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Need for improving COVID-19 mortality registries: the case of Peru

Need for improving COVID-19 mortality registries: the case of Peru Hernández-Vásquez et al. Journal of the Egyptian Public Health Association (2021) 96:16 Journal of the Egyptian https://doi.org/10.1186/s42506-021-00079-w Public Health Association LETTER TO THE EDITOR Open Access Need for improving COVID-19 mortality registries: the case of Peru 1* 2 3 Akram Hernández-Vásquez , Rodrigo Vargas-Fernández , Jesús Eduardo Gamboa-Unsihuay and Diego Azañedo To the Editor: According to the World Health Organization (WHO), The SARS-CoV-2 pandemic has generated unprece- for epidemiological surveillance purposes, death by dented health consequences with a record of nearly 117 COVID-19 is considered to occur as a result of a clinical million cases and more than two million deaths in 188 picture compatible with COVID-19, whether a suspected countries as of July 2020 [1]. Peru was the 19th country or confirmed case [7]. Likewise, the Pan American in the world and fifth in Latin America [1] with the high- Health Organization (PAHO) points out that the codes est number of identified cases (1.5 million). In addition, U07.1 (identified virus) and U07.2 (unidentified virus) of there are 50 thousand deaths [2], and an excess of 355 the International Classification of Diseases 10th edition deaths per 100,000 inhabitants by 2020 attributed to this (ICD-10) should be used to record the cases of deaths condition compared to previous years [3]. Correct record- due to this disease [8]. Despite these recommendations, ing and monitoring of the dynamics of COVID-19 mortal- in July 2020, the Situation Room of MINSA reported the ity are important to know the impact of the pandemic and presence of an under-registration of more than 3000 the effectiveness of health measures, as well as to allow deaths in the period from March to July 2020 compared timely rethinking of these measures if necessary. However, to the SINADEF records [9]. This reflects a major prob- under-registration of mortality has been identified in most lem that does not allow assessment of the actual impact Latin American countries, including Peru [4]. of the pandemic according to the recommendations of In Peru, the main sources of information on the WHO and PAHO, generating confusion among the COVID-19 mortality are the National Informatics population and decision-makers. Deaths System (SINADEF in Spanish) and the Situ- To determine the extent of this under-registration ational Room of the Ministry of Health of Peru throughout the national territory and to know where this (MINSA in Spanish). SINADEF is a virtual informa- problem is concentrated, an ecological study was carried tion system, in which medical personnel record the out to estimate mortality by COVID-19 at the departmen- causes (basic, intermediate, direct, or intervening) of tal level from codes U07.1 and U07.2 recorded in SINA the death of patients, including those with suspected DEF (https://bit.ly/3hjRbOA) from the first reported case or confirmed COVID-19 cases [5]. In turn, the Situ- of COVID-19 in Peru to March 6, 2021, and compare the ational Room of MINSA takes the National Center results with the figures reported by the Situational for Epidemiology, Prevention and Disease Control Room of MINSA in the same period (https://covid19. (CDC) as a source of information, which centralizes minsa.gob.pe/sala_situacional.asp). Furthermore, the code reports of all cases of death by COVID-19 verified by enabling the replicability of results in the R statistical pro- a laboratory test, recorded by health services at the gram is available on the GitHub collaborative develop- national level through its systems of epidemiological ment platform (https://github.com/jeguns/ surveillance and health intelligence [6]. ComparacionMortalidad). A total of 94,574 COVID-19 deaths recorded under the ICD-10 codes were identified: U07.1 (n = 70,099) and U07.2 (n = 24,475) in SINADEF, while the Situ- * Correspondence: ahernandez@usil.edu.pe Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Centro ational Room recorded 47,491 deaths by the same path- de Excelencia en Investigaciones Económicas y Sociales en Salud, Lima, Peru ology (a difference of 47,088 deaths). This inconsistency Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Hernández-Vásquez et al. Journal of the Egyptian Public Health Association (2021) 96:16 Page 2 of 3 Table 1 Comparison of the reported deaths from COVID-19 between the National Informatics Deaths System (SINADEF) and the Ministry of Health (MINSA) records (during the period from the first reported case of COVID-19 in Peru to March 6, 2021) SINADEF MINSA Departments Confirmed COVID-19 deaths Suspected COVID-19 deaths Total COVID-19 deaths Total COVID-19 deaths Lima 32,273 12,671 44,944 20,770 Piura 3959 1725 5684 2429 Callao 3699 1378 5077 2515 Ica 3444 983 4427 2297 Arequipa 3025 1319 4344 2039 La Libertad 2649 841 3490 2879 Junin 2798 607 3405 1560 Lambayeque 2280 711 2991 2164 Ancash 2198 616 2814 1891 Cusco 1737 332 2069 767 Loreto 1005 846 1851 1212 Puno 1479 315 1794 638 Cajamarca 1571 215 1786 809 Huanuco 1254 248 1502 766 San Martin 1043 274 1317 899 Tacna 931 160 1091 611 Ucayali 677 331 1008 541 Ayacucho 759 127 886 516 Moquegua 579 256 835 461 Huancavelica 565 113 678 243 Tumbes 530 105 635 449 Apurimac 451 112 563 277 Pasco 407 70 477 249 Amazonas 360 75 435 329 Madre de Dios 400 29 429 180 Sin Registro 26 16 42 NA Total 70,099 24,475 94,574 47,491 Data updated until March 06, 2021 MINSA Ministry of Health of Peru, SINADEF National Informatics Deaths System in the number of deaths by COVID-19 recorded by 42 “no registration” department deaths in SINADEF (see SINADEF (using encoding U07.1 and U07.2) and the Table 1). Situational Room of MINSA is also found in most de- These results show large differences between the fig- partments that make up Peru. Lima is the department ures reported by MINSA and SINADEF in all depart- with the highest number of deaths reported by COVID- ments of Peru taking into account COVID-19 coding. 19 by both entities; thus, while MINSA reported a total These differences could be linked to the non-recording of 20,770 deaths, SINADEF recorded 44,944, resulting in of deaths of suspected COVID-19 cases in a scenario of a difference of 24,184 deaths. Moreover, in the depart- scarcity of diagnostic methods and operational capacity ments of Piura, the constitutional province of Callao, affecting various Latin American countries. Ica, and Arequipa, there was a difference of more than two thounsands deaths when comparing the figures Abbreviations SINADEF: National Informatics Deaths System; MINSA: Ministry of Health of reported by MINSA and those estimated using the codes Peru; WHO: World Health Organization; PAHO: Pan American Health for COVID-19 of SINADEF. In addition, most depart- Organization; COVID-19: coronavirus disease ments of the mountains range have double or up to three times as many deaths according to SINADEF com- Acknowledgements pared to MINSA. It should be noted that there are also Not applicable. Hernández-Vásquez et al. Journal of the Egyptian Public Health Association (2021) 96:16 Page 3 of 3 Authors’ contributions AHV conceived the study. JG analyzed and interpreted the mortality data. AHV, JG, RVF, and DA have written, reviewed the submitted manuscript, and approved the final manuscript for submission. Funding Self-funded Availability of data and materials The datasets analyzed during the current study are available in the SINADEF repository, https://bit.ly/3hjRbOA Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Author details Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Centro de Excelencia en Investigaciones Económicas y Sociales en Salud, Lima, Peru. 2 3 Universidad Científica del Sur, Lima, Peru. Universidad Nacional Agraria La Molina, Lima, Peru. Independent Researcher, Lima, Peru. Received: 26 April 2021 Accepted: 26 May 2021 References 1. Johns Hopkins. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University [Internet]. JHU; 2020 [cited 2020 Jul 28]. Available from: https://coronavirus.jhu.edu/map.html 2. Covid 19 en el Perú - Ministerio del Salud. [cited 2020 Jul 28]. Available from: https://www.covid19.minsa.gob.pe/sala_situacional.asp 3. The Economist. Tracking covid-19 excess deaths across countries [Internet]. 2020 [cited 2021 Mar 23]. Available from: https://www.economist.com/gra phic-detail/coronavirus-excess-deaths-tracker 4. Programa de las Naciones Unidas para el Desarrollo. Una tragedia peor de lo que creemos: las tasas de exceso de mortalidad sugieren que el número de muertes por COVID-19 se subestima enormemente en ALC UNDP; 2020 [cited 2021 March 6]. Available from: https://www.latinamerica.undp.org/ content/rblac/es/home/presscenter/director-s-graph-for-thought/a-greater- tragedy-than-we-know%2D%2Dexcess-mortality-rates-suggest-t.html 5. Vargas-Herrera J, Pardo Ruiz K, Garro Nuñez G, Miki Ohno J, Pérez-Lu JE, Valdez Huarcaya W, et al. Resultados preliminares del fortalecimiento del sistema informático nacional de defunciones. Rev Peru Med Exp Salud Publica. 2018;35(3):505–14. https://doi.org/10.17843/rpmesp.2018.353.3913. 6. Ministerio de Salud. Directiva Sanitaria para la Vigilancia Epidemiológica de la Enfermedad por Coronavirus (COVID-19) en el Perú MINSA; 2020 [cited 2021 March 6]. Available from: http://www.dge.gob.pe/portal/docs/tools/ teleconferencia/2020/SE452020/03.pdf 7. World Health Organization. Medical certification, ICD mortality coding, and reporting mortality associated with COVID-19 WHO; 2020 [cited 2021 March 6]. Available from: https://www.who.int/publications/i/item/WHO-2019- nCoV-mortality-reporting-2020-1 8. Pan American Health Organization. Coding of COVID-19 with ICD-10; 2020 [cited 2020 Jul 29]. Available from: https://www.paho.org/arg/ dmdocuments/2019-ncov-1/documentos/COVID-19-CIE-codigos-2020-03-25- spa.pdf 9. IDL-Reporteros. Los muertos que el Gobierno no cuenta [cited 2020 Dec 20]. Available from: https://www.idl-reporteros.pe/los-muertos-que-el- gobierno-no-cuenta/ Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

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Hernández-Vásquez et al. Journal of the Egyptian Public Health Association (2021) 96:16 Journal of the Egyptian https://doi.org/10.1186/s42506-021-00079-w Public Health Association LETTER TO THE EDITOR Open Access Need for improving COVID-19 mortality registries: the case of Peru 1* 2 3 Akram Hernández-Vásquez , Rodrigo Vargas-Fernández , Jesús Eduardo Gamboa-Unsihuay and Diego Azañedo To the Editor: According to the World Health Organization (WHO), The SARS-CoV-2 pandemic has generated unprece- for epidemiological surveillance purposes, death by dented health consequences with a record of nearly 117 COVID-19 is considered to occur as a result of a clinical million cases and more than two million deaths in 188 picture compatible with COVID-19, whether a suspected countries as of July 2020 [1]. Peru was the 19th country or confirmed case [7]. Likewise, the Pan American in the world and fifth in Latin America [1] with the high- Health Organization (PAHO) points out that the codes est number of identified cases (1.5 million). In addition, U07.1 (identified virus) and U07.2 (unidentified virus) of there are 50 thousand deaths [2], and an excess of 355 the International Classification of Diseases 10th edition deaths per 100,000 inhabitants by 2020 attributed to this (ICD-10) should be used to record the cases of deaths condition compared to previous years [3]. Correct record- due to this disease [8]. Despite these recommendations, ing and monitoring of the dynamics of COVID-19 mortal- in July 2020, the Situation Room of MINSA reported the ity are important to know the impact of the pandemic and presence of an under-registration of more than 3000 the effectiveness of health measures, as well as to allow deaths in the period from March to July 2020 compared timely rethinking of these measures if necessary. However, to the SINADEF records [9]. This reflects a major prob- under-registration of mortality has been identified in most lem that does not allow assessment of the actual impact Latin American countries, including Peru [4]. of the pandemic according to the recommendations of In Peru, the main sources of information on the WHO and PAHO, generating confusion among the COVID-19 mortality are the National Informatics population and decision-makers. Deaths System (SINADEF in Spanish) and the Situ- To determine the extent of this under-registration ational Room of the Ministry of Health of Peru throughout the national territory and to know where this (MINSA in Spanish). SINADEF is a virtual informa- problem is concentrated, an ecological study was carried tion system, in which medical personnel record the out to estimate mortality by COVID-19 at the departmen- causes (basic, intermediate, direct, or intervening) of tal level from codes U07.1 and U07.2 recorded in SINA the death of patients, including those with suspected DEF (https://bit.ly/3hjRbOA) from the first reported case or confirmed COVID-19 cases [5]. In turn, the Situ- of COVID-19 in Peru to March 6, 2021, and compare the ational Room of MINSA takes the National Center results with the figures reported by the Situational for Epidemiology, Prevention and Disease Control Room of MINSA in the same period (https://covid19. (CDC) as a source of information, which centralizes minsa.gob.pe/sala_situacional.asp). Furthermore, the code reports of all cases of death by COVID-19 verified by enabling the replicability of results in the R statistical pro- a laboratory test, recorded by health services at the gram is available on the GitHub collaborative develop- national level through its systems of epidemiological ment platform (https://github.com/jeguns/ surveillance and health intelligence [6]. ComparacionMortalidad). A total of 94,574 COVID-19 deaths recorded under the ICD-10 codes were identified: U07.1 (n = 70,099) and U07.2 (n = 24,475) in SINADEF, while the Situ- * Correspondence: ahernandez@usil.edu.pe Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Centro ational Room recorded 47,491 deaths by the same path- de Excelencia en Investigaciones Económicas y Sociales en Salud, Lima, Peru ology (a difference of 47,088 deaths). This inconsistency Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Hernández-Vásquez et al. Journal of the Egyptian Public Health Association (2021) 96:16 Page 2 of 3 Table 1 Comparison of the reported deaths from COVID-19 between the National Informatics Deaths System (SINADEF) and the Ministry of Health (MINSA) records (during the period from the first reported case of COVID-19 in Peru to March 6, 2021) SINADEF MINSA Departments Confirmed COVID-19 deaths Suspected COVID-19 deaths Total COVID-19 deaths Total COVID-19 deaths Lima 32,273 12,671 44,944 20,770 Piura 3959 1725 5684 2429 Callao 3699 1378 5077 2515 Ica 3444 983 4427 2297 Arequipa 3025 1319 4344 2039 La Libertad 2649 841 3490 2879 Junin 2798 607 3405 1560 Lambayeque 2280 711 2991 2164 Ancash 2198 616 2814 1891 Cusco 1737 332 2069 767 Loreto 1005 846 1851 1212 Puno 1479 315 1794 638 Cajamarca 1571 215 1786 809 Huanuco 1254 248 1502 766 San Martin 1043 274 1317 899 Tacna 931 160 1091 611 Ucayali 677 331 1008 541 Ayacucho 759 127 886 516 Moquegua 579 256 835 461 Huancavelica 565 113 678 243 Tumbes 530 105 635 449 Apurimac 451 112 563 277 Pasco 407 70 477 249 Amazonas 360 75 435 329 Madre de Dios 400 29 429 180 Sin Registro 26 16 42 NA Total 70,099 24,475 94,574 47,491 Data updated until March 06, 2021 MINSA Ministry of Health of Peru, SINADEF National Informatics Deaths System in the number of deaths by COVID-19 recorded by 42 “no registration” department deaths in SINADEF (see SINADEF (using encoding U07.1 and U07.2) and the Table 1). Situational Room of MINSA is also found in most de- These results show large differences between the fig- partments that make up Peru. Lima is the department ures reported by MINSA and SINADEF in all depart- with the highest number of deaths reported by COVID- ments of Peru taking into account COVID-19 coding. 19 by both entities; thus, while MINSA reported a total These differences could be linked to the non-recording of 20,770 deaths, SINADEF recorded 44,944, resulting in of deaths of suspected COVID-19 cases in a scenario of a difference of 24,184 deaths. Moreover, in the depart- scarcity of diagnostic methods and operational capacity ments of Piura, the constitutional province of Callao, affecting various Latin American countries. Ica, and Arequipa, there was a difference of more than two thounsands deaths when comparing the figures Abbreviations SINADEF: National Informatics Deaths System; MINSA: Ministry of Health of reported by MINSA and those estimated using the codes Peru; WHO: World Health Organization; PAHO: Pan American Health for COVID-19 of SINADEF. In addition, most depart- Organization; COVID-19: coronavirus disease ments of the mountains range have double or up to three times as many deaths according to SINADEF com- Acknowledgements pared to MINSA. It should be noted that there are also Not applicable. Hernández-Vásquez et al. Journal of the Egyptian Public Health Association (2021) 96:16 Page 3 of 3 Authors’ contributions AHV conceived the study. JG analyzed and interpreted the mortality data. AHV, JG, RVF, and DA have written, reviewed the submitted manuscript, and approved the final manuscript for submission. Funding Self-funded Availability of data and materials The datasets analyzed during the current study are available in the SINADEF repository, https://bit.ly/3hjRbOA Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Author details Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Centro de Excelencia en Investigaciones Económicas y Sociales en Salud, Lima, Peru. 2 3 Universidad Científica del Sur, Lima, Peru. Universidad Nacional Agraria La Molina, Lima, Peru. Independent Researcher, Lima, Peru. Received: 26 April 2021 Accepted: 26 May 2021 References 1. Johns Hopkins. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University [Internet]. JHU; 2020 [cited 2020 Jul 28]. Available from: https://coronavirus.jhu.edu/map.html 2. Covid 19 en el Perú - Ministerio del Salud. [cited 2020 Jul 28]. Available from: https://www.covid19.minsa.gob.pe/sala_situacional.asp 3. The Economist. Tracking covid-19 excess deaths across countries [Internet]. 2020 [cited 2021 Mar 23]. Available from: https://www.economist.com/gra phic-detail/coronavirus-excess-deaths-tracker 4. Programa de las Naciones Unidas para el Desarrollo. Una tragedia peor de lo que creemos: las tasas de exceso de mortalidad sugieren que el número de muertes por COVID-19 se subestima enormemente en ALC UNDP; 2020 [cited 2021 March 6]. Available from: https://www.latinamerica.undp.org/ content/rblac/es/home/presscenter/director-s-graph-for-thought/a-greater- tragedy-than-we-know%2D%2Dexcess-mortality-rates-suggest-t.html 5. Vargas-Herrera J, Pardo Ruiz K, Garro Nuñez G, Miki Ohno J, Pérez-Lu JE, Valdez Huarcaya W, et al. Resultados preliminares del fortalecimiento del sistema informático nacional de defunciones. Rev Peru Med Exp Salud Publica. 2018;35(3):505–14. https://doi.org/10.17843/rpmesp.2018.353.3913. 6. Ministerio de Salud. Directiva Sanitaria para la Vigilancia Epidemiológica de la Enfermedad por Coronavirus (COVID-19) en el Perú MINSA; 2020 [cited 2021 March 6]. Available from: http://www.dge.gob.pe/portal/docs/tools/ teleconferencia/2020/SE452020/03.pdf 7. World Health Organization. Medical certification, ICD mortality coding, and reporting mortality associated with COVID-19 WHO; 2020 [cited 2021 March 6]. Available from: https://www.who.int/publications/i/item/WHO-2019- nCoV-mortality-reporting-2020-1 8. Pan American Health Organization. Coding of COVID-19 with ICD-10; 2020 [cited 2020 Jul 29]. Available from: https://www.paho.org/arg/ dmdocuments/2019-ncov-1/documentos/COVID-19-CIE-codigos-2020-03-25- spa.pdf 9. IDL-Reporteros. Los muertos que el Gobierno no cuenta [cited 2020 Dec 20]. Available from: https://www.idl-reporteros.pe/los-muertos-que-el- gobierno-no-cuenta/ Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Journal

Journal of the Egyptian Public Health AssociationSpringer Journals

Published: Jun 16, 2021

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