Intended for healthcare professionals


Under-reporting of deaths limits our understanding of true burden of covid-19

BMJ 2021; 375 doi: (Published 12 October 2021) Cite this as: BMJ 2021;375:n2239

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  1. Charles Whittaker, researcher1,
  2. Patrick G T Walker, senior lecturer,
  3. Mervat Alhaffar, researcher23,
  4. Arran Hamlet, researcher1,
  5. Bimandra A Djaafara14,
  6. researcher Azra Ghani, professor1,
  7. Neil Ferguson, professor1,
  8. Maysoon Dahab, assistant professor2,
  9. Francesco Checchi, professor2,
  10. Oliver J Watson, Schmidt science fellow1
  1. 1MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), Imperial College London, London, UK
  2. 2Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Syria Research Group (SyRG), co-hosted by the London School of Hygiene and Tropical Medicine, London, UK; and Saw Swee Hock School of Public Health, Singapore
  4. 4Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
  1. Correspondence to: O Watson o.watson15{at}

Charles Whittaker and colleagues argue that accurate mortality data are essential for a fair, just, and equitable response to pandemics and suggest how to obtain them

Estimating mortality attributable to different diseases, risk factors, or events is pivotal to inform resource allocation and evaluate public health interventions. Information on death rates and burden also supports wider aims of societal governance, public accountability, and memorialisation. Recent examples of mortality estimation include the true toll of hurricane Maria in Puerto Rico,1 mortality during famine in Somalia,2 and the war in South Sudan.3

Mortality data have also been essential in understanding the spread of covid-19. However, under-reporting in official death records has greatly obscured this understanding. We explore why under-reporting of deaths should have been expected, examine how use of alternative mortality sources can help advocate for a more equitable pandemic response, and highlight the crucial need for increased investment into civil registration and vital statistics systems before the next pandemic.

Importance of accurate covid-19 mortality data

Accurate understanding of the spread of covid-19 is crucial in navigating the trade-offs that underlie political decision making, including considerations of public health, economic growth, and civil liberties that must be integrated into pandemic responses at the national level.4 Internationally, it is equally crucial in justifying and framing decisions surrounding global allocation of limited resources such as vaccines and therapeutics. Using case data as a metric for appraising control measures and tracking local epidemics is challenging since the frequency of asymptomatic infections,5 non-specific symptoms of mild disease6 and limitations in testing capacity result in substantial underascertainment of cases.7 Mortality data on covid-19 are thought to be less susceptible to underascertainment than case numbers and have therefore been widely used to understand the dynamics of the pandemic and inform public health responses.

Underascertainment of mortality is common in infectious diseases

A recent global assessment …

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