COVID-19 mortality, excess mortality, deaths per million and infection fatality ratio, Belgium, 9 March 2020 to 28 June 2020.

BackgroundCOVID-19 mortality, excess mortality, deaths per million population (DPM), infection fatality ratio (IFR) and case fatality ratio (CFR) are reported and compared for many countries globally. These measures may appear objective, however, they should be interpreted with caution.AimWe examined reported COVID-19-related mortality in Belgium from 9 March 2020 to 28 June 2020, placing it against the background of excess mortality and compared the DPM and IFR between countries and within subgroups.MethodsThe relation between COVID-19-related mortality and excess mortality was evaluated by comparing COVID-19 mortality and the difference between observed and weekly average predictions of all-cause mortality. DPM were evaluated using demographic data of the Belgian population. The number of infections was estimated by a stochastic compartmental model. The IFR was estimated using a delay distribution between infection and death.ResultsIn the study period, 9,621 COVID-19-related deaths were reported, which is close to the excess mortality estimated using weekly averages (8,985 deaths). This translates to 837 DPM and an IFR of 1.5% in the general population. Both DPM and IFR increase with age and are substantially larger in the nursing home population.DiscussionDuring the first pandemic wave, Belgium had no discrepancy between COVID-19-related mortality and excess mortality. In light of this close agreement, it is useful to consider the DPM and IFR, which are both age, sex, and nursing home population-dependent. Comparison of COVID-19 mortality between countries should rather be based on excess mortality than on COVID-19-related mortality.

Establishing an ad hoc COVID-19 mortality surveillance during the first epidemic wave in Belgium, 1 March to 21 June 2020.

BackgroundCOVID-19-related mortality in Belgium has drawn attention for two reasons: its high level, and a good completeness in reporting of deaths. An ad hoc surveillance was established to register COVID-19 death numbers in hospitals, long-term care facilities (LTCF) and the community. Belgium adopted broad inclusion criteria for the COVID-19 death notifications, also including possible cases, resulting in a robust correlation between COVID-19 and all-cause mortality.AimTo document and assess the COVID-19 mortality surveillance in Belgium.MethodsWe described the content and data flows of the registration and we assessed the situation as of 21 June 2020, 103 days after the first death attributable to COVID-19 in Belgium. We calculated the participation rate, the notification delay, the percentage of error detected, and the results of additional investigations.ResultsThe participation rate was 100% for hospitals and 83% for nursing homes. Of all deaths, 85% were recorded within 2 calendar days: 11% within the same day, 41% after 1 day and 33% after 2 days, with a quicker notification in hospitals than in LTCF. Corrections of detected errors reduced the death toll by 5%.ConclusionBelgium implemented a rather complete surveillance of COVID-19 mortality, on account of a rapid investment of the hospitals and LTCF. LTCF could build on past experience of previous surveys and surveillance activities. The adoption of an extended definition of 'COVID-19-related deaths' in a context of limited testing capacity has provided timely information about the severity of the epidemic.

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

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.

High impact of COVID-19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020.

Residents in long-term care facilities (LTCF) are a vulnerable population group. Coronavirus disease (COVID-19)-related deaths in LTCF residents represent 30-60% of all COVID-19 deaths in many European countries. This situation demands that countries implement local and national testing, infection prevention and control, and monitoring programmes for COVID-19 in LTCF in order to identify clusters early, decrease the spread within and between facilities and reduce the size and severity of outbreaks.