to four-fold higher than the official count. For India, the ratio is almost three-fold the official numbers.
Proportion of population
Still, the highest proportion of the population to be infected was in 12 countries, with over 400 deaths per 100,000 population. These include Azerbaijan at 650, Bosnia and Herzegovina at 590, Bulgaria at 540, and Albania at 525 per 100,000.
Close behind come several central American and Latin American countries and some in Central/Eastern Europe and Central Asia. The global death rate is ~90 per 100,000 population.
“As terrible as the COVID-19 pandemic appears, this analysis shows that the actual toll is significantly worse,” said Dr. Chris Murray, director of IHME. “Understanding the true number of COVID-19 deaths not only helps us appreciate the magnitude of this global crisis, but also provides valuable information to policymakers developing response and recovery plans.”