ABSTRACT
Introduction/ Background: Excess mortality reports suggest underreporting of COVID-19 related deaths, as routine surveillance utilizes mainly in-facility data. SARS-CoV-2 postmortem testing (PMT) for home deaths from natural causes has been implemented in South Africa. We provide information to highlight the critical role of morticians in improving mortality surveillance in South Africa. Methods: Sentinel surveillance was implemented in three Districts to support SARS-CoV-2 PMT and reporting in two provinces of South Africa. A repository of out of-facility natural deaths was compiled using mortuary registers from public and private sectors, with multiple stakeholder involvement. Deaths were linked to cumulative COVID-19 laboratory test data and case linelists. Data from August 2020 to October 2021 were analyzed to assess the contribution of community COVID-19 related deaths to the overall reported mortality. Results: A total of 8,254 COVID-19 related deaths were reported, comprising of 70% (n=5,751) hospital and 30% (n=2,503) community deaths. Most of the deaths were females (57.5%;n=4,742) and 60 years and older (61.5%;n=5,079). Of the 2,503 community deaths, 47% (n=1,184) were tested prior to death and 53% (n=1,319) post-mortem. Overall, reporting of COVID-19 related deaths markedly improved by 16% (1,319/8,254) with engagement and additional reporting of data from post-mortem testing. Impact: Morticians play a critical role in COVID-19 mortality surveillance, providing the much-needed sociodemographic information and vital to the handling and transport of corpses to health facilities for specimen collection. Conclusion: The number of reported COVID-19 related deaths was enhanced by linking mortuary registers with laboratory test data and case line lists. Expansion of this model to all mortuaries, across the districts in South Africa, could be a vital component of efforts to improve community-based surveillance.