Collectively have map of the system necessary to record peoples deaths in a way that protect livelihood. List is not only dishonor sacrifices but to creates unnecessary suffering how is it possible to assess with a large share of dust in the noncovered year go unreported . If mortality data of any kind is being reported in the Public Domain according to the 2019 mortality report. And to on death in real time and then to generate the reliable cause of death we look at examples of countries have started off for those a struggle to produce accurate and timely data what can we do and what other Innovative Strategies are being tested what can we see on the Global Community and this work and how to remove this further up the agenda . And with those vital strategies the assistant director general for Data Analytics of the who Just Launched their own initiative and Aaron Nichols with Vital Statistics at the us center for Disease Control so lets get started now i will turn it over. Thank you so much. Just give me one moment to share my screen. And now i put into presentation mode. Thank you for joining us. This is an important topic this is know your epidemic andat response claimed over a decade ago but during the covid pandemic we believe every country should know the scope and scale to the greatest extent possible to shape the datadriven response here we have the who global dashboard. Itoa does represent death and unconfirmed cases do to cope 19. We need to be careful to interpret these numbers particularly the measures of death and immortality in the data coming from middle Income Countries. As amanda indicated this will focus to access mortality we feel captures the full scope and scale of the goal of the pandemic. It should be known the early days in the pandemic there have been shortages and concerns over testing with the scopert and scal scale. There have been worries of over Testing Capacity not to mention high Income Countries like the united states. Looking at the implications when it comes to interpreting big numbers. One plant i would like to make is testing as has been argued is an essential service and in the absence of the vaccine are highly effective treatment , this is something that which we could all concur and the reality on the ground is it is highlygh variable and often inadequate. Gifted in the scarcity it is on symptomatic cases and to identify cases so the question here is what are the implications for that scope and scale of the total burden of the pandemic . And as can be seen the center counts cases in the Community Meaning who warned it could be the tip of the iceberg in terms of the actual number of cases detected. What about death . The key picture im trying to paint today is a murky picture because we do not have data in hand in many places. The who dashboard tallied those covid deaths as of the past wednesday but again, we need to unpack those numbers coming from countries that are robust statisticsl and civil legislation programs and those systems that are in the Health Sector not yet capable of delivering and providing timely data on the cause of death so there are two issues pricing in particular the first pertains to getting the death numbers might themselves so that depends on the adoption of important guidance issued by the who and how to code a covid19 death suspected or confirmed this can get a little complicated those comorbidities for example but the upshot is both sides need to be disseminated and manifested in the practices of those to have a very robust measure of suspected mortality. The second issue to call attention to is what is left out of the frame completely i focus on covid death and mortality. Namely those they cannot be certified with the stark reality in her opening remarks. We weed out those that arise from descriptions due to overextended Health Systems and those that people avoid or delay seeking hospital care for your action or they might be infected or separated from family and taken away. Also excluding emergency room death those who are not counted all of these and many places for the majority of deaths even before the pandemic were occurring at home and in many african context this contributes to a murky picture we only have a hypothesis at the moment of the indications comparatively few were for unexpectedly low cases at the moment of death occurring during the pandemic. Is this really a factor of limited Testing Program and because of Surveillance Systems were not in place we might of missed the arrival of the virus and with those that are older ages in particular and with that age structure and residential patterns of the population. So when we need to think in terms of parsing out mortality but then this brings us to the idea of access mortality. A fairlyay comprehensive way the full cost of the pandemic all those regardless of cause age and sex and location to get that on a weekly basis so we are tracking today the current levels of mortality the second piece of measuring access mortality is to establish a baseline of those historically observed death for the same epidemiological weight and location sometime in the past and to be expected. And with those causes of death are a result of the factors i outlined a moment sor ago and those visualizations are more common we have the graph from switzerland published by the economist they are increasingly using visualization to represent the pandemic. Thats well and good but paying us back to her main concern that they are not able to particularly from the community . At the moment at least 13 countries and more every day with the support of bloomberg the word philanthropy leverage to measure access mortality in part the package we have produced in partnership with the who and with those partners in africa and asia. The technical packages assisting countries on the spectrum of system readiness if you well. s showing a graph from brazil the countries produce seen rapid mortality rapid mortality surveillance was the innovative use of public data brazil and other countries such as colombia and peru have the availability of data to make fairly minor innovations compared to where we haverd been working to establish those measures ofre access mortality that surveillance can produce. So now with discussion of low Income Countries we find that in the settings systems due to lack coverage and Company Lists on completeness and coming up with ways to measure incident death more complex and resource intensive with the notable exception of south africa this is generally thehege case of africa and Southeast Asia were government has a need to measure mortality from the community because her such a big burden that exist regardless and to form a complete picture. Our early experience has shown the Community Based surveillance piece of the Technical Work that needs to be accomplished is a bit more challenging than the facility based up and running but in that regard Growth Strategy has been working including bangladesh and senegal so with those routine Health Information system memphis reporting to a weekly basis those that leverage and functionality and the district Health Information. And Community Based rapidh surveillance that is reported o on, we are supporting the government g of columbia and bangladesh to undertake this work. The intention is to reach remote and harder to access parts of the population and in bangladesh we have us expanding model be able to identify that on a more rapid basis than previously was the case under the Civil Registration system there. Supporting countries to produce this data in addition to advocacy or misinformatio misinformation, access mortality data is in with other indicators with the geographicic disparities. Death registration during the pandemic that is rampant mortality can shore up the death registration during the pandemic and in fact, we are working with one country we know knowledge is key to the response and a focus on solely covid19 deaths we have to unpack it whether its insufficient to understand the magnitude it was the relative thing to do to fill the space of knowing the epidemic and the crucial statistics. I would argue that it also adds to the urgency. The longterm solution for a resilient system they summed it up nicely i thought and these are the words i will leave you with. She said weve als we also reale need for the resilience emergency systems such as covid19 to meet the needs not only of the population but of theio vulnerable and marginalizd populations in the country. Great overview to get us kicked off and now i would like to turn over with vital strategies for work in brazil looking at the mortality measurement. Good morning, good afternoon, good evening. With a consortium for the department and states and also to [inaudible] and 2020. Natural cause and data because we compare it today and we can y the views and you can see it is one state and you can see the gap between the blu blue line ad the red line. This is in 2020 and the red line we apply the correction when needed as an example. Also used as a reference. [inaudible] and to get it by state or region. Next, please. We fused the definition and the data but we work to continue it [inaudible] with a consortium of the Health State Department and using the Historical Data using the data the resistant and the country with more distant parties. But you can see here it is increasing and areas at the end of may and beginning of june start to decline. So we dont believe that its going down so fast as we are discussing with the administration. Next, please. [inaudible] and you see that its started to peak in june at the peak of mortality and this is still going on in the region. In the radio dj genaro state it was early. Now we see in this period its starting to increase again. We are following this space closely and other spaces as well. In the last few numbers we had the most popular states in the country with higher numbers and in the percentage we see that 74 in the amazon space, so it was early, the beginning of marchaz and it collaborated in e most [inaudible] and also with argentina its a small increase in infant mortality because it is still ongoing in this area so to the current country sides now it is moving to the south. Next, please. We have mortality, but who was dying . Much more male dying compared to women, the average compared to women, 18 . But we have 50 in the north region so its a huge difference among men and women and also in the age group, 60 or moreyearsold so the impact was in the average 28 but in some regions itn was higher. And also more balance so we have this cooperation we hav weve sn the next slide please [inaudible] it is an ongoing work for the vulnerable pollution and the Inadequate Health to focus. Its the most popular in the states in the country with 60 of the population white, but you see the excess mortality among the black and brown compared to 11 among the white population. In other states yo the other ste it, tomac. More black and brown people dying than white in this excess mortality. And when we move it to the right, we can see we had 42 excess mortality among black and brown in this age group compared to 24 within the white populations in the group. The other states have more balanced distribution. We are discussing this more vulnerable population and how we can use the excess mortality to paint a picture of the impact. Next, please. , so the excess mortality [inaudible] its been used for decisionmakers, Civil Societies and others to discuss with us how to [inaudible] the national new space is showing they havent been following every week so its fallen. Next please. So, also it is a source of data and agencies using the excess mortality data, so for instance 100,000 deaths and massive 100,000 deaths [inaudible] they would die anyway so they started to use the excess mortality to show people are dying excess mortality. We estimate that its very close, around 80 . [inaudible] to the next one. Here is the dashboard recognizing mortality and then the new dashboard in comparing the resistance by states using [inaudible] [inaudible] its higher compared to hear, but here its a lower population. We realize we need to correct because when the pandemic moves, they are delaying it we are discussing about it with the groups how to do this correction but right now we should be focused on describing the direction. Thats what i have to show you and i would like to thank you for the opportunity to show the excess mortality rate. Ou thank you so much. That was really interesting and in particular completely obvious the implications of this data for the system response and geographical focus and reaching vulnerable groups and the implications arege very clear, o thank you for that presentation. Lets now turn to Aaron Nichols. Youve been working on this from a global perspective but also sitting at the u. S. Centers for Disease Control. Whats your view on the sort of state of the systems at this stage, and what else do we need to do better on . Good day, everyone. I lead a small team focused on global registration and Vital Statistics improvements situated at the cdc and the National Center for health statistics. Since15 2015 weve partnered wih vital strategies and who through the bloomberg data initiative. To support one of the growing number of initiatives that in the last ten to 15 years focused on improving Civil Registration and Vital Statistics or low and middle Income Countries so its all laid out the forces behind the challenges we are trying to tackle through that initiative. So now in parallel to this ongoing momentum for fear of the improvement, there is a critical demand for a timely mortality data. Surveillance callings throughout the cdc are looking at what data is available across a multitude of existing surveillance platforms and thinking about how these platformsms can be leverad to compile mortality information. A unique openness and convergence of the Data Collection efforts among the cert communities they lead us to lasting change. If i could be a bit academic for a minute, Civil Registration is the continuous permanent universal recording of the occurrence and characteristics of the vital events. So in this case, we focus on death or mortality. Civil registration is the ideal source of mortality information because of these characteristics in the system. Unlike surveys which are more oneoff or intermittent, Civil Registration is continuous, permanent and universal. Because it is compulsory by law it provides the basis for everyone to participate in f the system. Weve always recognized the value of the data and one of the most regular users engaged in that with other sectors including registration officials that are typically in the home affairs required to achieve a comprehensive Mortality Program that is linked with Civil Registration. This engagement requires more time, attention and coordination than the vertical disease Surveillance System has traditionally been able to give and so we hope to leverage the interest and mortality surveillance. I will share a little more background about the team and how weve pivoted with the arrival of covid19 and what we are thinking about as we move ahead in this space. As the partner for the initiative, our team has been supported in the guidance just described in its development and implementation wereon helping to coordinate multiple partners to support a comprehensive mortality Surveillance Program with components in both uganda and zambia. We coordinate a Community Focused on the Death Investigation which is f to shae covid19 death certification guidelines among a global forum of medical examiners. To help identify a probable cause of death when theres no position to certify it, the team also works with who and the Reference Group and for covid19, we have compiled guidance on the use of the verbal and context of covid19 and we are now coordinating an evaluation to assess whether the new t questions can identify probable covid19 deaths. And finally, supporting the u. S. Cdc International Covid response, the team iss working for the existing surveillance platforms in response to the demand for information on mortality. So, to slides to show here. Can you help show those, please. There we go. We developed this slide to show the various potential sources of information across the platforms. Cdcs purported activities include the Child Health MortalityPrevention Initiative which is funded by the bill and Melinda Gates foundation, and mortality surveillance work through u. S. U government suppo. With the many possible sources of information theres opportunities at bringing these together in a useful manner requires extensive coordination and support that our team is working to provide the next slide, please. So, in the second slide we see a contrast among the countries on the complete lack of information on the ca