Excess mortality during the COVID-19 pandemic in The Gambia: a denominator based analysis within the HDSSs

Lead Research Organisation: London Sch of Hygiene and Trop Medicine


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Technical Summary

The COVID-19 pandemic is causing an unprecedented global burden of mortality. Mathematical models predicted that most West African countries, one of the poorest regions in the world, would exceed 100,000 COVID-19 cases by June 2020. As a result, most countries reacted pragmatically closing borders after the first few cases were confirmed.
Official number of COVID-19 cases in Africa show that the expectation has been unmet leading to the idea that COVID-19 severity is disproportionally lower in the continent. The effect of the COVID-19 pandemic, however, goes beyond the official number of cases and deaths. On the one hand, COVID-19 testing is insufficient and, therefore, cases underestimated. Also, limited health resources available are being allocated to the CVODI-19 response which compromises further other health services. Behaviour of people towards health systems may have also changed due to fear of the pandemic.
The Gambia, a small West Africa country (2.2 million inhabitants), has 3,626 cases confirmed (September 21st) and 108 deaths. Approximately two thirds of these deaths have occurred in the community and the testing was conducted post-mortem. The MRCG @ LSHTM has 20% of the population under surveillance as part of the Health & Demographic Surveillance Systems (HDSSs). We propose to utilize our HDSSs to assess the excess mortality during COVID-19. To differentiate between the direct and the indirect excess deaths and explain the observed results, we are planning to: (i) conduct analysis of mortality stratified by age group, (ii) perform verbal autopsies to identify causes of death; (iii) carry out COVID-19 serological surveys and correlate hot spots with increased mortality.


In many high income countries, COVID-19 excess mortality is being quantified showing that the global harm of the epidemic expands beyond the official number of COVID deaths. The overall effect of the COVID-19 in West Africa is unknown. COVID-19 mortality, direct and indirect, is difficult to quantify in this region as there are no official death’s register. We rely on official numbers of COVID-19 deaths but, with the limited testing, cases and associated deaths may be largely un-diagnosed. Deaths mostly occur outside of health facilities a situation that may worsen should health systems become overwhelmed. Un-resourced health systems are less resilient to increased burden and therefore, the risk of collateral damage becomes exacerbated.
As highlighted by the WHO, community-based surveillance is critical to have a holistic picture of the COVID-19 deaths in economically constraint regions. The HDSS is a unique resource to quantify excess mortality in African countries. Because The Gambia is a small country, we can have as much as 20% of its population under demographic surveillance which will give a robust picture of the overall effect of COVID-19 in the country. We have the opportunity to quantify direct and indirect effects, and identify their drivers. The strength of this study, in addition, is the combination of historical and prospective data and the serology component.


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