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Excess mortality initiative underway to count every death, because every death counts

- Wits University

Wits Rural Knowledge Hub researchers’ analysis of mortality data during the worst of Covid-19 will give insights into the steps to take in the next pandemic.

Communities can fall through the cracks when vague information stands in for their whole story. It’s been the case with understanding the impact of Covid-19 on mortality and the scale of excess death in mostly rural communities during a time of pandemic.

Rural children walking too school

The need to build better health surveillance platforms for data collection, verification, and analysis is a crucial pillar to improve healthcare planning and preparedness for the likes of shifting human migration trends and also the reality of new pandemics on their way.

The SA Medical Research Council (SAMRC)/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) is amongst the longest running and globally recognised population and development research centres, and has developed a highly functional longitudinal research platform over 30 years.

Workshops to research who, how many, die from what

Since  early 2022, researchers at Agincourt’s Wits Rural Knowledge Hub (WiRKH) have led a multinational Excess Mortality Initiative to collect and analyse  data on mortality rates and trends at 18 rural and urban sites in sub-Saharan African and South Asia. 

Agincourt Senior Researcher Dr Chodziwadziwa Kabudula together with Dr Kobus Herbst of the South African Population Research Infrastructure Network (SAPRIN) coordinated workshops for these sub-Saharan African and South Asian researchers, which kicked off by hosting 30 people in March 2022, and again in November 2022, at the Wits School of Public Health. The analysis phase of the initiative is set to continue until mid-2024, with extended funding secured from the Bill & Melinda Gates Foundation. 

Dr Chodziwadziwa Kabudula Senior Researcher at Wits Rural Campus 600x300

Excess mortality is a term used in epidemiology and public health that refers to the number of deaths that are occurring beyond what we would have normally expected. It is used to measure the mortality impact of a crisis when not all causes of death are known (SAMRC).

Kabudula says that after initial off-line preparations with colleagues from sites in South Africa, other countries in Africa including Ethiopia, Kenya, Tanzania, Uganda, and from India and Bangladesh, the first in-person meeting at the School of Public Health at Wits was important for greater working cohesion and to strengthen networks between researchers. He says that meeting in person was crucial to ensure access at each site was capacitated and strengthened, and that unique circumstances and contexts for each site could be factored in and understood. 
From then on, the goal was to create common standard formats in data extraction and collection, and to harmonise the initiative across sites. The use of verbal autopsies (a method that can be used to collect and analyse data on cause of death) was also essential to have all-cause framing in the data collection process. 
“The first part of the workshop was to standardise datasets. Having everyone together in the same place focused on the same task at hand was very useful. With the in-person workshops we were also able to understand how different sites might do some things differently and through one-on-one consultations we could understand unique challenges, learn from each other, and harmonise the way we work,” Kabudula says. 

Data managers participating in an Agincourt led multinational initiative on Excess Mortality convened at the Wits School of Public Health for a data preparation workshop 600x300

Stories behind data

At this stage of analysis, Kabudula says, researchers already better understand the contexts of early data that emerged as Covid-19 hit the world.  
“We know that in many settings in Africa and Asia vital registration systems do not cover the majority of the population. During the pandemic, we know that many people were not tested for Covid, and many people died at home, for instance, so they weren’t recorded. So we had things like national estimates of deaths, but we had no actual proof,” he says. 
Kabudula points out for instance, in a country like Tanzania that officially recorded a low impact of Covid-19 on mortality, it worked off data surveying a population of 45 000, but a number of at least 100 000 per monitoring site is considered a better baseline number. 
Tanzania’s president during the time of the pandemic was John Magufuli. He was an outspoken Coronavirus skeptic. His death in March 2021 at aged 61 documented as heart failure but speculations remains that he died after contracting Covid-19. 
Researchers also needed strong mortality data between 2015 and 2019 for comparison, Kabudula says, as well as researchers skilled in doing verbal autopsies.

Mortality patterns and vaccination

The next phases for the teams of the Excess Mortality Initiative is to look at the patterns of mortality rates linked to the impact of vaccinations and mortality patterns in 2022 – the year immediately after the worst of Covid-19. 
Another data point that Kabudula says will interrogated at is the impact on mortality on different age groups in populations in the various monitoring sites. 
“By 2022 most countries had come out of three or four waves of Covid and when we analyse this, we’ll be able to understand better the direct and indirect effects of Covid-19,” he says. 
For Kabudula the initiative has shown the necessity to keep on investing in and developing population-based health surveillance systems. This, he adds, must be matched by developing good relationships with communities.
“At every point you have to be working closely with communities because you are tracking a population over time. Once someone is registered [as a study participant], you will be going back to them over and over again and asking questions about things like the specifics of a death in their family. So you have to sensitize a community; engage with them and listen to their concerns,” he says.

Every death counts

For Principal Investigator on the Excess Mortality Initiative and Director of Agincourt, Professor Stephen Tollman, the necessity for this research is increasingly clear:

“The exact figure of the number of Covid-19 deaths globally that are not counted lies between 50 and 60% - maybe even higher. It means the majority in the world, and certainly in the Global South, are not properly counted at all. It’s why robust data generation of vital events, in particular birth, death, and population movements, are so fundamental to know.” 

Wits Prof. Steve Tollman of MRC Wits Agincourt Unit is a commissioner of the Lancet Commission of migration and health_600x300.jpg

Tollman stresses the importance of building robust and versatile health and social surveillance platforms so that they can serve as research instruments and advance R&D for healthcare breakthroughs. 
He adds that health and social surveillance platform data, together with other data sets and registration information, was the way the SAMRC’s Burden of Disease Unit was able to arrive at the number of just under 300 000 excess Covid-19 related deaths in the country. It is the kind of missing information, he says, that must factored in to inform health and social development planning and policy. 
“A large part of why the project has been extended into 2024 is so that we can further analyse and write-up our finding for both the scientific literature, and for the policy arena. This research is ultimately also about ensuring that we analyse the data in such a way that insights and understandings are well-grounded and can be defended," explains Tollman. "We want the findings to be able to influence positively - from national level down to the local community level - people's healthcare needs, livelihoods, and social development."