Reported COVID-19 cases and associated mortality remain low in many sub-Saharan countries relative to global averages, but true impact is difficult to estimate given limitations around surveillance and mortality registration. In Lusaka, Zambia, burial registration and SARS-CoV-2 prevalence data during 2020 allow estimation of excess mortality and transmission. Relative to pre-pandemic patterns, we estimate age-dependent mortality increases, totalling 3212 excess deaths (95% Crl: 2104-4591), representing an 18.5% (95% Crl: 13.0-25.2%) increase relative to pre-pandemic levels. Using a dynamical model-based inferential framework, we find that these mortality patterns and SARS-CoV-2 prevalence data are in agreement with established COVID-19 severity estimates. Our results support hypotheses that COVID-19 impact in Lusaka during 2020 was consistent with COVID-19 epidemics elsewhere, without requiring exceptional explanations for low reported figures. For more equitable decision-making during future pandemics, barriers to ascertaining attributable mortality in low-income settings must be addressed and factored into discourse around reported impact differences.

Richard J. Sheppard, Oliver J. Watson, Rachel Pieciak, James Lungu, Geoffrey Kwendas, Crispin Moyo, Stephen Longa Chanda, Gregory Barnsley, Nicholas F. Brazeau, Ines C. G. Gerard-Ursin, Daniela Olivera Mesa, Charles Whittaker, Simon Gregson, Lucy C. Okell, Azra C. Ghani, William B. MacLeod, Emanuele Del Fava, Alessia Melegaro, Jonas Z. Hines, Lloyd B. Mulenga, Patrick G. T. Walker, Lawrence Mwananyanda, Christopher J. Gill