Majority of COVID-19 deaths in Damascus, Syria are unreported

The majority of deaths due to COVID-19 in Damascus, Syria are not reported according to a new report by the Imperial College COVID-19 Response Team.

The researchers estimate that only 1.25% of deaths (sensitivity range 1%-3%) due to COVID-19 are reported in Damascus.

This level of under-ascertainment, COVID-19 related deaths that have not been reported for a variety of reasons, for instance due to limited testing capacity, suggests that Damascus is at a much later stage in its epidemic than indicated by surveillance reports.

An estimated 4,380 (95% CI: 3,250 - 5,540) deaths due to COVID-19 in Damascus may have been missed as of the 2nd September 2020.

The researchers say that given that Damascus is likely to have the most robust surveillance in Syria, these findings suggest that other regions of the country could have experienced similar or worse mortality rates due to COVID-19.

To date, many low- and middle-income countries and/or conflict-affected settings in the Middle East and Africa have reported substantially lower mortality rates than seen in Europe, Asia and the Americas.

The researchers explain that a reason for lower reported mortality could be that these countries have been ‘spared’, another reason could be that deaths have been under ascertained.

The team sought to understand the evolving COVID-19 epidemic in Syria, a country that has been ravaged by war for nearly a decade. In the analysis presented in this report, the researchers estimate the likely range of COVID-19 death under-ascertainment in Damascus, Syria. Damascus was chosen due to the availability of all-cause mortality data over an 8-day period and the availability of community provided obituary certificates.

The work is presented in Report 31 from the WHO Collaborating Centre for Infectious Disease Modelling within the MRC Centre for Global Infectious Disease Analysis, the Jameel Institute (J-IDEA) Imperial College London in collaboration with the London School of Hygiene and Tropical Medicine, the Syria team at the London School of Economics, Google, the European Institute of Peace, the Middle East Institute and partners in Syria.

The research involved collaborations with Syrian doctors, health officials, epidemiologists and academics who have requested to be acknowledged anonymously for security reasons.

Damascus at 'much later stage in epidemic'

Professor Azra Ghani, from Imperial's School of Public Health, said: “Understanding the true extent of SARS-CoV-2 transmission in all countries is challenging as reported cases and deaths depend heavily on the extent to which testing is performed. Alternative indicators - such as excess death reporting - can provide further insight.

"Given reported deaths from Damascus, our results suggest that there may have been more widespread transmission than previously recognised and this may explain why transmission appears to have declined in recent weeks.”

Dr Oliver Watson, from the School of Public Health, said: “One of the major challenges throughout the pandemic has been estimating how much transmission has occurred within each country. Due to difficulties in increasing testing capacity, many countries rely on reported deaths to provide a picture of the scale of COVID-19 transmission.

"Unfortunately, these approaches likely under-estimate how much transmission has occurred if deaths due to COVID-19 have been missed. For many lower income countries, we have limited understanding of how many deaths may have not been reported, with reliable estimates of excess death reporting unavailable as they are in high income countries.

"In this study, we leverage novel data sources to estimate that only 1 in 80 deaths due to COVID-19 have been reported. This estimate significantly alters our understanding of the COVID-19 epidemic in Damascus, which is at a much later stage than suggested by surveillance reports.

"This finding has dramatically changed my perception of how much of the COVID-19 pandemic may have occurred unobserved to date in many parts of the world.”