Births and deaths are registrable events in the lives of everyone. Before burial or cremation can occur, a burial certificate has to be obtained. This requires the issuance of a death certificate.
Excess deaths is a term used in public health that refers to the number of deaths from all causes during a crisis, above and beyond what would have expected to see under non-crisis conditions.
In the context of Covid-19, this would refer to the number of deaths during the pandemic compared to deaths that would have occurred had the pandemic not occurred.
Excess mortality provides a more comprehensive measure of the total impact of Covid-19 on deaths than deaths directly attributed to confirmed Covid-19 cases alone. It includes:
- Confirmed Covid-19 deaths.
- Covid-19 deaths that were not correctly diagnosed and/or reported.
- Deaths from other causes attributable to the Covid-19 pandemic.
The number of deaths attributable to Covid-19 can be problematic as its definition depends on whether the death occurred in a person who tested positive for SARS-CoV-2, the causative agent of Covid-19.
This is complicated by a fraction of the cases classified as Covid-19 deaths which had underlying health conditions (comorbidities) and were probably at increased risk of death from any serious infection, which, in this instance, was Covid-19.
Although most deaths may be attributed to those who had the SARS-CoV-2 infection, some of the deaths may be attributed to major non-communicable diseases e.g. diabetes, hypertension, heart and/or chronic renal failure, and stroke. The latter is more likely to occur in those who had been discharged after admission for Covid-19.
In addition, deaths due to the socio-economic effects of Covid-19 have to be taken into account, e.g. suicides.
Deaths due to Covid-19 can be estimated by the infection fatality ratio (IFR), which is the proportion of deaths among all infected individuals; and the case fatality ratio (CFR), which is the proportion of deaths among identified confirmed cases.
As a measurement of the IFR requires a complete number of infections of, and deaths caused by SARS-CoV-2, which is not available, a proxy indicator would be the CFR which is based on confirmed cases.
It is rare to find anyone in the scientific community who does not acknowledge that the actual deaths due to Covid-19 are under-reported because of various reasons.
Excess Deaths In High Income Countries
Woolf et al analysed the excess mortality in the US between March 1, 2020 and January 2, 2021. There were more than 500,000 excess deaths in 2020, an increase of 23 per cent above pre-pandemic levels.
The increase exceeded considerably the annual increases of 2.5 per cent or less in recent years. The excess deaths in non-Hispanic blacks (16.9 per cent) exceeded their composition in the population (12.5 per cent).
The excess deaths were greater in states that “weakly embraced or discouraged pandemic control measures and lifted restrictions earlier than other states”. Death rates from non-Covid-19 diseases increased during surges of the SARS-CoV-2 infection.
Data from the US National Centre for Health Statistics (NCHS) National Vital Statistics System (NVSS) indicate that Covid-19 was the third most common cause of death in the US in 2020, behind heart disease and cancer.
The excess mortality during the Covid-19 and previous pandemics is shown in the table below.
|Pandemic||Years||Global mortality||US mortality||Source|
|2009 H1N1 influenza||2009-2010||151,700-575,400||12,469||CDC|
|1968 H3N2 influenza||1968-1969||1,000,000||40,000||PopulationReferenceBureau|
|1957-1958 H2N2 influenza||1957-1958||2,000,000||60,000|
|1918 H1N1 avian influenza||1918-1919||50,000,000||675,000|
In an analysis of excess deaths in 29 high income countries in 2020, N Islam et al reported that an estimated 979,000 excess deaths occurred. All the countries had excess deaths except New Zealand, Norway and Denmark.
The countries with the highest absolute number of excess deaths were the US, Italy, the UK, Spain and Poland. However, New Zealand had a lower overall mortality than expected.
The estimated number of excess deaths exceeded substantially the number of reported deaths from Covid-19 in many countries. The highest excess death rates in males were in Lithuania, Poland, Spain, Hungary and Italy.
The highest rates in women were in Lithuania, Spain, Hungary, Slovenia and Belgium. There was little evidence of subsequent compensatory reductions following the excess deaths.
One is often reminded of the Ministry of Health (MOH) leadership holding up placards on July 1, 2020 when only one Covid-19 case was reported, with no deaths. The impression given was that the worst was over.
However, a year later, on July 1, 2021 alone, there were 6,988 cases and 84 deaths reported.
The Department of Statistics publishes Malaysia’s vital statistics annually. According to the department, there were 43,545 deaths in the first quarter of 2021 compared to 43,226 in the first quarter of 2020, an increase of 0.7 per cent. 801 of the deaths were due to Covid-19.
The department did not provide comparisons with deaths for the same period in the preceding five to 10 years, which is the usual practice when addressing the issue of excess deaths. Why did the department not do so?
The number of Covid-19 deaths was 5,170 on June 30, 2021, an increase of 4,369 in the second quarter of 2021. May and June 2021 were the two most devastating months, with 3,664 deaths, i.e. 60 deaths daily.
Since the first Covid-19 death on March 17, 2020, it took 337 days to reach the first thousandth death; 92, 15, 12 and 13 days, the two thousandth, three thousandth, four thousandth, and five thousandth deaths respectively.
The US, India and Brazil are the only countries with more than 300,000 Covid-19 deaths. Malaysia had 2.35 deaths per million people, on June 30, 2021 (seven-day rolling average), compared to 7.36, 0.78 and 0.77 per million population for Brazil, the US and India respectively.
On June 30, 2021, Malaysia also had the highest number of daily new confirmed Covid-19 deaths per million people in ASEAN (Figure 1).
The above data is a reflection of the mismanagement of Covid-19 in Malaysia, notwithstanding whatever claims may be made.
The overall CFR for Malaysia, as at June 30, 2021, was 0.69, compared to 0.42 on December 31, 2020. The highest CFRs on June 30, 2021 were in Labuan (1.49), Perlis (1.35), and Kedah (0.86).
The lowest CFRs were in Penang (0.35), Perak (0.49) and Putrajaya (0.52).
Eight states or territories had CFRs above the national CFR i.e. Labuan, Perlis, Kedah, Johore, Negri Sembilan, Malacca, Pahang and Sabah in descending order.
|States||Cumulative positive cases||Cumulative deaths||Case fatality ratio|
The numbers of Covid-19 sufferers brought in dead (BID) is of concern. While some of these might be due to access factors in rural Malaysia, the numbers of BID in the Klang Valley raises fundamental questions about health care delivery.
It has been acknowledged the data reported by the MOH did not include those who had recovered from Covid-19, but subsequently died from complications.
This meant that the official mortality data underestimated the actual Covid-19 mortality.
Health care resources have been diverted to manage Covid-19, with more hospitals and beds in MOH facilities allocated for Covid-19 cases. There were reports about a year ago when doctors reported on the postponements of clinic appointments and surgeries because of Covid-19.
No subsequent reports have been forthcoming. Is this related to the gag order imposed on MOH staff that was reinforced by explicit warnings reported anonymously by some staff?
Delayed treatment of non-communicable diseases, e.g. heart disease and cancer hasten morbidity and mortality in the medium and longer terms.
Add to that suicides which, according to the police, numbered 468 in the first five months of 2021, compared to 631 and 609 in 2020 and 2019 respectively. Were they a consequence of the socio-economic and health consequences of Covid-19?
One can appreciate that the story of excess Covid-19 related deaths in Malaysia has yet to commence.
Could Some Of The Deaths Have Been Prevented?
The Confidential Enquiry into Maternal Deaths (CEMD) has been established in Malaysia since 1991. It deals with the direct, indirect and fortuitous causes of maternal deaths.
The personal and health system issues of every death are analysed and a determination made as to whether the particular death was preventable.
The objective of CEMD was to provide evidence-based information for improvements in service delivery to address the remediable causes of maternal deaths.
An enquiry based on the principles of the CEMD is necessary to provide answers and recommendations from the excess deaths from Covid-19 in Malaysia.
Deborah Birx, who was the White House coronavirus response coordinator in the Donald Trump administration spoke about its non-scientific approach in CNN documentary “Covid War: The Pandemic Doctors Speak Out”, aired on March 27, 2021.
“I look at it this way. The first time we have an excuse. There were about a hundred thousand deaths that came from that original surge. All of the rest of them, in my mind, could have been mitigated or decreased substantially,” she acknowledged.
Are the health authorities prepared to address the unpalatable question of whether some of the excess Covid-19 related deaths could have been prevented?
Do they have humility to assess, reflect and implement improvements in health care delivery and governance from the lessons to be learnt?
Malaysia cannot squander the opportunity to do what it takes to be better prepared for the continuation of Covid-19 into 2022 and 2023, as well as the next pandemic, whatever the cause of the latter may be.
Dr Milton Lum is a Past President of the Federation of Private Medical Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.