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COVID-19, a new infectious disease, has originated from Wuhan in China on December 8, 2019.¹ It has spread to more than two hundred countries causing different rates of infection and fatality, especially affecting the elders with higher rates of mortality.² However, many countries, without realizing their initial missteps,³ have been claiming self-laurels for best COVID-19 management than other countries. The penetration of infection and the disease burden caused by COVID-19, particularly its mortality burden, suffered by the countries and its impact on the annual crude death rates of the concerned countries will speak of the effectiveness of the control measures and interventions initiated by the countries to prevent the entry of the infection into their countries. Thus, the findings from this study may serve as an alert, at least, while evolving future policy decisions,³ against any new foreign diseases.

The mortality suffered by a country in a year is known as ‘Annual Crude Death Rate’ and is denoted by the number of deaths occurring among the population of the country during a given calendar year, per 1000 mid-year total population of that country.⁴ This annual crude death rate includes the mortality caused by all causes viz: ageing, accidental, crime, suicide, morbidity, disease etc. This rate may vary from country to country and year to year depending upon the birth rate, differential distribution of different age groups, health status, new disease, natural calamities etc. prevailing in the respective countries.

The measurement of mortality in a population caused by any morbidity or other causes is felt as burdensome on the population and public health. As infectious diseases are more likely to quickly kill people than non-communicable diseases, they bring in more burdensome to individuals, families, health care systems and societies. Hence any upward shift in the mortality suffered by a population, as a result of a particular disease assumes importance in measuring its disease burden. Tremendous efforts and early preventive measures are the thumb rules to be adopted to mitigate the disease burden of any infectious disease.⁵ 

COVID-19 is a new pandemic health threat, currently suffered by the world countries. Hence no prior data or testing for assessing the disease burden or mortality burden of COVID are available. However, when current fatality data of a new disease is available, it can be used to study the mortality burden of such new disease from the estimation of increase in deaths, if any, suffered after such new infection, than the expected normal mortality, had there been no such pandemic.⁶ 

Excess deaths, if any, caused by a new disease will necessarily affect the annual crude death rates of the concerned countries. Hence the excess death approach will be useful to understand and estimate the COVID mortality burden currently suffered by the world countries.

Seventeen countries, including China, representing each Continent, were selected for this study. COVID data for the first seven months of 2020, population and crude death rates for these countries were collected from the public domains:

https://news.google.com/covid19/map?hl=en-IN&mid=/m/02j71&gl=IN&ceid=IN:en

https://en.wikipedia.org/wiki/COVID-19_pandemic_deaths#Second_half_5

https://population.un.org/ProfilesOfAgeing2017/

https://www.un.org/en/development/desa/population/publications/pdf/mortality/WMR2019/WorldMortality2019DataBooklet.pdf

https://ourworldindata.org/coronavirus-testing#world-map-total-tests-performed-relative-to-the-size-of-population

https://www.sis.gov.eg/Story/146052/Presidential-adviser-Over-1-million-COVID-19-tests-conducted-nationwide?lang=en-us&fbclid=IwAR2PGkzuV7LLKoj8mWsiZ2cugOxQtz0fQWmFI-mCOnOIfvxLx_jysRkBUI

https://www.bbc.com/news/world-us-canada-53221801

The Data collected for this analysis were considered, as such, without any correction or adjustment. Various control measures and interventions initiated by these countries in the management of COVID-19 pandemic along with the degree of incidence of infection and fatality suffered by the countries are shown in Table 1, wherein the countries are arranged in chronological order of COVID infection entering into the country.

Table 1. COVID-19 Status and Interventions in Select Countries as on July 31, 2020

Total COVID confirmed persons reported for each country, as on July 31, 2020, has been considered as the representative sample population of that country and used to derive the expected crude deaths of all causes among this sample population for seven months period. This expected deaths for the given infected population, for seven months, is compared with the actual COVID deaths suffered by the country during the same period to determine the excess deaths caused by COVID, as shown in Table 2. 

Table 2. Estimation of Excess Deaths Caused by COVID in 7 Months of 2020 in Select Countries

The excess COVID deaths together with the expected seven months crude deaths for total population has been used to compute the impact caused by the excess COVID deaths on the country’s annual crude death rate, as shown in Table 3. 

Table 3. Impact of COVID Mortality Burden of 7 Months on the Annual Crude Death Rates of the Countries

Among the countries studied here, except Singapore, all other countries are found to have suffered excess deaths, of varying numbers, than the expected crude deaths in this period. The excess deaths suffered by the countries, except Singapore and Thailand, even during this seven months, are found to have an impact of increasing the annual crude death rates of the concerned countries, with an estimated increase ranging between 0.005 (0.068%) and 1.124 (11.957%).

Among the six Asian countries studied here, India is found to have suffered the highest mortality burden with an estimated increase of 0.036 (0.493%) in its annual crude death rate while Singapore’s crude death rate is found to have a likely decrease by -0.034 (-0.739%). Australia, the lone country chosen from Oceania, is likely to suffer a nominal increase of 0.009 (0.136%) in its crude death rate. Among the two African countries studied here, Egypt is to suffer an estimated increase of 0.075 (1.293%) while South Africa is likely to suffer a much higher increase of 0.153 (1.628%) in their crude death rates. Brazil is to suffer a likely increase of 0.665 (10.231%) while United States is likely to register an increase of 0.683 (7.761%) in their crude death rates. Among the six European countries taken for this study, Russia is likely to suffer the lowest increase of 0.091 (0.716%) while United Kingdom is to suffer the highest likely increase of 1.124 (11.957%), which is also the highest mortality burden among the seventeen countries studied here.

Any pandemic infection is a health threat affecting the life and safe living of the people. Ensuring the right to live and right to life of the people are the Sovereign and Constitutional responsibilities reposed on the States. Hence timely intervention by the authorities is cardinal to prevent the import of any foreign disease into the country. COVID-19 has originated in China, and no vaccine or curative therapy is available as on date to save the people. Hence preventing its import and entry into the country ought to have been the prime strategy for any welfare State.

Border closing, Entry restriction, Quarantine law, Epidemic diseases prevention law etc. are all at the disposal of the States for this purpose. The past experience of tackling the pandemic outbreaks and the effectiveness of the medical law in the containment of such pandemics are all well known to the medical authorities and policy makers.⁷ 

The World Health Organization (WHO) has come to know about the prevalence of cluster cases of pneumonia in Wuhan, China on December 31, 2019, and shared this input with world countries on January 4, 2020. WHO has also published its first disease outbreak news on a new virus in China on January 5, 2020. It has declared it as a Public Health Emergency of International Concern on January 30, 2020, and later as pandemic on March 11, 2020.⁸ Even before such declarations by WHO, China, the country of origin of COVID-19, has deployed the time tested medical law, on January 23, 2020, to prevent the spread of this infection to other provinces of China, by ordering the lockdown of Wuhan along with strict isolation, quarantine and curfew measures.^9,10 Such control measures, though appeared or criticized as draconian and oppressive,⁹ alone have helped China to slow down the COVID spread rate R_t to lower than 1¹¹ and in the effective containment of the spread of COVID-19 within the next 3 months.⁹ Thus as experienced in the past, these interventions have been proved as useful and effective only when they are applied quickly at the earliest stage.¹² 

A follow up of the status of infection at Wuhan, in the early stage, has revealed the vulnerability of the health care personnel, with higher infection rate than the public, denoting the spread by contact. The Chinese have immediately ordered the withdrawal and isolation of the entire health care personnel with a replacement of 30000 health personnel drawn from other provinces,¹⁰ and this has not only ensured the safety of the Health professionals but has also prevented the potent infection to others through this infected personnel. However, most of the world countries have failed to take any cue from this.

At the time of outburst of this disease, China was in the midst of celebrating its culturally most important Chinese Lunar New year, which has already attracted many billion person trips by Chinese and visitors, from around the world from December 2019.⁹ China was about to cancel the celebration and to impose strict interventions to contain the COVID spread. Hence most of the people had advanced their return journeys through the available direct or indirect flights before the impending suspension of air traffic. Thus there was a huge human migration between January 10 and 22,¹⁰ travelling in packed flights, trains and buses for long duration with continuous contact with other persons with the risk of getting infected or transmitting the pathogen to others or to the objects in contact with them during these journeys. Thus, a large number of infected persons, among the thousands of travelers returning from China, have landed in many countries even before January 23, 2020, when none of the countries has ordered any border control or quarantine measures, except the less effective thermal screening protocol¹³ in few of their ports or points of entries.

Though China has alerted the WHO and was rightly determined to prevent the spread of infection into its other provinces, it was not equally alert to prevent the large-scale human migration out of the country, on the eve of imposing control measures. However, during those days, WHO was also not interested in advising the world countries in banning the flights or imposing travel restrictions, on economics considerations¹⁴ while seemingly ignoring the health threat to the world countries. Major populated countries like USA, Brazil, India etc. though aware, in the first week of January 2020, of the outbreak of a new Chinese disease,⁸ have apparently failed to initiate timely border control or quarantine measures to prevent the entry of this foreign infection.

COVID infected persons will normally develop symptoms within 12 days of infection.¹⁵ Such symptomatic person was first detected, out of China, on January 13 at Thailand and subsequently in all the countries studied now, as shown in Table 1. Thus by the time when travel restrictions or border closures or curfew or tracing of the already landed persons were ordered by some of these countries,^{16 - 21} each of the infected person, already entered into the country would have transmitted the infection to many of his local contacts also. Hence the spread of the infection has become inevitable in these countries. Though Egypt, Brazil and South Africa were having more buying time than other countries, they have also apparently failed to prevent such import.

Demographically, as seen in Table 1, Egypt, South Africa and India are in an advantageous position with more younger aged population than Japan followed by all other countries taken for this study, wherein older-aged population, vulnerable for infection, is more. Singapore is the most densely populated country in this study group. However, these demographic factors seem to be of no relevance to the penetration of infection into these countries where no stricter and earlier non-pharmaceutical interventions were resorted to.

PCR testing for COVID reveals the presence of more asymptomatic persons among the PCR positive persons. These asymptomatic persons are all potent carriers of the pathogen,²² and thus require to be isolated from other normal persons and particularly away from the vulnerable elder people. Unless universal screening is resorted, the asymptomatic persons among the non-tested population cannot be identified and isolated to avoid further spread of infection.^{22 - 24} The economic prosperity of the countries seem to influence the affordability of large scale PCR testing in some countries, in view of the cost of PCR testing. This could be overcome by resorting to a seroprevalence blood test for COVID antibodies,²⁵ at least, by the larger populated countries. This would have helped in isolating a large number of infected and asymptomatic persons among the public and especially among the health and other front-line workers.^22,23,25 

As many of these countries have not resorted to universal testing, they inadvertently allow continuing transmission of the infection through a large number of non-tested but infected and asymptomatic persons in the population. Typical evidence in this regard can be seen in the Indian scenario, wherein, ironically, there is a hesitation to accept COVID-19 as community spread. During the continuing lockdown period, more than a million persons, mostly millennial, were booked for criminal cases by the Indian Police, throughout the country for violation of curfew orders. A fine amount of more than 200 million INR has also been levied on them by the patrolling Police officials.^{26 - 28} Subsequently more than ten thousand police personnel, in the State of Tamil Nadu alone, are infected with COVID including few COVID deaths among them. These police personnel were not on medical or front-line health care duties. Thus they ought to have got infected from the curfew violators whom they have physically handled and were in contact while arresting them. But the Governments and Police seem to be not aware of this potent source of infection with the result that many of the infected but untested persons among curfew violators and their subsequent contacts are still freely spreading the infection to other susceptible and old people in the community.

Another potent source of infection is the hospital discharged COVID patients. As the viral shedding, from the infected persons, is continuing for more than 56 days,²⁹ all the hospital discharged COVID patients also require continuous monitoring and isolation for longer periods.³⁰ But in the absence of any continuous seroprevalence screening or isolation surveillance over the discharged COVID patients, they also have become a continuing source of infection in the community.

Curfew and restriction of free movement of Individuals may be deemed as a violation of the right to freedom of movement of people. But protecting the life and ensuring the safe living of people at large are the Sovereign and Constitutional duties of the States. The States can not simply uphold the rights of the individuals at the cost of life and safe living of the other vulnerable people in the community. Thus, in the event of a serious foreign infection, that too when the medical emergency law is in operation, the States are bound to protect the life of the entire people of the country in spite of the certain amount of restrictions on the individual’s rights of freedom.^7,9,12 

Thus apparently, many countries have not resorted to effective control measures to prevent the import of COVID-19 infection into their countries at the earliest point of time and thus have to suffer different levels of COVID mortality burden in terms of their crude death rates. Further, most of the country leaders, seem to have neither realized their acts of constitutional negligence nor evinced any sympathetic or empathetic or remorse feelings over the unwarranted and premature deaths of thousands of their countrymen.

- Prof. N. Gunachandran [Formerly: Professor of Forensic Science and Deputy Director, Forensic Sciences Department, Govt. of Tamil Nadu] Chennai, India) email: This email address is being protected from spambots. You need JavaScript enabled to view it.

References:

1. Min Wei, Jingping Yuan, Yu Liu, Tao Fu, Xue Yu, Zhi-Jiang Zhang. Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China. JAMA. 2020; 323 (13): 1313-1314. doi:10.1001/jama.2020.2131

2. Lang Wang, Wenbo He, Xiaomei Yu et al. Coronavirus disease 2019 in elderly patients: Characteristics and prognostic factors based on 4-week follow-up. Journal of Infection 80, 2020. pp 639-645. https://doi.org/10.1016/j.jinf.2020.03.019

3. Joshua M. Sharfstein, Scott J. Becker and Michelle M. Mello. Diagnostic Testing for the Novel Coronavirus. JAMA April 21, 2020 Volume 323, Number 15 pp. 1437-1438

4. https://stats.oecd.org/glossary/detail.asp?ID=491

5. https://nccid.ca/publications/exploring-the-concept-of-burden-of-disease/ [(2016) Project No. 274]

6. Daniel M Weinberger, Jenny Chen, Ted Cohen, et al. Estimation of Excess Deaths Associated With the COVID-19 Pandemic in the United States, March to May 2020. JAMA Intern Med. Pub. Online July 1, 2020, doi:10.1001/jamainternmed.2020.3391

7. Agnel Desai. Twentieth-Century Lessons for a Modern Coronavirus Pandemic. JAMA Published online April 27, 2020

8. https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19

9. Zun Yu Wu and Jennifer M. McGoogan Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA (Apr 7, 2020) 323 (13), pp. 1239-1242. doi:10.1001/jama.2020.2648

10. An Pan, Li Liu, Chaolong Wang, et al. Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in Wuhan, China. JAMA Published online April 10, 2020. doi:10.1001/jama.2020.6130

11. Thomas V. Linglesby. Public Health Measures and the Reproduction Number of SARS-CoV-2. JAMA Published Online: May 1, 2020. doi:10.1001/jama.2020.7878

12. David M Hurtley and Eli N Perencevich, EDITORIAL: Public Health Interventions for COVID-19 Emerging Evidence and Implications for an Evolving Public Health Crisis. JAMA Published online April 10, 2020 doi:10.1001/jama.2020.5910

13. https://www.gov.uk/government/news/dont-rely-on-temperature-screening -products-for-detection-of-coronavirus-covid-19-says-mhra

14. WHO: Jan, 10 Travel Advice : No travel Restrictions recommended: https://www.who.int/news-room/articles-detail/who-advice-for-international-travel-and-trade-in-relation-to-the-outbreak-of-pneumonia-caused-by-a-new-coronavirus-in-china

15. M. Joost Weirsinga, Andrew Rhodes, Allen C. Cheng, et al. Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19) A Review. JAMA Published online July 10, 2020. doi:10.1001/jama.2020.12839

16. Presidential Proclamation USA: January 31, 2020. https://www.govinfo.gov/content/pkg/FR-2020-02-05/pdf/2020-02424.pdf

17. https://www.bbc.com/news/world-middle-east-51787238

18. https://elpais.com/cultura/2020-03-11/coronavirus-el-mundo-de-la-cultura-pone-en-mayo-sus-esperanzas-tras-el-aluvion-de-cancelaciones.html

19. Govt. of India status report filed on March 31, 2020 before the Supreme Court of India in Diary No. 10789 of 2020 in Writ Pet. Civil No. 468 of 2020.

20. 15 lakh air travelers entered India in 2 months: Cabinet Secretary: News coverage by Economic Times: March 27, 2020. https://economictimes.indiatimes.com/news/politics-and-nation/15-lakh-air-travellers-entered-india-in-2-months-cabinet-secretary/articleshow/74849839.cms?from=mdr

21. http://www.in.gov.br/en/web/dou/-/portaria-n-152-de-27-de-marco-d e-2020-250060288

22. Yan Bai, Lingsheng Yao, Tao Wei, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA (April 14, 2020) 323, (14), PP 1406-1407 Published Online: February 21, 2020. doi:10.1001/jama.2020.2565

23. Alison C. Roxby, Alexander L. Greninger, Kelly M. Hatfield, et al. Outbreak Investigation of COVID-19 Among Residents and Staff of an Independent and Assisted Living Community for Older Adults in Seattle, Washington. JAMA Intern Med. Published online May 21, 2020. doi:10.1001/jamainternmed.2020.2233

24. Joan Stevenson. Universal, Repeated Testing for SARS-CoV-2 and Isolation of Infected Patients Curbed Spread in a Long-Term Care Nursing Facility. JAMA Health Forum In the News June 12, 2020 COVID-19

25. Deborah Steensels, Els Oris, Laura Coninx, et al. Quick screening of large cohorts is important to control the pandemic Hospital-wide antibody screening for SARS-CoV-2 can help monitor transmission dynamics and evaluate infection control policies. JAMA Published online June 15, 2020 doi:10.1001/jama.2020.111608

26. https://www.thehindu.com/news/national/tamil-nadu/1044-crore-fine-collected-from-lockdown-violators/article31769790.ece

27. https://timesofindia.indiatimes.com/city/mumbai/maharashtra-cops-collect-rs-8-41-crore-fine-for-lockdown-violations/articleshow/76513641.cms

28. https://timesofindia.indiatimes.com/city/jaipur/rs-1-3-crore-collected-in-fines-due-to-lockdown-violations/articleshow/76259754.cms

29. Jinru Wu, BS; Xinyi Liu, BS; Jianjun Liu, B, et al. Coronavirus Disease 2019 Test Results After Clinical Recovery and Hospital Discharge Among Patients in China. JAMA Network Open. 2020;3(5). doi:10.1001/jamanetworkopen.2020.9759

30. Angelo Carfì, Roberto Bernabei, Francesco Landi et al. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020;324(6):603-605.Published Online: July 9, 2020. doi:10.1001/jama.2020.12603

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