Alternative epidemic indicators for COVID-19 in three settings with incomplete death registration systems.

Not all COVID-19 deaths are officially reported, and particularly in low-income and humanitarian settings, the magnitude of reporting gaps remains sparsely characterized. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries, and social media-conducted surveys of infection may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modeling framework, we aim to better understand the range of underreporting using examples from three major cities: Addis Ababa (Ethiopia), Aden (Yemen), and Khartoum (Sudan) during 2020. We estimate that 69 to 100%, 0.8 to 8.0%, and 3.0 to 6.0% of COVID-19 deaths were reported in each setting, respectively. In future epidemics, and in settings where vital registration systems are limited, using multiple alternative data sources could provide critically needed, improved estimates of epidemic impact. However, ultimately, these systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality is reported and understood worldwide.

Reconstructing subdistrict-level population denominators in Yemen after six years of armed conflict and forced displacement.

Introduction: Yemen has experienced widespread insecurity since 2014, resulting in large-scale internal displacement. In the absence of reliable vital events registration, we tried to reconstruct the evolution of Yemen's population between June 2014 and September 2021, at subdistrict (administrative level 3) resolution, while accounting for growth and internal migration. Methods: We reconstructed subdistrict-month populations starting from June 2014 WorldPop gridded estimates, as a function of assumed birth and death rates, estimated changes in population density, net internal displacement to and from the subdistrict and assumed overlap between internal displacement and WorldPop trends. Available displacement data from the Displacement Tracking Matrix (DTM) project were subjected to extensive cleaning and imputation to resolve missingness, including through machine learning models informed by predictors such as insecurity. We also modelled the evolution of displaced groups before and after assessment points. To represent parameter uncertainty, we complemented the main analysis with sensitivity scenarios. Results: We estimated that Yemen's population rose from about 26.3 M to 31.1 M during the seven-year analysis period, with considerable pattern differences at sub-national level. We found that some 10 to 14 M Yemenis may have been internally displaced during 2015-2016, about five times United Nations estimates. By contrast, we estimated that the internally displaced population had declined to 1-2 M by September 2021. Conclusions: This analysis illustrates approaches to analysing the dynamics of displacement, and the application of different models and data streams to supplement incomplete ground observations. Our findings are subject to limitations related to data quality, model inaccuracy and omission of migration outside Yemen. We recommend adaptations to the DTM project to enable more robust estimation.

How to identify epistemic injustice in global health research funding practices: a decolonial guide.

Epistemic injustice is a growing area of study for researchers and practitioners working in the field of global health. Theoretical development and empirical research on epistemic injustice are crucial for providing more nuanced understandings of the mechanisms and structures leading to the exclusion of local and marginalised groups in research and other knowledge practices. Explicit analysis of the potential role of epistemic injustice in policies and practices is currently limited with the absence of methodological starting points. This paper aims to fill this gap in the literature by providing a guide for individuals involved in the design and review of funding schemes wishing to conduct epistemic injustice analysis of their processes using a decolonial lens. Placing contemporary concerns in a wider historical, political and social context and building from the intertwined issues of coloniality of power, coloniality of knowledge and coloniality of being that systematically exclude non-Western epistemic groups, this practice paper presents a three-step decolonial approach for understanding the role and impact of epistemic injustices in global health research funding. It starts with an understanding of how power operates in setting the aim of a call for research proposals. Then, the influence of pose and gaze in the review process is analysed to highlight the presence of epistemological colonisation before discussing methods to address the current funding asymmetries by supporting new ways of being and doing focused on knowledge plurality. Expanding research on how epistemic wrongs manifest in global health funding practices will generate key insights needed to address underlying drivers of inequities within global health project conception and delivery.

A method for small-area estimation of population mortality in settings affected by crises.

BACKGROUND: Populations affected by crises (armed conflict, food insecurity, natural disasters) are poorly covered by demographic surveillance. As such, crisis-wide estimation of population mortality is extremely challenging, resulting in a lack of evidence to inform humanitarian response and conflict resolution. METHODS: We describe here a 'small-area estimation' method to circumvent these data gaps and quantify both total and excess (i.e. crisis-attributable) death rates and tolls, both overall and for granular geographic (e.g. district) and time (e.g. month) strata. The method is based on analysis of data previously collected by national and humanitarian actors, including ground survey observations of mortality, displacement-adjusted population denominators and datasets of variables that may predict the death rate. We describe the six sequential steps required for the method's implementation and illustrate its recent application in Somalia, South Sudan and northeast Nigeria, based on a generic set of analysis scripts. RESULTS: Descriptive analysis of ground survey data reveals informative patterns, e.g. concerning the contribution of injuries to overall mortality, or household net migration. Despite some data sparsity, for each crisis that we have applied the method to thus far, available predictor data allow the specification of reasonably predictive mixed effects models of crude and under 5 years death rate, validated using cross-validation. Assumptions about values of the predictors in the absence of a crisis provide counterfactual and excess mortality estimates. CONCLUSIONS: The method enables retrospective estimation of crisis-attributable mortality with considerable geographic and period stratification, and can therefore contribute to better understanding and historical memorialisation of the public health effects of crises. We discuss key limitations and areas for further development.

Excess mortality during the COVID-19 pandemic: a geospatial and statistical analysis in Aden governorate, Yemen.

BACKGROUND: The burden of COVID-19 in low-income and conflict-affected countries remains unclear, largely reflecting low testing rates. In parts of Yemen, reports indicated a peak in hospital admissions and burials during May-June 2020. To estimate excess mortality during the epidemic period, we quantified activity across all identifiable cemeteries within Aden governorate (population approximately 1 million) by analysing very high-resolution satellite imagery and compared estimates to Civil Registry office records. METHODS: After identifying active cemeteries through remote and ground information, we applied geospatial analysis techniques to manually identify new grave plots and measure changes in burial surface area over a period from July 2016 to September 2020. After imputing missing grave counts using surface area data, we used alternative approaches, including simple interpolation and a generalised additive mixed growth model, to predict both actual and counterfactual (no epidemic) burial rates by cemetery and across the governorate during the most likely period of COVID-19 excess mortality (from 1 April 2020) and thereby compute excess burials. We also analysed death notifications to the Civil Registry office over the same period. RESULTS: We collected 78 observations from 11 cemeteries. In all but one, a peak in daily burial rates was evident from April to July 2020. Interpolation and mixed model methods estimated ≈1500 excess burials up to 6 July, and 2120 up to 19 September, corresponding to a peak weekly increase of 230% from the counterfactual. Satellite imagery estimates were generally lower than Civil Registry data, which indicated a peak 1823 deaths in May alone. However, both sources suggested the epidemic had waned by September 2020. DISCUSSION: To our knowledge, this is the first instance of satellite imagery being used for population mortality estimation. Findings suggest a substantial, under-ascertained impact of COVID-19 in this urban Yemeni governorate and are broadly in line with previous mathematical modelling predictions, though our method cannot distinguish direct from indirect virus deaths. Satellite imagery burial analysis appears a promising novel approach for monitoring epidemics and other crisis impacts, particularly where ground data are difficult to collect.