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Accurate cause-of-death statistics are vital for public health policy, but less than one-third of deaths globally are assigned a cause. Verbal autopsy (VA) methods are crucial in low- and middle-income countries lacking complete civil registration and vital statistics (CRVS) systems. We explored VA implementation in Zambia by using a previously developed framework. The National Mortality Surveillance Subcommittee under the Monitoring and Evaluation Technical Working Group within the Ministry of Health coordinates mortality surveillance activities in Zambia. To date, passive, non-population-representative VA data collection mechanisms have been used, leading to underrepresentation of some communities. In spite of the use of electronic data collection tools, VA systems have not been electronically linked to public health surveillance or CRVS systems. Funding for VA has largely been donor driven. Increasing government funding may ensure sustainability, while the adoption of sample-based platforms while linking VA information technology systems may make VA data more useful, timely, and accessible.

Objectives: Pandemic response in low-income countries (LICs) or settings often suffers from scarce epidemic surveillance and constrained mitigation capacity. The drivers of pandemic burden in such settings, and the impact of limited and delayed interventions remain poorly understood., Methods: We analysed COVID-19 seroprevalence and all-cause excess deaths data from the peri-urban district of Kabwe, Zambia between March 2020 and September 2021 with a novel mathematical model. Data encompassed three consecutive waves caused by the wild-type, Beta and Delta variants., Results: Across all three waves, we estimated a high cumulative attack rate, with 78% (95% credible interval [CrI] 71-85) of the population infected, and a high all-cause excess mortality, at 402 (95% CrI 277-473) deaths per 100,000 people. Ambitiously improving health care to a capacity similar to that in high-income settings could have averted up to 46% (95% CrI 41-53) of accrued excess deaths, if implemented from June 2020 onward. An early and accelerated vaccination rollout could have achieved the highest reductions in deaths. Had vaccination started as in some high-income settings in December 2020 and with the same daily capacity (doses per 100 population), up to 68% (95% CrI 64-71) of accrued excess deaths could have been averted. Slower rollouts would have still averted 62% (95% CrI 58-68), 54% (95% CrI 49-61) or 26% (95% CrI 20-38) of excess deaths if matching the average vaccination capacity of upper-middle-, lower-middle- or LICs, respectively., Conclusions: Robust quantitative analyses of pandemic data are of pressing need to inform future global pandemic preparedness commitments., Competing Interests: Declarations of competing interest The authors have no competing interests to declare., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The number of COVID-19 deaths reported in Zambia (N = 4069) is most likely an underestimate due to limited testing, incomplete death registration and inability to account for indirect deaths due to socioeconomic disruption during the pandemic. We sought to assess excess mortality during the COVID-19 pandemic in Zambia., Methods: We conducted a retrospective analysis of monthly-death-counts (2017-2022) and individual-daily-deaths (2020-2022) of all reported health facility and community deaths at district referral health facility mortuaries in 12 districts in Zambia. We defined COVID-19 wave periods based on a sustained nationally reported SARS-CoV-2 test positivity of greater than 5%. Excess mortality was calculated as the difference between observed monthly death counts during the pandemic (2020-2022) and the median monthly death counts from the pre-pandemic period (2017-2019), which served as the expected number of deaths. This calculation was conducted using a Microsoft Excel-based tool. We compared median daily death counts, median age at death, and the proportion of deaths by place of death (health facility vs. community) by wave period using the Mann-Whitney-U test and chi-square test respectively in R., Results: A total of 112,768 deaths were reported in the 12 districts between 2020 and 2022, of which 17,111 (15.2%) were excess. Wave periods had higher median daily death counts than non-wave periods (median [IQR], 107 [95-126] versus 96 [85-107], p < 0.001). The median age at death during wave periods was older than non-wave periods (44.0 [25.0-67.0] versus 41.0 [22.0-63.0] years, p < 0.001). Approximately half of all reported deaths occurred in the community, with an even greater proportion during wave periods (50.6% versus 53.1%, p < 0.001), respectively., Conclusion: There was excess mortality during the COVID-19 pandemic in Zambia, with more deaths occurring within the community during wave periods. This analysis suggests more COVID-19 deaths likely occurred in Zambia than suggested by officially reported numbers. Mortality surveillance can provide important information to monitor population health and inform public health programming during pandemics., (© 2024. The Author(s).)

Deaths from COVID-19 likely exceeded official statistics in Zambia because of limited testing and incomplete death registration. We describe a sentinel COVID-19 mortality surveillance system in Lusaka, Zambia. We analyzed surveillance data on deceased persons of all ages undergoing verbal autopsy (VA) and COVID-19 testing at the University Teaching Hospital (UTH) mortuary in Lusaka, Zambia, from April 2020 through August 2021. VA was done by surveillance officers for community deaths and in-patient deaths that occurred <48 hours after admission. A standardized questionnaire about the circumstances proximal to death was used, with a probable cause of death assigned by a validated computer algorithm. Nasopharyngeal specimens from deceased persons were tested for COVID-19 using polymerase chain reaction and rapid diagnostic tests. We analyzed the cause of death by COVID-19 test results. Of 12,919 deceased persons at UTH mortuary during the study period, 5,555 (43.0%) had a VA and COVID-19 test postmortem, of which 79.7% were community deaths. Overall, 278 (5.0%) deceased persons tested COVID-19 positive; 7.1% during waves versus 1.4% during nonwave periods. Most (72.3%) deceased persons testing COVID-19 positive reportedly had fever, cough, and/or dyspnea and most (73.5%) reportedly had an antemortem COVID-19 test. Common causes of death for those testing COVID-19 positive included acute cardiac disease (18.3%), respiratory tract infections (16.5%), other types of cardiac diseases (12.9%), and stroke (7.2%). A notable portion of deceased persons at a sentinel site in Lusaka tested COVID-19 positive during waves, supporting the notion that deaths from COVID-19 might have been undercounted in Zambia. Many had displayed classic COVID-19 symptoms and been tested before death yet nevertheless died in the community, potentially indicating strained medical services during waves. The high proportion of cardiovascular diseases deaths might reflect the hypercoagulable state during severe COVID-19. Early supportive treatment and availability of antivirals might lessen future mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Introduction: since March 2020, Zambia has been experiencing a SARS-CoV-2 epidemic. Little data has been reported on cases and deaths arising from COVID-19 in Africa. We described the demographic characteristics of these cases and deaths in Zambia., Methods: we analyzed data on all persons testing positive for SARS-CoV-2 from 18 th March 2020 to 25 th April 2021 in Zambia. COVID-19 cases were identified through port-of-entry surveillance, contact-tracing, health-care-worker testing, health-facility-based and community-based screening and community-death screening. All diagnoses were confirmed using real-time-polymerase-chain-reaction and rapid-antigen-test-kits of nasopharyngeal specimens. We analyzed age, sex, and date-of-reporting according to whether the cases or deaths occurred during the first wave (1 st July to 15 th September 2020) or the second wave (15 th December 2020 to 10 th April 2021). We computed Mann-Whitney-U-test to compare medians of continuous variables and chi-square tests to compare differences between proportions using R., Results: a total 1,246 (1.36%) deaths were recorded among 91,378 confirmed cases during March 2020-April 2021 in Zambia. Persons who died were older than those who did not (median age 50 years versus 32.0 years, p< 0.001). Although only 4.7% of cases were among persons aged >60 years, most deaths (31.6%) occurred in this age group (p<0.001). More deaths (83.5%) occurred in the community than in health facilities (p<0.001)., Conclusion: during the SARS-CoV-2 epidemic in Zambia, most deaths occurred in the community, indicating potential gaps in public health messaging about COVID-19. Improving health-seeking behaviors for COVID-19 through public messaging campaigns and engaging key community stakeholders in Zambia might reduce avoidable mortality. As the group most impacted by COVID-19 mortality, older persons might need enhanced outreach and linkage to care., Competing Interests: The authors declare no competing interests., (Copyright: Stephen Longa Chanda et al.)

Reported COVID-19 cases and associated mortality remain low in many sub-Saharan countries relative to global averages, but true impact is difficult to estimate given limitations around surveillance and mortality registration. In Lusaka, Zambia, burial registration and SARS-CoV-2 prevalence data during 2020 allow estimation of excess mortality and transmission. Relative to pre-pandemic patterns, we estimate age-dependent mortality increases, totalling 3212 excess deaths (95% CrI: 2104-4591), representing an 18.5% (95% CrI: 13.0-25.2%) increase relative to pre-pandemic levels. Using a dynamical model-based inferential framework, we find that these mortality patterns and SARS-CoV-2 prevalence data are in agreement with established COVID-19 severity estimates. Our results support hypotheses that COVID-19 impact in Lusaka during 2020 was consistent with COVID-19 epidemics elsewhere, without requiring exceptional explanations for low reported figures. For more equitable decision-making during future pandemics, barriers to ascertaining attributable mortality in low-income settings must be addressed and factored into discourse around reported impact differences., (© 2023. The Author(s).)