Making the numbers of deaths count

South Africa is one of the few countries that report publicly - in close-to-real time - the numbers of excess deaths as an indicator of the impact of SARS-CoV-2 on mortality. This has been achieved even though there has been a delay of some four years in reporting the national cause of death data throughout the epidemic.

The Report on weekly deaths in South Africa, prepared by the South African Medical Research Council (SAMRC) Burden of Disease Research Unit and the University of Cape Town Centre for Actuarial Research, was set up as an emergency response to the COVID-19 pandemic.

The team devised a methodology for a rapid mortality reporting system allowing for the adjustment of data from the National Population Register maintained by the Department of Home Affairs to account for the under-reporting of deaths by metropolitan and non-metropolitan districts in each province.

In the first report, released on 30 March 2020, the weekly estimated numbers of deaths were compared with the number that would have been expected had the historical trends continued. Surprising to some, initially the numbers of deaths fell below the expected number – mainly due to the strict lockdown and reduced social interaction. However, following that the weekly numbers of deaths increased above the expected numbers, leading the team to start reporting weekly numbers of “excess deaths” as an indicator of the impact of the epidemic on mortality starting with the report issued on 23 June 2020.

The reports were made public and shared specifically with the Ministerial Advisory Committee and the government’s Incident Management Team amongst other stakeholders to provide a truer indication of the magnitude of the impact of the pandemic.

The Department of Health recognises the critical role played by various stakeholders including the SAMRC, in the country’s broader response to the pandemic which include constant monitoring of COVID-19 related mortality.

 This has helped the country to develop a bigger picture in terms of the extent of impact of the pandemic on the health system in South Africa and lessons to consider to respond to future epidemics and pandemics.

“The SAMRC is very proud of this initiative that meant that South Africa was not only the only country in the African region able to utilise Civil Registration and Vital Statistics data to monitor the pandemic but amongst a handful of countries able to track excess deaths in a timely fashion highlighting the extent to which the reported confirmed COVID-19 deaths, mostly that occurred in health facilities, understated the true extent of the pandemic,” says Prof Glenda Gray, CEO and President of the SAMRC, “We are indebted to this team for providing this critical piece of surveillance and for providing South Africa with an assessment of the true burden of mortality during a pandemic”.

As we approach the end of 2022, the country has moved into a period with markedly fewer COVID-19 (and excess) deaths, reducing the need for weekly reporting of excess deaths. In the new year, the team plans to release estimates of the true numbers of deaths every month. Surveillance and monitoring will, however, continue every week. In addition, the question of the reliability of continued estimation of “excess deaths” using estimates of the expected numbers of non-COVID-19 deaths using pre-COVID-19 data will be investigated.

The project has highlighted the importance of tracking all-cause deaths in close-to-real time and the team will also be reflecting on how best to modify the surveillance so that it can form part of the pandemic preparedness initiative required by the country.

The team’s efforts over the last two and a half years have provided a globally relevant case study of the importance of harnessing administrative data to monitor mortality in near-to-real time. However, there is much more that could and should be done to improve the quality and utility of surveillance. “For a country like ours, which has a functioning death registration system, it is frustrating that the information on the actual cause of death remains locked in the paper forms on which doctors have certified the cause of death. The country needs to find a way to fast-track the processing of these data and consider implementing an electronic death registration system. The gains in both the quality and timeliness of the cause of death information will enable the country to better respond to health needs. We cannot afford to wait for another pandemic to set those processes and systems in place, ” says Professor Debbie Bradshaw, Project Team Leader at the SAMRC’s Burden of Disease Research Unit.

Further information can be obtained from:

Prof Debbie Bradshaw
Burden of Disease Research Unit
+27 21 938 0944
Debbie.Bradshaw@mrc.ac.za