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Reporting COVID-19 deaths in

Austria, France, Germany,

Italy, Portugal and the UK

Anne West, Thomas Czypionka, Monika Steffen,

Stefanie Ettelt, Simone Ghislandi, Céu Mateus

Working Paper Series

November 2020

Working Paper 10-20

Social Policy Working Paper 10-20

LSE Department of Social Policy

The Department of Social Policy is an internationally recognised centre of research and teaching in social and public policy. From its foundation in 1912 it has carried out cutting edge research on core social problems, and helped to develop policy solutions. T he Department today is distinguished by its multidisciplinarity, its international and comparative approach, and its particular strengths in behavioural public policy, criminology, development, economic and social inequality, education, migration, non -governmental organisations (NGOs) and population change and the lifecourse. T he Department of Social Policy multidisciplinary working paper series publishes high quality research papers across the broad field of social policy.

Department of Social Policy

London School of Economics and

Political Science Houghton Street

London WC2A 2AE

Email: socialpolicy.workingpaper@lse.ac.uk

Telephone: +44 (0)20 7955 6001

lse.ac.uk/social-policy

Short sections of text, not to exceed two paragraphs, may be quoted without explicit permission provided that full credit,

including © notice, is given to the source. T o cite this paper:

West, A., Czypionka, T., Steffen, M., Ettelt,

S., Ghislandi, S. and Mateus, C. (2020) Reporting of COVID-19 deaths in Austria,

France, Germany, Italy, Portugal and the UK

, Social Policy Working Paper 10-20, London: LSE Department of Social Policy.

Anne West, Thomas Czypionka, Monika Steffen,

Stefanie Ettelt, Simone Ghislandi, Céu Mateus

Table of contents

Abstract ........................................................................ ...................................................... 1 Acknowledgments ........................................................................ ..................................... 1 Authors ........................................................................ ....................................................... 1 Introduction ........................................................................ ................................................ 2

1 COVID-19: The European context ........................................................................

...... 3

2 Comparing national legislative provision and guidance .......................................... 4

3 Comparing the recording of deaths and death certificates .................................... 5

4 Comparing the reporting of deaths at a national level ............................................ 7

5 Limitations of comparability ........................................................................

.............. 8

6 Discussion and implications for policy ..................................................................... 9 References ........................................................................

. COVID-19 Country dashboards/overviews ....................... Annex 1 EEA/EU and UK COVID-19 cases, deaths, incidence, testing

Annex 2 Au stria C ountry

Report: Thoma

s

Czypionka,

I sabel Pha m A nnex 3 France Country Report: Monika Steffen .......................................................... 19

Annex 4 Germany Country Report: Stefanie Ettelt ......................................................... 26

Annex 5 Italy Country Report: Simone Ghislandi ........................................................... 30 Annex 6 Portugal Country Report: Céu Mateus ............... Annex 7 United Kingdom Country Report: Anne West.....

1 Social Policy Working Paper 10-20

Abstract

The reporting of deaths associated with the SARS-CoV-2 virus has had a high policy profile during the COVID-19 pandemic. This in turn is related to how deaths are counted. In this paper we focus on six European countries: Austria, France, Germany, Italy, Portugal and the United

Kingdom and

seek to address the following research questions: How do countries vary in terms of legislative provision, recording of deaths and reporting deaths? And what limits the comparability of data across countries? The methods comprised an analysis of policy documents in each of the six countries. Our findings reveal differences between countries in terms of legislative provision, recording deaths, and reporting deaths. These differences have an impact on the comparability of data on deaths associated with COVID-19 across countries. Our findings suggest that there is a case for data collection and statistics to be harmonised, which would facilitate accurate comparison between countries. However, reporting is also related to testing capacity for COVID -19,

so this is not simply a question of comparable data being available, rather a question of the overall

functioning of the public health system. Keywords: Comparative health policy, comparative administration, data for policy making, data harmonization, COVID-19, comparable health data.

Acknowledgments

The views expressed in this paper are those of the authors alone and should not be attributed to the organisations to which they are affiliated. Authors Thoma s

Czypionka

i s Head of

Health

Economics

and H eal th

Policy

D epartment at the In stitute f or

Advanced

S tudies in

Vienna.

St efanie Ettelt is an Honorary Associate Professor at the London School of Hygiene and Tropical

Medicine.

Si mone Ghislandi is Associate Professor of Public and Health Economics at the Social and Political Science Department of Bocconi University, Milan. Cé u Mateus is Professor of Health Economics at Lancaster University. Mo nika Steffen is Research Professor Emeritus at the CNRS (French National Centre for Scientific Research), affiliated to the PACTE Social Science Laboratory, Science -Po Grenoble (School of Political Studies), University Grenoble-Alps, Grenoble, France. Ann e West is a Professor in the Department of Social Policy at the London School of Economics and Political Science.

Anne West, Thomas Czypionka, Monika Steffen,

Stefanie Ettelt, Simone Ghislandi, Céu Mateus 2

Introduction

A s a result of the COVID-19 pandemic, much attention has been focused on the reporting of deaths associated with the SARS-CoV-2 virus. This in turn is related to how deaths are counted. During the pandemic, individual countries have provided data on the n umber of deaths associated with COVID-19 that are then reported to international agencies (see for example, ECDC, 2020c) in real

time; in addition, national statistical offices analyse data provided on death certificates. As regards

death certificates, the World Health Organization (WHO) provides guidance on recording deaths due to COVID-19: 'Deaths due to COVID-19 are different from COVID-19-related (or COVID-19- associated) deaths. These may be deaths due to accidental or incidental causes, or natural causes when COVID-19 is not identified as the underlying cause of death...' The guidance also states that 'COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease caused, or is assumed to have caused, or contributed to death' (WHO, 2020, p.

1). The focus on causation is important as people may die with but not of COVID-19.

A lthough death certificates are not used for reporting real-time deaths related to COVID-19, data relating to causes of death are routinely provided to international statistical agencies. Such data can be used to make comparisons between countries, as is the case with influenza, AIDS and many other diseases of transmissible as well as non-transmissible nature. It is thus important to understand how the reporting systems function in different countries in the specific unprecedented context of COVID-19. In Europe, a physician normally submits information relating to the causes of death electronically or in paper format. The information is provided on the medical certificate of causes of death (hereafter, for convenience, termed death certificate) and is coded using the International Statistical Classification of Diseases and Related Health Problems (ICD) (currently the tenth version - ICD10). The purpose of the coding is to select the underlying cause of death, which is the disease/injury that initiated the train of events leading directly to death. Although international definitions are harmonised, the statistics may not be fully comparable among countries, as classifications may vary when the cause of death is multiple or difficult to evaluate, and because of different notification procedures (Eurostat, n.d; 2020). The variation between

countries and different notification procedures are particularly relevant in the context of the COVID

19 pandemic.

1 Wh ilst international comparisons are routinely made regarding deaths from COVID-19, with or without relevant caveats, there are notable differences as regards the legislative context and the adminis trative processes employed that determine what is reported. Public health delivery systems vary markedly across Europe and structural differences may influence how they operate (see Mays et al., 2010). I n this paper, we seek to assess the approaches used to report deaths associated with COVID-19 in a sample of European countries. We focus specifically on six countries: Austria, France, Germany, Italy, Portugal and the UK. In order to understand the reporting systems in place, we address the 1 The WHO has issued a new code for COVID-19 - U07. New ICD-10 codes for COVID-19 have been introduced by the WHO, U07.1 COVID-19, virus identified and U07.2 COVID-19, virus not identified (WHO,

2020).

3 Social Policy Working Paper 10-20

legislation enacted and other legislative provision related to recording COVID-19 cases and deaths; how deaths associated with SARS-CoV-2 are reported on death certificates; and how data on deaths are reported nationally. For each country, a separate report has been produced (see Annexes 2 to 7) drawing on legislative provision, policies, academic papers, and media reports (see Czypionka and Pham, 2020; Ettelt, 2020; Ghislandi, 2020; Mateus, 2020; Steffen, 2020; West, 2020). It is important to stress that the paper is not concerned primarily with statistics or epidemiology, but with legislative provision, policy, practice, and administration. T he countries were selected in order to represent a diversity of countries in terms of the reported deaths from/with COVID-19 (ECDC, 2020b). During the period when this research was carried out (April to August 2020) testing rates varied between countries and over time, with relatively high testing rates across much of the period in Portugal (600 -900 per 100,000 population), Austria (400 to 600) and Germany (400 to 500). The rates were generally lower in France and fluctuated in Italy; no data were available for the UK (ECDC, 2020), but were acknowledged to be low compared with

Germany (Rough, 2020).

S pecifically, the paper aims to answer the following research questions: How do countries vary in terms of legislative provision, recording of deaths and reporting deaths? And what limits the comparability of data across countries? In so doing we aim to understand better why the debates about comparability are complex and also unravel some of the administrative complexities that exist. T he following section outlines the European context regarding the COVID-19 pandemic. The subsequent sections, which focus on our six case study countries, assess three different domains:

legislative provision; recording of deaths by physicians; and reporting of deaths nationally. In each

section we compare and contrast the countries' systems and policies in response to the pandemic, and provide illustrative examples. The penultimate section discusses the limits to comparability of data based on the analysis we have undertaken. The final section discusses the findings, noting convergence over time, and implications for policy. C

OVID-19: The European Context

Bet ween 31 st

December 2019 and 2

nd August 2020, over 17,800,000 cases of COVID-19 were reported worldwide, including over 685,000 deaths. European Union/European Economic Area (EU/EEA) countries and the United Kingdom (UK) reported over 1,7000,000 cases including over

182,000 deaths (European Centre for Disease Prevention and Control (ECDC), 2020a).

I n this paper we focus on the period of the COVID -19 pandemic between March and August 2020. According to the ECDC, the EU/EEA and the UK reached a peak in nationally reported cases in the firsquotesdbs_dbs4.pdfusesText_8