Monitoring the Temporal Trajectory of Sars-Cov-2 in Hong Kong - Daily Antigen Rapid Testing Surveillance (Darts) System

Intro: The number of PCR-confirmed cases may serve poorly as a surveillance data for a representative disease activity, due to its bias towards symptomatic cases or people having an identifiable risk exposure, and the high dependency on changing testing policy. We reported a large-scale ad-hoc community surveillance initiative, Daily Antigen Rapid Testing Surveillance (DARTS) System, using self-performed rapid antigen tests(RAT). Method(s): A representative cohort of 10000+ individuals was enrolled over the territory. Participants were divided into 7 sub-cohorts to achieve a rolling schedule with 1400+ individuals on a daily basis. Participant performed the RAT regularly irrespective of symptom or exposure history, with a self-sampled throat-and-nasal swab. RAT result and photo were reported on the same day of testing through an online platform. Daily point prevalence was disseminated on a real-time dashboard to inform the situation awareness(https://covid19.sph.hku.hk/dashboard). Finding(s): Since its launch during the peak of the fifth wave in March 2022, the system has tracked the changing trajectory of different phases of the Omicron pandemic, including the rapidly subsiding daily prevalence from an initial high value of 12.7% (8.4-18.7) in early March to a baseline of 0.6% (0.2-1.4) in early April, maintained with a non-zero baseline (0.1-0.3%) over May, and subsequent stepwise increase to 0.5% (0.2-1.2) in June. The reproduction number increased from 0.66(0.63,0.70) to 1.23(1.14,1.33) from March to June, signifying the gradual increase of residual Omicron transmission. Conclusion(s): Our DARTS system has demonstrated the feasibility of a participatory surveillance system using self-performed RAT, and its utility as an ad-hoc surveillance to timely reflect the rapidly changing epidemic trajectory. Regular testing irrespective of symptom and exposure risk helps to give more representative picture, including subclinical cases who also carried an implication of disease transmission. The use of RAT also helps to avoid the constraint of manpower and testing capacity, and has been quickly adopted for case definition.Copyright © 2023

Trends of SARS-CoV-2 Infection Among Couriers in Risky Business After the Optimization of Prevention and Control Measures - China, December 2022 to January 2023.

Introduction: On December 7, 2022, China implemented "Ten New Measures" to optimize prevention and control measures for coronavirus disease 2019 (COVID-19). The purpose of this study was to evaluate the national and regional trends of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among couriers in China from December 2022 to January 2023. Methods: Data from the National Sentinel Community-based Surveillance in China was utilized, including participants from 31 provincial-level administrative divisions and Xinjiang Production and Construction Corps. Participants were tested for SARS-CoV-2 infection twice a week from December 16, 2022 to January 12, 2023. Infection was defined as a positive result for SARS-CoV-2 nucleic acid or antigen. The daily average newly positive rate of SARS-CoV-2 infection and the estimated daily percentage change (EDPC) were calculated. Results: In this cohort, 8 rounds of data were collected. The daily average newly positive rate of SARS-CoV-2 infection decreased from 4.99% in Round 1 to 0.41% in Round 8, with an EDPC of -33.0%. Similar trends of the positive rate were also observed in the eastern (EDPC: -27.7%), central (EDPC: -38.0%) and western regions (EDPC: -25.5%). Couriers and community population showed a similar temporal trend, with the peak daily average newly positive rate of couriers being higher than that of community population. After Round 2, the daily average newly positive rate of couriers decreased sharply, becoming lower than that of community population in the same period. Conclusions: The peak of SARS-CoV-2 infection among couriers in China has passed. As couriers are a key population for SARS-CoV-2 infection, they should be monitored continuously.

Trends of SARS-CoV-2 Infection in Sentinel Community-Based Surveillance After the Optimization of Prevention and Control Measures - China, December 2022-January 2023.

Introduction: On December 7, 2022, China implemented the "Ten New Measures" to optimize its prevention and control measures for coronavirus disease 2019 (COVID-19). To provide the latest data after the optimization, we evaluated trends of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among the community population in China. Methods: We utilized data from the National Sentinel Community-Based Surveillance (NSCS) system in China to assess trends of SARS-CoV-2 infection. NSCS is a national community-based surveillance cohort with 0.42 million participants from all 31 provincial-level administrative divisions (PLADs) and Xinjiang Production and Construction Corps (XPCC). Participants were tested for infection twice a week (a total of eight rounds) from December 16, 2022 to January 12, 2023. SARS-CoV-2 infection was defined as testing positive for SARS-CoV-2 nucleic acid or antigen. We calculated the daily average of newly positive rates of SARS-CoV-2 infection. Results: In this national cohort, the daily average newly positive rate of SARS-CoV-2 infection decreased from 4.13% in Round 1 (December 16-19, 2022) to 0.69% in Round 8 (January 10-12, 2023). The epidemic peak occurred in Round 2 (December 20-22, 2022). Similar trends were observed in urban areas (decreasing from 4.65% to 0.73%), rural areas (decreasing from 2.83% to 0.57%), the eastern region (decreasing from 4.18% to 0.67%), the central region (decreasing from 5.43% to 0.61%), and the western region (decreasing from 3.01% to 0.77%). Conclusions: NSCS data showed that the peak of SARS-CoV-2 infection in China had passed. SARS-CoV-2 infection in community populations in China is currently at a low epidemic level.

Trends of SARS-CoV-2 Infection in Rural Area in Sentinel Community-Based Surveillance - China, December 2022 to January 2023.

Introduction: In late 2022, a rapid transmission of Omicron variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurred throughout China. The purpose of this study was to provide the latest data and evaluate trends of SARS-CoV-2 infection in rural China among the community population. Methods: Data on SARS-CoV-2 infection among approximately 90,000 participants in rural China were collected by the National Sentinel Community-Based Surveillance (NSCS) system. Participants were tested for SARS-CoV-2 infection (defined as positive for SARS-CoV-2 nucleic acid or antigen) twice weekly from December 16, 2022 to January 12, 2023. The daily average of newly positive rate and its estimated daily percentage change were calculated to describe the national and regional trends of SARS-CoV-2 infection in rural China. Results: In rural China, the daily average new positive rate of SARS-CoV-2 infection peaked at 4.79% between December 20-22, 2022 and then decreased to 0.57% between January 10-12, 2023, with an average decrease of 29.95% per round. The peak of new SARS-CoV-2 infection was slightly earlier and lower in North China (5.28% between December 20-22, 2022) than in South China (5.63% between December 23-26, 2022), and then converged from December 30, 2022 to January 2, 2023. The peak of 6.09% occurred between December 20-22, 2022 in eastern China, while the peak of 5.99% occurred later, between December 27-29, 2022, in central China. Conclusions: Overall, the epidemic wave in rural China peaked between December 20-22, 2022, and passed quickly following the optimization of prevention and control measures. Currently, SARS-CoV-2 infection in community populations in rural China is sporadic.

Prevalence of COVID-19 in West Gondar zone, Northwest Ethiopia: a population-based retrospective study.

OBJECTIVE: Coronavirus disease-19 (COVID-19) has spread rapidly around the world, affecting every community directly or indirectly. Therefore, this study aims to investigate the prevalence of COVID-19 infection in the population of the West Gondar zone. METHOD: A retrospective cross-sectional study was conducted from November 2020 to January 2021, in the West Gondar zone, Northwest Ethiopia. Records of study participants with required information like of age, gender, travel history, type of specimen taken, and site of specimen taken were included. Statistical package for social sciences (SPSS) version 20 software was used for analysis. Descriptive statistics were summarized as percentages and means ±SD. The Chi-square test is used to compare categorical data. RESULTS: A total of 1,166 participants were enrolled in this study. Of them, 16 individuals had positive results, giving a prevalence of 1.37% (95% CI: 0.66-2.08). Living in an urban area (P-value=0.035) and being female (P-value=0.045) was statistically associated with the positive rate for COVID-19. CONCLUSION: This study revealed a low prevalence of COVID-19 infection in the study area despite the increasing and rapid dissemination of the disease. State-wide population prevalence study should be done to estimate the general prevalence of COVID-19 in Ethiopia.

Community-Based Surveillance and Geographic Information System‒Linked Contact Tracing in COVID-19 Case Identification, Ghana, March‒June 2020.

In response to the COVID-19 pandemic, Ghana implemented various mitigation strategies. We describe use of geographic information system (GIS)‒linked contact tracing and increased community-based surveillance (CBS) to help control spread of COVID-19 in Ghana. GIS-linked contact tracing was conducted during March 31-June 16, 2020, in 43 urban districts across 6 regions, and 1-time reverse transcription PCR testing of all persons within a 2-km radius of a confirmed case was performed. CBS was intensified in 6 rural districts during the same period. We extracted and analyzed data from Surveillance Outbreak Response Management and Analysis System and CBS registers. A total of 3,202 COVID-19 cases reported through GIS-linked contact tracing were associated with a 4-fold increase in the weekly number of reported SARS-CoV-2 infected cases. CBS identified 5.1% (8/157) of confirmed cases in 6 districts assessed. Adaptation of new methods, such as GIS-linked contact tracing and intensified CBS, improved COVID-19 case detection in Ghana.

The Landscape of Participatory Surveillance Systems Across the One Health Spectrum: Systematic Review.

BACKGROUND: Participatory surveillance systems augment traditional surveillance systems through bidirectional community engagement. The digital platform evolution has enabled the expansion of participatory surveillance systems, globally, for the detection of health events impacting people, animals, plants, and the environment, in other words, across the entire One Health spectrum. OBJECTIVE: The aim of this landscape was to identify and provide descriptive information regarding system focus, geography, users, technology, information shared, and perceived impact of ongoing participatory surveillance systems across the One Health spectrum. METHODS: This landscape began with a systematic literature review to identify potential ongoing participatory surveillance systems. A survey was sent to collect standardized data from the contacts of systems identified in the literature review and through direct outreach to stakeholders, experts, and professional organizations. Descriptive analyses of survey and literature review results were conducted across the programs. RESULTS: The landscape identified 60 ongoing single-sector and multisector participatory surveillance systems spanning five continents. Of these, 29 (48%) include data on human health, 26 (43%) include data on environmental health, and 24 (40%) include data on animal health. In total, 16 (27%) systems are multisectoral; of these, 9 (56%) collect animal and environmental health data; 3 (19%) collect human, animal, and environmental health data; 2 (13%) collect human and environmental health data; and 2 (13%) collect human and animal health data. Out of 60 systems, 31 (52%) are designed to cover a national scale, compared to those with a subnational (n=19, 32%) or multinational (n=10, 17%) focus. All systems use some form of digital technology. Email communication or websites (n=40, 67%) and smartphones (n=29, 48%) are the most common technologies used, with some using both. Systems have capabilities to download geolocation data (n=31, 52%), photographs (n=29, 48%), and videos (n=6, 10%), and can incorporate lab data or sample collection (n=15, 25%). In sharing information back with users, most use visualization, such as maps (n=43, 72%); training and educational materials (n=37, 62%); newsletters, blogs, and emails (n=34, 57%); and disease prevention information (n=32, 53%). Out of the 46 systems responding to the survey regarding perceived impacts of their systems, 36 (78%) noted "improved community knowledge and understanding" and 31 (67%) noted "earlier detection." CONCLUSIONS: The landscape demonstrated the breadth of applicability of participatory surveillance around the world to collect data from community members and trained volunteers in order to inform the detection of events, from invasive plant pests to weekly influenza symptoms. Acknowledging the importance of bidirectionality of information, these systems simultaneously share findings back with the users. Such directly engaged community detection systems capture events early and provide opportunities to stop outbreaks quickly.

New networks in improving mortality surveillance beyond COVID-19, 2021

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.

Virtual Yoga and Mindfulness Training Among Juvenile Court Involved Youth

Purpose: Juvenile court involved youth (JCIY) experience unique psychosocial challenges. The COVID-19 pandemic generated additional stressors for this vulnerable population. Promoting mindfulness strategies may increase well-being among JCIY, but few such interventions have been developed. We sought to evaluate the impact of a longitudinal mindfulness intervention incorporating healing-centered, anti-oppression yoga delivered through a virtual platform on multiple psychological outcomes among JCIY involved in community-based monitoring. Methods: We partnered with YogaRoots on Location (YROL), a healing-centered, anti-oppression yoga instruction group, to implement a longitudinal mindfulness training program to youth aged 11-21 involved in the Allegheny County Community Intensive Supervision Program (CISP). Starting in March 2020, this program transitioned to a remote format in light of the COVID-19 pandemic. Sessions were delivered via Zoom and incorporated Raja yoga practice, breathing techniques, meditation and mindfulness exercises, and strengths-based social justice exploration. Sessions lasted one hour and occurred weekly. Youth attending nine sessions completed end-of-program (EOP) evaluations. Baseline surveys assessed demographic characteristics and prior experiences with racism and trauma. EOP surveys were administered to assess for changes in multiple psychological outcomes: mindfulness, acceptance and action, resilience, future orientation, emotion dysregulation, and psychological distress. Demographic data were summarized with descriptive statistics. McNemar or Wilcoxon signed rank tests were used to compare outcomes at baseline and EOP. Results: 99 youth completed baseline assessments. Mean age of participants was 16.2 (SD: 1.4). 85 (86%) were male. 60 (61%) identified as Black/African-American, 17 (17%) White, and 14 (14%) other racial identities. 7 (7%) were Hispanic/Latino. 74 (75%) youth reported prior experiences of trauma, with 47 (47%) reporting three or more. Perceptions of racism were common, with 63 (64%) youth reporting being treated unfairly by a police officer and 67 (68%) being accused of something they did not do at school. 16 youth (16%) completed EOP surveys. No significant changes in any psychological outcomes were noted from baseline to EOP among this cohort of youth who completed nine or more sessions. Many reported likelihood of using yoga in the future to deal with stress (11;69%), to calm down (12;75%), and to deal with racism (8;50%). Conclusions: JCIY face significant psychosocial stressors, and many report histories of trauma and discrimination. The COVID-19 pandemic may exacerbate existing challenges for these youth, and further supports are needed to engender well-being in this population, including strategies to retain youth in programming. Despite its feasibility and acceptability among JCIY, mindfulness training, particularly in a virtual format, may have limited immediate impact on psychological outcomes due to broader structures of oppression and situational factors. Reflecting the transiency of this population, changing living situations, going “on the run,” and other challenges, retaining youth in ongoing programming is challenging. Additional follow-up is needed to determine the effects of such interventions on long-term youth coping and resilience as well as to elucidate implementation facilitators to increase receipt of such skills-building programs for this population. Sources of Support: Heinz Endowments.

Prevalence and Impact of Post-Acute Sequelae of COVID-19 among People Experiencing Homelessness in King County, WA between September 2020 - May 2021

Background. Homeless shelters are high risk settings for SARS-CoV-2 transmission. People experiencing homelessness (PEH) have high rates of chronic illness, and have been disproportionately affected by COVID-19. The burden of post-acute sequelae of COVID-19 (PASC) in PEH has not been well-studied and PEH may be uniquely affected due to barriers to medical care and the potential exacerbation of existing threats to health, housing, employment, and self-care. Methods. The Seattle Flu Study conducted community-based surveillance for SARS-CoV-2 in nine homeless shelters from September 1, 2020 and May 31, 2021. Individuals with and without respiratory symptoms were tested for SARS-CoV-2 infection using a PCR assay. We completed follow-up surveys with shelter residents age ≥18 years at days 5, 10, 30 and 60+ after positive or inconclusive diagnosis with SARS-CoV-2 infection. Individuals were asked about residual symptoms, impact on activities of daily living, access to medical care, and health-related quality of life. Results. Of 51 eligible participants, 22 (43%) completed a follow-up survey, with six at day 5 or 10 survey, 11 at day 30, and 18 at day 60+. The median time from enrollment to last follow-up survey was 77 (range 49-138) days. Five (23%) participants reported at least one symptom at day 0, five (83%) at day 5 or 10, eight (73%) at day 30 and seven (39%) at day 60+ (Figure 1). Eight (36%) reported at least one symptom on a day 30 or 60+ follow up survey that interfered or prevented their daily activities. Nine (41%) received medical care at the quarantine facility. Of those with symptoms persisting beyond day 10, four (30%) received medical care outside of a medical provider at the quarantine facility. Prevalence of self-reported symptoms at Day 0 (enrollment), Day 5 or 10, Day 30, and Day 60+ in shelter residents who tested positive or inconclusive for SARS-CoV-2. Conclusion. PEH reported a high prevalence of persistent COVID-19 symptoms 30+ days after their SARS-CoV-2 detection. Few participants accessed medical care for their persistent illness. The impact of COVID-19 extends beyond acute illness and PASC may exacerbate existing challenges PEH face in health and wellbeing.

Halting Epidemics at the Outset: Community-Based Surveillance (CBS) in an Epidemic Preparedness Model for Early Detection and Early Action

Purpose: An innovative epidemic preparedness model establishing an SMS real-time community-based surveillance (CBS) system enables earlier detection and earlier action to control outbreaks at the outset. Methods & Materials: The One Health preparedness program has been piloted in 5 countries: Guinea, Indonesia, Kenya, Sierra Leone and Uganda, since 2019. A tiered model building on a foundation of volunteer skill-building, community health and epidemic awareness activities, building trust and motivating communities, and establishing connections with local health and veterinary authorities. CBS extends on that foundation establishing a simple, low-cost, real-time system for community volunteers to identify and notify of potentially serious health events triggering investigation and response by local authorities. Communities are prepared to take immediate actions to halt the spread. Materials and methodology are standardised: mobile phone SMS to signal alerts, Kobo application to log and monitor alerts, training packages, and job aids. Results: Volunteers and communities have successfully raised CBS alerts, taken action, and controlled outbreaks of measles, polio, acute watery diarrhoea, anthrax and rabies which minimised the spread and impact. To be effective CBS must achieve timely notification of alerts, accuracy to minimise needless investigation, action must be taken, and volunteers must remain engaged. Results from July 2020 – March 2021 show successful rapid notification: 76% of alerts were communicated to authorities within 24hrs. Volunteers accurately recognised the key signs for 77% of alerts. Owing to the relationships with local Government an average of 75% of alerts were investigated, although human health alerts have higher investigation rates than animal alerts. Volunteer reliability fluctuates from 44% to 88% across the 5 countries. Positive predictive value for human alerts is high in most countries;63% of alerts overall were confirmed positive as epidemic diseases. This established CBS system has readily incorporated detection of COVID-19 and been rapidly scaled-up during Ebola high-alert demonstrating agility for detection of emerging threats. Conclusion: Communities themselves have the potential to identify and combat epidemic threats. Preparedness programs which engage communities, build skills, establish simple and effective surveillance mechanisms and connect with local service providers, can control outbreaks at the outset and communities can enjoy greater resilience.

Uganda Mountain Community Health System-Perspectives and Capacities towards Emerging Infectious Disease Surveillance.

In mountain communities like Sebei, Uganda, which are highly vulnerable to emerging and re-emerging infectious diseases, community-based surveillance plays an important role in the monitoring of public health hazards. In this survey, we explored capacities of village health teams (VHTs) in Sebei communities of Mount Elgon in undertaking surveillance tasks for emerging and re-emerging infectious diseases in the context of a changing climate. We used participatory epidemiology techniques to elucidate VHTs' perceptions on climate change and public health and assessed their capacities to conduct surveillance for emerging and re-emerging infectious diseases. Overall, VHTs perceived climate change to be occurring with wider impacts on public health. However, they had inadequate capacities in collecting surveillance data. The VHTs lacked transport to navigate through their communities and had insufficient capacities in using mobile phones for sending alerts. They did not engage in reporting other hazards related to the environment, wildlife, and domestic livestock that would accelerate infectious disease outbreaks. Records were not maintained for disease surveillance activities and the abilities of VHTs to analyze data were also limited. However, VHTs had access to platforms that could enable them to disseminate public health information. The VHTs thus need to be retooled to conduct their work effectively and efficiently through equipping them with adequate logistics and knowledge on collecting, storing, analyzing, and relaying data, which will improve infectious disease response and mitigation efforts.

Community-based surveillance in internally displaced people's camps and urban settings during a complex emergency in Yemen in 2020.

BACKGROUND: The need for early identification of coronavirus disease (COVID-19) cases in communities was high in Yemen during the first wave of the COVID-19 epidemic because most cases presenting to health facilities were severe. Early detection of cases would allow early interventions to interrupt the transmission chains. This study aimed to describe the implementation of community-based surveillance (CBS) in in internally displaced people (IDP) camps and urban settings in Yemen from 15 April 2020 to 30 September 2020. METHODS: Following the Centers for Disease Control and Prevention guidance for evaluation of surveillance systems, we assessed the usefulness and acceptability of CBS. For acceptability, we calculated the proportion of trained volunteers who reported disease alerts. To assess the usefulness, we compared the alerts reported through the electronic diseases early warning system (eDEWS) with the alerts reported through CBS and described the response activities implemented. RESULTS: In Al-Mukalla City, 18% (14/78) of the volunteers reported at least one alert. In IDP camps, 58% (18/31) of volunteers reported at least one alert. In Al-Mukalla City, CBS detected 49 alerts of influenza-like illness, whereas health facilities detected 561 cases of COVID-19. In IDP camps, CBS detected 91 alerts of influenza-like illness, compared to 10 alerts detected through eDEWS. In IDP camps, CBS detected three other syndromes besides influenza-like illness (febrile illness outbreak suspicion, acute diarrhoea, and skin disease). In IDP camps, public health actions were implemented for each disease detected and no further cases were reported. CONCLUSIONS: In Yemen, CBS was useful for detecting suspected outbreaks in IDP camps. CBS implementation did not yield expected results in general communities in urban areas in the early stage of the COVID-19 pandemic when little was known about the disease. In the urban setting, the system failed to detect suspected COVID-19 cases and other diseases despite the ongoing outbreaks reported through eDEWS. In Yemen, as in other countries, feasibility and acceptability studies should be conducted few months before CBS expansion in urban communities. The project should be expanded in IDP camps, by creating COVID-19 and other disease outbreak reporting sites.

The COVID-19 pandemic is deepening the health crisis in South Kivu, Democratic Republic of Congo.

OBJECTIVE: The outbreak of coronavirus disease 2019 (COVID-19) in South Kivu, Democratic Republic of Congo raised concerns regarding additional morbidity and mortality. Updating these indicators before a second wave is essential in order to prepare for additional help. METHODS: From mid-May to mid-December 2020, weekly surveys were undertaken in sampled streets from 10 health areas to quantify the use of barrier measures, and interview pedestrians about sickness and deaths in their households. Crude death rates (CDRs) were estimated. RESULTS: Minimal use or no use of face masks was observed in at least half of the streets. From May to December 2020, the number of suspected cases of COVID-19 increased six-fold (P < 0.05). Of deaths within 30 days preceding the interviews, 20% were considered to be related to COVID-19. The monthly CDRs at the beginning and end of the study were approximately 5 and 25 per 1000 population, respectively (P < 0.05); that is, annual CDRs of 60 and 260 per 1000 population, respectively. Thus, during the first wave, the estimated mortality rate increased by 50% compared with previous years, and increased at least four-fold by the end of 2020. CONCLUSION: Despite possible overestimations, the excess mortality in South Kivu is extremely concerning. This crisis calls for a rapid response and increased humanitarian assistance.