Adult mortality before and during the COVID-19 pandemic in nine communities of Yemen: a key informant study

Introduction Widespread armed conflict has affected Yemen since 2014. To date, the mortality toll of seven years of crisis, and any excess due to the COVID-19 pandemic, are not well quantified. We attempted to estimate population mortality during the pre-pandemic and pandemic periods in nine purposively selected urban and rural communities of southern and central Yemen (Aden and Ta’iz governorates), totalling > 100,000 people. Methods Within each study site, we collected lists of decedents between January 2014-March 2021 by interviewing different categories of key community informants, including community leaders, imams, healthcare workers, senior citizens and others. After linking records across lists based on key variables, we applied two-, three- or four-list capture-recapture analysis to estimate total death tolls. We also computed death rates by combining these estimates with population denominators, themselves subject to estimation. Results After interviewing 138 disproportionately (74.6%) male informants, we identified 2445 unique decedents. While informants recalled deaths throughout the study period, reported deaths among children were sparse: we thus restricted analysis to persons aged ≥15 years old. We noted a peak in reported deaths during May-July 2020, plausibly coinciding with the first COVID-19 wave. Death rate estimates featured uninformatively large confidence intervals, but appeared elevated compared to the non-crisis baseline, particularly in two sites where a large proportion of deaths were attributed to war injuries. There was no clear-cut evidence of excess mortality during the pandemic period. Conclusions We found some evidence of a peak in mortality during the early phase of the pandemic, but death rate estimates were otherwise too imprecise to enable strong inference on trends. Estimates suggested substantial mortality elevations from baseline during the crisis period, but are subject to serious potential biases. The study highlighted challenges of data collection in this insecure, politically contested environment. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The study was funded by the United Kingdom Foreign Commonwealth and Development Office, grant reference 300708-139. Funders were not involved in study design, data collection, analysis, or manuscript preparation. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Ethics Committee of the London School of Hygiene and Tropical Medicine (Ref: 22080) and Faculty of Medicine and Health Science, University of Aden, Yemen (REC-76-2020). Local approvals from the Ministry of Public Health and Health and Population Office in Taiz Governorate were obtained. All research participants provided verbal informed consents before the interviews. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Due to ongoing armed conflict and insecurity in Yemen, we believe that the benefit of publishing data, even if anonymised, is outweighed by the risk to participants. We may publish data in the future if the situation allows. All statistical code, and a dummy dataset that can be used to implement capture-recapture methods, is published at https://github.com/francescochecchi/mortality\_capture\_recapture_analysis [https://github.com/francescochecchi/mortality\_capture\_recapture_analysis][1] [1]: https://github.com/francescochecchi/mortality_capture_recapture_analysis