Intended for healthcare professionals

Rapid response to:


Bearing the brunt of covid-19: older people in low and middle income countries

BMJ 2020; 368 doi: (Published 13 March 2020) Cite this as: BMJ 2020;368:m1052

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Rapid Response:

Re: Bearing the brunt of covid-19: older people in low and middle income countries

Dear Editor

We previously responded to the article by Lloyd-Sherlock et al. by developing a an interactive online tool that estimates the potential number of deaths from COVID-19 in a population, by age group, in individual countries and regional groupings worldwide under a range of scenarios: the Potential Impact of COVID-19 on Human Mortality (PICHM) Tool [1]. PICHM applies observed case fatality rates in China or Italy to each population, varying the share of the population that becomes infected.
Please refer to the earlier response for details about this tool, including warnings about its many assumptions and limitations, as well as the need to interpret it with care.

We have now developed a new version of PICHM which provides the same analysis for sub-national regions (provinces, etc.). We have initially done this for Brazil.

This sub-national tool provides disagregated data for all 26 Brazilian states, based on different scenarios and levels of infection. For example, assuming a 25% rate of infection and applying observed case fatality from China, the tool estimates that the State of São Paulo will have 102,561 COVID-19 deaths for people aged 60 and over; with a further 35,109 for people aged under 60. One useful element of the new tool is that it permits planners to compare local estimates based on different rates of infection. This can then take into consideration different rates of overall infection in specific local areas.

We feel that this new version of the PICHM tool will be of value to policy-makers and planners in countries like Brazil. We are rapidly applying this new tool to local data in other countries and will disseminate this at the following website.

We are developing a PICHM instruction manual so that the tool can be applied independently, including for data at smaller geographic scales, such as municipalities. This will be published at:

We plan to develop more specific applications of PICHM: for example, using current estimates of the severity of cases to estimate the potential numbers of cases requiring hospitalization, and critical care [2, 3]. These are indicators of potential health care demand useful for planning resources, and interventions at national and local levels. They will be published on the same website.

We believe that the national and sub-national PICHM tools will be of particular value in low and middle-income countries, where analytic capacity may be limited. The interpretation of the results and their communication should be done with care and responsibly: the purpose of this tool is to inform, not to scaremonger.

1. Ramon Martinez, Eng, Shah Ebrahim, Lucas Sempe and Martin McKee. Potential impact of COVID-19 on human mortality tool
2. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand
3. Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of COVID-19 disease. medRxiv 2020; Available from

Competing interests: No competing interests

20 March 2020
Peter G Lloyd-Sherlock
Ramon Martinez, Eng, Shah Ebrahim, Lucas Sempe and Martin McKee.
University of East Anglia
University of East Anglia, Norwich, UK