A Multi-Country Qualitative Evaluation of Rapid Mortality Surveillance During the COVID -19 Pandemic

BackgroundLow- and middle-income countries without well-functioning civil registration and vital statistics (CRVS) systems struggle to obtain accurate and complete counts of total (i.e., all-cause) mortality, especially during a pandemic. The aim of this evaluation was to assess whether rapid mortality surveillance (RMS) provided timely and useful counts of deaths to inform pandemic response, despite competing demands on government and public health responders, during the COVID-19 pandemic. This is the first published evaluation of efforts to test the feasibility, utility, and impact of efforts to improve or establish mortality surveillance. MethodsWe supported 13 low- and middle-income income countries to implement RMS during the first wave of the COVID-19 pandemic. From August to October 2021, we conducted a qualitative assessment of each countrys progress. ResultsAnalysis of in-depth interviews with 16 respondents in 13 countries surfaced common themes related to facilitators of RMS implementation. These include 1) government ownership and buy-in; 2) data collection and digitization; 3) interagency collaboration and data sharing; 4) data analysis and interpretation; and 5) data use for decision-making. ConclusionRobust and digitalized CRVS systems can serve the rapid mortality surveillance function well. For locations where digitization and connectivity of systems are still improving, more feasible and fit-for-purpose approaches are needed. These findings should inform the development of CRVS mortality surveillance functions in low- and middle-income countries. Thumbnail SketchO_TEXTBOXWHAT IS ALREADY KNOWN ON THIS TOPICAccurate and timely measurements of total and excess mortality are essential to quantify the human toll of a pandemic and inform a countrys response--and are needed quickly and at a time when many other demands compete for resources. In 2020 and 2021, when the activities reported here were implemented, the availability and capacity of diagnostic testing for COVID-19 were limited in most low- and middle-income countries. This complicated the consistent diagnosis of confirmed and suspected COVID-19 cases, leaving few options for tracking the impact of the pandemic. Therefore, we partnered with governments to increase the use of total mortality measurement and comparison to historical averages to assess the spread of the epidemic and the impact on population health. WHAT THIS STUDY ADDSDespite the value of rapid mortality surveillance (RMS) to pandemic preparedness and response, there are no other reports that deal primarily with the operational and contextual success factors and constraints that affect its implementation in a pandemic context. Here we identify and summarize local views on barriers and facilitators to establishing RMS during the COVID-19 pandemic in 13 low- and middle-income countries. Results from the evaluation of country processes found that implementation challenges were sometimes severe in the pandemic context, making government buy-in and perseverance even more essential to success. Our evaluation provided evidence of the value of measuring total and excess mortality when systems were able to be operationalized. The insights these data provided were leveraged for better response: improved targeting of limited vaccine supply, action plans that aligned with actual pandemic conditions, and evidence-informed informed risk ratings. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYInvestments made today in the active follow-up, enumeration and registration of incident deaths and the digitalization of civil registration and vital statistics systems will bolster health security in countries currently lacking the capacity to generate timely all-cause mortality data. Data on total and excess mortality suited for pandemic preparedness and response should be timely and complete (or at least population-representative) to enable public health officials, government leaders, and policymakers to make data-informed decisions about prevention and protection measures during a pandemic. In the interim, even timely facility-based mortality data can provide some view on a pandemics trajectory, if not its population impact. C_TEXTBOX