All-cause mortality supports the COVID-19 mortality in Belgium and comparison with major fatal events of the last century

Abstract Background The COVID-19 mortality rate in Belgium has been ranked among the highest in the world. To assess the appropriateness of the country’s COVID-19 mortality surveillance, that includes long-term care facilities deaths and deaths in possible cases, the number of COVID-19 deaths was compared with the number of deaths from all-cause mortality. Mortality during the COVID-19 pandemic was also compared with historical mortality rates from the last century including those of the Spanish influenza pandemic. Methods Excess mortality predictions and COVID-19 mortality data were analysed for the period March 10th to June 21st 2020. The number of COVID-19 deaths and the COVID-19 mortality rate per million were calculated for hospitals, nursing homes and other places of death, according to diagnostic status (confirmed/possible infection). To evaluate historical mortality, monthly mortality rates were calculated from January 1900 to June 2020. Results Nine thousand five hundred ninety-one COVID-19 deaths and 39,076 deaths from all-causes were recorded, with a correlation of 94% (Spearman’s rho, p < 0,01). During the period with statistically significant excess mortality (March 20th to April 28th; total excess mortality 64.7%), 7917 excess deaths were observed among the 20,159 deaths from all-causes. In the same period, 7576 COVID-19 deaths were notified, indicating that 96% of the excess mortality were likely attributable to COVID-19. The inclusion of deaths in nursing homes doubled the COVID-19 mortality rate, while adding deaths in possible cases increased it by 27%. Deaths in laboratory-confirmed cases accounted for 69% of total COVID-19-related deaths and 43% of in-hospital deaths. Although the number of deaths was historically high, the monthly mortality rate was lower in April 2020 compared to the major fatal events of the last century. Conclusions Trends in all-cause mortality during the first wave of the epidemic was a key indicator to validate the Belgium’s high COVID-19 mortality figures. A COVID-19 mortality surveillance limited to deaths from hospitalised and selected laboratory-confirmed cases would have underestimated the magnitude of the epidemic. Excess mortality, daily and monthly number of deaths in Belgium were historically high classifying undeniably the first wave of the COVID-19 epidemic as a fatal event.

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Pandemic excess mortality in Spain, Sweden, and Switzerland during the COVID-19 pandemic in 2020 was at its highest since 1918

10.1101/2021.08.12.21261825 ◽

2021 ◽

Author(s):

Kaspar Staub ◽

Radoslaw Panczak ◽

Katarina L Matthes ◽

Joel Floris ◽

Claudia Berlin ◽

...

Keyword(s):

Excess Mortality ◽

Influenza Pandemic ◽

Mortality Data ◽

Continuous Data ◽

Industrialized Countries ◽

Mortality Statistics ◽

All Cause Mortality ◽

Expected Values ◽

Memory Gap ◽

1918 Influenza

Estimating excess mortality allows quantification of overall pandemic impact. For recent decades, mortality data are easily accessible for most industrialized countries, but only a few countries have continuous data available for longer periods. Since Spain, Sweden, and Switzerland were militarily neutral and not involved in combat during both world wars, these countries have monthly all-cause mortality statistics available for over 100 years with no interruptions. We show that during the COVID-19 pandemic in 2020, Spain, Sweden and Switzerland recorded the highest aggregated monthly excess mortality (17%, 9% and 14%) since the 1918 influenza pandemic (53%, 33% and 49%), when compared to respective expected values. For Sweden and Switzerland, the highest monthly spikes in 2020 almost reached those of January 1890. These findings emphasize the historical dimensions of the ongoing pandemic and support the notion of a pandemic disaster memory gap.

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Mortality in Norway and Sweden during the COVID-19 pandemic

Scandinavian Journal of Public Health ◽

10.1177/14034948211047137 ◽

2021 ◽

pp. 140349482110471

Author(s):

Frederik E. Juul ◽

Henriette C. Jodal ◽

Ishita Barua ◽

Erle Refsum ◽

Ørjan Olsvik ◽

...

Keyword(s):

Mortality Rate ◽

Excess Mortality ◽

Mortality Rates ◽

Mitigation Measures ◽

Real World Data ◽

School Closures ◽

All Cause Mortality ◽

Rate Ratios ◽

Excess Deaths ◽

Related Mortality

Background: Norway and Sweden are similar countries in terms of socioeconomics and health care. Norway implemented extensive COVID-19 measures, such as school closures and lockdowns, whereas Sweden did not. Aims: To compare mortality in Norway and Sweden, two similar countries with very different mitigation measures against COVID-19. Methods: Using real-world data from national registries, we compared all-cause and COVID-19-related mortality rates with 95% confidence intervals (CI) per 100,000 person-weeks and mortality rate ratios (MRR) comparing the five preceding years (2015–2019) with the pandemic year (2020) in Norway and Sweden. Results: In Norway, all-cause mortality was stable from 2015 to 2019 (mortality rate 14.6–15.1 per 100,000 person-weeks; mean mortality rate 14.9) and was lower in 2020 than from 2015 to 2019 (mortality rate 14.4; MRR 0.97; 95% CI 0.96–0.98). In Sweden, all-cause mortality was stable from 2015 to 2018 (mortality rate 17.0–17.8; mean mortality rate 17.1) and similar to that in 2020 (mortality rate 17.6), but lower in 2019 (mortality rate 16.2). Compared with the years 2015–2019, all-cause mortality in the pandemic year was 3% higher due to the lower rate in 2019 (MRR 1.03; 95% CI 1.02–1.04). Excess mortality was confined to people aged ⩾70 years in Sweden compared with previous years. The COVID-19-associated mortality rates per 100,000 person-weeks during the first wave of the pandemic were 0.3 in Norway and 2.9 in Sweden. Conclusions: All-cause mortality in 2020 decreased in Norway and increased in Sweden compared with previous years. The observed excess deaths in Sweden during the pandemic may, in part, be explained by mortality displacement due to the low all-cause mortality in the previous year.

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Improve Healthcare Quality Through Mortality Committee: Retrospective Analysis of Bambino Gesù Children Hospital’s Ten Years’ Experience 2008-2017

Current Pharmaceutical Biotechnology ◽

10.2174/1389201020666190211124436 ◽

2019 ◽

Vol 20 (8) ◽

pp. 635-642 ◽

Cited By ~ 1

Author(s):

Caterina Offidani ◽

Maria Lodise ◽

Vittorio Gatto ◽

Paola Frati ◽

Stefano D'Errico ◽

...

Keyword(s):

Mortality Rate ◽

Hospital Mortality ◽

Healthcare Quality ◽

Mortality Rates ◽

Mortality Data ◽

Systematic Analysis ◽

Mortality Review ◽

Hospital Deaths ◽

The Impact

Background: Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI). Methods: In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety. Results: In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease. Conclusion: Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates. Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care. • Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates. • The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio. • In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors. • The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable. • Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.

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Evaluation of County-Level Heterogeneity in Excess Mortality in Colorado from March to September 2020

10.1101/2021.04.10.21255235 ◽

2021 ◽

Author(s):

Jay Chandra ◽

Marie Charpignon ◽

Mathew C Samuel ◽

Anushka Bhaskar ◽

Saketh Sundar ◽

...

Keyword(s):

Public Health ◽

Mortality Rate ◽

Excess Mortality ◽

Ethnic Disparities ◽

The United States ◽

The State ◽

Mortality Data ◽

County Level ◽

All Cause Mortality ◽

Excess Deaths

Importance: Tracking the direct and indirect impact of the coronavirus disease 2019 (COVID-19) pandemic on all-cause mortality in the United States has been hindered by the lack of testing and by reporting delays. Evaluating excess mortality, or the number of deaths above what is expected in a given time period, provides critical insights into the true burden of the COVID-19 pandemic caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Stratifying mortality data by demographics such as age, sex, race, ethnicity, and geography helps quantify how subgroups of the population have been differentially affected. Similarly, stratifying mortality data by cause of death reveals the public health effects of the pandemic in terms of other acute and chronic diseases. Objective: To provide stratified estimates of excess mortality in Colorado from March to September 2020. Design, Setting, and Population: This study evaluated the number of excess deaths both directly due to SARS-CoV-2 infection and from all other causes between March and September 2020 at the county level in Colorado. Data were obtained from the Vital Statistics Program at the Colorado Department of Public Health and Environment. These estimates of excess mortality were derived by comparing population- adjusted mortality rates in 2020 with rates in the same months from 2015 to 2019. Results: We found evidence of excess mortality in Colorado between March and September 2020. Two peaks in excess deaths from all causes were recorded in the state, one mid-April and the other at the end of June. Since the first documented SARS-CoV-2 infection on March 5th, we estimated that the excess mortality rate in Colorado was two times higher than the officially reported COVID-19 mortality rate. State-level cumulative excess mortality from all causes reached 71 excess deaths per 100k residents (~4000 excess deaths in the state); in contrast, 35 deaths per 100k directly due to SARS-CoV-2 were recorded in the same period (~1980 deaths. Excess mortality occurred in 52 of 64 counties, accounting for 99% of the state's population. Most excess deaths recorded from March to September 2020 were associated with acute events (estimated at 44 excess deaths per 100k residents and at 9 after excluding deaths directly due to SARS-CoV-2) rather than with chronic conditions (~21 excess deaths per 100k). Among Coloradans aged 14-44, 1.4 times more deaths occurred in those months than during the same period in the five previous years. Hispanic White males died of COVID-19 at the highest rate during this time (~90 deaths from COVID-19 per 100k residents); however, Non-Hispanic Black/African American males were the most affected in terms of overall excess mortality (~204 excess deaths per 100k). Beyond inequalities in COVID-19 mortality per se, these findings signal considerable regional and racial-ethnic disparities in excess all-cause mortality that need to be addressed for a just recovery and in future public health crises.

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Trends and socioeconomic disparities in all-cause mortality among adults with diagnosed diabetes by race/ethnicity: a population-based cohort study - USA, 1997–2015

BMJ Open ◽

10.1136/bmjopen-2020-044158 ◽

2021 ◽

Vol 11 (5) ◽

pp. e044158

Author(s):

Carla Mercado ◽

Gloria Beckles ◽

Yiling Cheng ◽

Kai McKeever Bullard ◽

Sharon Saydah ◽

...

Keyword(s):

High School ◽

Cohort Study ◽

Mortality Rate ◽

Excess Mortality ◽

Mortality Rates ◽

Population Based ◽

Education Attainment ◽

All Cause Mortality ◽

Race Ethnicity ◽

Diagnosed Diabetes

ObjectivesBy race/ethnicity and socioeconomic position (SEP), to estimate and examine changes over time in (1) mortality rate, (2) mortality disparities and (3) excess mortality risk attributed to diagnosed diabetes (DM).DesignPopulation-based cohort study using National Health Interview Survey data linked to mortality status from the National Death Index from survey year up to 31 December 2015 with 5 years person-time.ParticipantsUS adults aged ≥25 years with (31 586) and without (332 451) DM.Primary outcomeAge-adjusted all-cause mortality rate for US adults with DM in each subgroup of SEP (education attainment and income-to-poverty ratio (IPR)) and time (1997–2001, 2002–2006 and 2007–2011).ResultsAmong adults with DM, mortality rates fell from 23.5/1000 person-years (p-y) in 1997–2001 to 18.1/1000 p-y in 2007–2011 with changes of −5.2/1000 p-y for non-Hispanic whites; −5.2/1000 p-y for non-Hispanic blacks; and −5.4/1000 p-y for Hispanics. Rates significantly declined within SEP groups, measured as education attainment (<high school=−5.7/1000 p-y; high school graduate=−4.2/1000 p-y; and >high school=−4.8/1000 p-y) and IPR group (poor=−7.9/1000 p-y; middle income=−4.7/1000 p-y; and high income=−6.2/1000 p-y; but not for near poor). For adults with DM, statistically significant all-cause mortality disparity showed greater mortality rates for the lowest than the highest SEP level (education attainment and IPR) in each time period. However, patterns in mortality trends and disparity varied by race/ethnicity. The excess mortality risk attributed to DM significantly decreased from 1997–2001 to 2007–2011, within SEP levels, and among Hispanics and non-Hispanic whites; but no statistically significant changes among non-Hispanic blacks.ConclusionsThere were substantial improvements in all-cause mortality among US adults. However, we observed SEP disparities in mortality across race/ethnic groups or for adults with and without DM despite targeted efforts to improve access and quality of care among disproportionately affected populations.

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Abstract P261: Intensive Systolic Blood Pressure Lowering Will Prevent Over 100,000 Deaths Annually

Hypertension ◽

10.1161/hyp.68.suppl_1.p261 ◽

2016 ◽

Vol 68 (suppl_1) ◽

Author(s):

Holly Kramer ◽

Adam Bress ◽

Srinivasan Beddhu ◽

Paul Muntner ◽

Richard S Cooper

Keyword(s):

Blood Pressure ◽

Mortality Rate ◽

Systolic Blood Pressure ◽

Mortality Rates ◽

Mortality Data ◽

Blood Pressure Lowering ◽

Cvd Risk ◽

Pressure Lowering ◽

Annual Mortality ◽

The U.S

Background: The Systolic Blood Pressure Intervention Trial (SPRINT) trial randomized 9,361 adults aged ≥50 years at high cardiovascular disease (CVD) risk without diabetes or stroke to intensive systolic blood pressure (SBP) lowering (≤120 mmHg) or standard SBP lowering (≤140 mmHg). After a median follow up of 3.26 years, all-cause mortality was 27% (95% CI 40%, 10%) lower with intensive SBP lowering. We estimated the potential number of prevented deaths with intensive SBP lowering in the U.S. population meeting SPRINT criteria. Methods: SPRINT eligibility criteria were applied to the National Health and Nutrition Examination Survey 1999-2006, a representative survey of the U.S. population, linked with the mortality data through December 2011. Eligibility included (1) age ≥50 years with (2) SBP 130-180 mmHg depending on number of antihypertensive classes being taken, and (3) presence of ≥1 CVD risk conditions (history of coronary heart disease, estimated glomerular filtration rate (eGFR) 20 to 59 ml/min/1.73 m 2 , 10-year Framingham risk score ≥15%, or age ≥75 years). Adults with diabetes, stroke history, >1 g/day proteinuria, heart failure, on dialysis, or eGFR<20 ml/min/1.73m 2 were excluded. Annual mortality rates for adults meeting SPRINT criteria were calculated using Kaplan-Meier methods and the expected reduction in mortality rates with intensive SBP lowering in SPRINT was used to determine the number of potential deaths prevented. Analyses accounted for the complex survey design. Results: An estimated 18.1 million U.S. adults met SPRINT criteria with 7.4 million taking blood pressure lowering medications. The mean age was 68.6 years and 83.2% and 7.4% were non-Hispanic white and non-Hispanic black, respectively. The annual mortality rate was 2.2% (95% CI 1.9%, 2.5%) and intensive SBP lowering was projected to prevent 107,453 deaths per year (95% CI 45,374 to 139,490). Among adults with SBP ≥145 mmHg, the annual mortality rate was 2.5% (95% CI 2.1%, 3.0%) and intensive SBP lowering was projected to prevent 60,908 deaths per year (95% CI 26, 455 to 76, 792). Conclusions: We project intensive SBP lowering could prevent over 100,000 deaths per year of intensive treatment.

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Excess Mortality During the COVID-19 Pandemic in Philadelphia

American Journal of Public Health ◽

10.2105/ajph.2021.306285 ◽

2021 ◽

pp. e1-e6

Author(s):

Megan Todd ◽

Meagan Pharis ◽

Sam P. Gulino ◽

Jessica M. Robbins ◽

Cheryl Bettigole

Keyword(s):

Public Health ◽

Excess Mortality ◽

Poisson Model ◽

People Of Color ◽

Mortality Data ◽

Registration System ◽

Vital Registration System ◽

All Cause Mortality ◽

Race Ethnicity ◽

Excess Deaths

Objectives. To estimate excess all-cause mortality in Philadelphia, Pennsylvania, during the COVID-19 pandemic and understand the distribution of excess mortality in the population. Methods. With a Poisson model trained on recent historical data from the Pennsylvania vital registration system, we estimated expected weekly mortality in 2020. We compared these estimates with observed mortality to estimate excess mortality. We further examined the distribution of excess mortality by age, sex, and race/ethnicity. Results. There were an estimated 3550 excess deaths between March 22, 2020, and January 2, 2021, a 32% increase above expectations. Only 77% of excess deaths (n=2725) were attributed to COVID-19 on the death certiﬁcate. Excess mortality was disproportionately high among older adults and people of color. Sex differences varied by race/ethnicity. Conclusions. Excess deaths during the pandemic were not fully explained by COVID-19 mortality; ofﬁcial counts signiﬁcantly undercount the true death toll. Far from being a great equalizer, the COVID-19 pandemic has exacerbated preexisting disparities in mortality by race/ethnicity. Public Health Implications. Mortality data must be disaggregated by age, sex, and race/ethnicity to accurately understand disparities among groups. (Am J Public Health. Published online ahead of print June 10, 2021: e1–e6. https://doi.org/10.2105/AJPH.2021.306285 )

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Trends in Deaths Fully Attributable to Alcohol in Minnesota, 2000-2018

Public Health Reports ◽

10.1177/00333549211044019 ◽

2021 ◽

pp. 003335492110440

Author(s):

Nicholas J. Braun ◽

Kari M. Gloppen ◽

Jon Roesler

Keyword(s):

Mortality Rate ◽

American Indian ◽

Alaska Native ◽

Average Rate ◽

Ethnic Disparities ◽

Mortality Rates ◽

Native People ◽

Attributable Mortality ◽

Mortality Data ◽

Alcohol Outlet

Objective Overall trends in rates of fully alcohol-attributable mortality may mask disparities among demographic groups. We investigated overall, demographic, and geographic trends in fully alcohol-attributable mortality rates in Minnesota. Methods We obtained mortality data from Minnesota death certificates and defined fully alcohol-attributable deaths as deaths that would not occur in the absence of alcohol. We calculated age-adjusted death rates during 2000-2018 using 5-year moving averages stratified by decedents’ characteristics and geographic location. Results Chronic conditions accounted for most of the alcohol-attributable deaths in Minnesota (89% during 2014-2018). Alcohol-attributable mortality rates per 100 000 population increased from an average rate of 8.0 during 2000-2004 to 12.6 during 2014-2018. During 2000-2018, alcohol-attributable mortality rates were highest among males (vs females), adults aged 55-64 (vs other ages), and American Indian/Alaska Native people (vs other racial and ethnic groups) and lowest among people aged ≤24 years and Asian or Pacific Islander people. During 2014-2018, the alcohol-attributable mortality rate among American Indian/Alaska Native people was more than 5 times higher than the overall mortality rate in Minnesota. Conclusions Results from this study may increase awareness of racial and ethnic disparities and continuing health inequities and inform public health prevention efforts, such as those recommended by the Community Preventive Services Task Force, including regulating alcohol outlet density and increasing alcohol taxes.

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Stroke Mortality Trends in the Population of Klaipėda From 1994 to 2008

Medicina ◽

10.3390/medicina47090071 ◽

2011 ◽

Vol 47 (9) ◽

pp. 512 ◽

Cited By ~ 3

Author(s):

Henrikas Kazlauskas ◽

Nijolė Raškauskienė ◽

Rima Radžiuvienė ◽

Vinsas Janušonis

Keyword(s):

Mortality Rate ◽

Mortality Rates ◽

Mortality Data ◽

World Population ◽

Stroke Mortality ◽

Middle Aged ◽

Elderly Men ◽

Men And Women ◽

Specific Mortality ◽

Permanent Residents

The objective of the study was to evaluate the trends in stroke mortality in the population of Klaipėda aged 35–79 years from 1994 to 2008. Material and Methods. Mortality data on all permanent residents of Klaipėda aged 35–79 years who died from stroke in 1994–2008 were gathered for the study. All death certificates of permanent residents of Klaipėda aged 35–79 years who died during 1994–2008 were examined in this study. The International Classification of Diseases (ICD-9 codes 430–436, and ICD-10 codes I60–I64) was used. Sex-specific mortality rates were standardized according to the Segi’s world population; all the mortality rates were calculated per 100 000 population per year. Trends in stroke mortality were estimated using log-linear regression models. Sex-specific mortality rates and trends were calculated for 3 age groups (35–79, 35–64, and 65–79 years). Results. During the entire study period (1994–2008), a marked decline in stroke mortality with a clear slowdown after 2002 was observed. The average annual percent changes in mortality rates for men and women aged 35–79 years were –4.6% (P=0.041) and –6.5% (P=0.002), respectively. From 1994 to 2002, the stroke mortality rate decreased consistently among both Klaipėda men and women aged 35–64 years (20.4% per year, P=0.002, and 14.7% per year, P=0.006, respectively) and in the elderly population aged 65–79 years (13.8% per year, P=0.005; and 12% per year, P=0.019). During 2003–2008, stroke mortality increased by 16.3% per year in middle-aged men (35–64 years), whereas among women (aged 35–64 and 65–79 years) and elderly men (aged 65–79 years), the age-adjusted mortality rate remained relatively unchanged. Conclusions. Among both men and women, the mortality rates from stroke sharply declined between 1994 and 2008 with a clear slowdown in the decline after 2002. Stroke mortality increased significantly among middle-aged men from 2003, while it remained without significant changes among women of the same age and both elderly men and women.

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EXCESS MORTALITY FROM COVID-19. WEEKLY EXCESS DEATH RATES BY AGE AND SEX FOR SWEDEN AND ITS MOST AFFECTED REGION

European Journal of Public Health ◽

10.1093/eurpub/ckaa218 ◽

2020 ◽

Author(s):

Karin Modig ◽

Anders Ahlbom ◽

Marcus Ebeling

Keyword(s):

Causes Of Death ◽

Excess Mortality ◽

National Level ◽

Mortality Rates ◽

Regional Level ◽

Death Rates ◽

Excess Death ◽

All Cause Mortality ◽

Specific Mortality ◽

Age And Sex

Abstract Background Sweden has one of the highest numbers of COVID-19 deaths per inhabitant globally. However, absolute death counts can be misleading. Estimating age- and sex-specific mortality rates is necessary in order to account for the underlying population structure. Furthermore, given the difficulty of assigning causes of death, excess all-cause mortality should be estimated to assess the overall burden of the pandemic. Methods By estimating weekly age- and sex-specific death rates during 2020 and during the preceding five years, our aim is to get more accurate estimates of the excess mortality attributed to COVID-19 in Sweden, and in the most affected region Stockholm. Results Eight weeks after Sweden’s first confirmed case, the death rates at all ages above 60 were higher than for previous years. Persons above age 80 were disproportionally more affected, and men suffered greater excess mortality than women in ages up to 75 years. At older ages, the excess mortality was similar for men and women, with up to 1.5 times higher death rates for Sweden and up to 3 times higher for Stockholm. Life expectancy at age 50 declined by less than 1 year for Sweden and 1.5 years for Stockholm compared to 2019. Conclusions The excess mortality has been high in older ages during the pandemic, but it remains to be answered if this is because of age itself being a prognostic factor or a proxy for comorbidity. Only monitoring deaths at a national level may hide the effect of the pandemic on the regional level.

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