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@article{kung_underestimation_2021,
	title = {Underestimation of {COVID}-19 mortality during the pandemic},
	volume = {7},
	issn = {2312-0541},
	url = {http://openres.ersjournals.com/lookup/doi/10.1183/23120541.00766-2020},
	doi = {10.1183/23120541.00766-2020},
	abstract = {Background
              There has been considerable international variation in mortality during the COVID-19 pandemic. The objective of this study was to investigate the differences between mortality registered as due to COVID-19 and the excess all-cause mortality reported in countries worldwide during the COVID-19 pandemic.
            
            
              Methods
              Ecological analysis of 22 countries compared 5-year historical all-cause mortality, reported all-cause mortality and expected all-cause mortality (calculated as historical mortality plus the reported deaths attributed to COVID-19). Data available from the first week of January 2020 to that most recently available were analysed.
            
            
              Results
              Compared to the preceding 5 years, there was an excess of 716 616 deaths, of which 64.3\% were attributed to COVID-19. The proportion of deaths registered as COVID-19-related/excess deaths varied markedly between countries, ranging between 30\% and 197\% in those countries that had an excess of deaths during the period of observation. In most countries where a definite peak in COVID-19-related deaths occurred, the increase in reported all-cause mortality preceded the increase in COVID-19 reported mortality. During the latter period of observation, a few countries reported fewer all-cause deaths than the historical figures.
            
            
              Conclusion
              The increases in all-cause mortality preceded the increase in COVID-19 mortality in most countries that had definite spikes in COVID-19 mortality. The number of deaths attributed to COVID-19 was underestimated by at least 35\%. Together these findings suggest that calculation of excess all-cause mortality is a better predictor of COVID-19 mortality than the reported rates, in those countries experiencing definite increases in mortality.},
	language = {en},
	number = {1},
	urldate = {2021-02-18},
	journal = {ERJ Open Research},
	author = {Kung, Stacey and Doppen, Marjan and Black, Melissa and Braithwaite, Irene and Kearns, Ciléin and Weatherall, Mark and Beasley, Richard and Kearns, Nethmi},
	month = jan,
	year = {2021},
	note = {Number: 1},
	pages = {00766--2020},
}