Monitoring for outbreak-associated excess mortality in an African city: Detection limits in Antananarivo, Madagascar

Fidisoa Rasambainarivo, Anjarasoa Rasoanomenjanahary, Joelinotahiana Hasina Rabarison, Tanjona Ramiadantsoa, Rila Ratovoson, Rindra Randremanana, Santatriniaina Randrianarisoa, Malavika Rajeev, Bruno Masquelier, Jean Michel Heraud, C. Jessica E. Metcalf, Benjamin L. Rice

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Objectives: Quantitative estimates of the impact of infectious disease outbreaks are required to develop measured policy responses. In many low- and middle-income countries, inadequate surveillance and incompleteness of death registration are important barriers. Design: Here, we characterize how large an impact on mortality would have to be for being detectable using the uniquely detailed mortality notification data from the city of Antananarivo, Madagascar, with application to a recent measles outbreak. Results: The weekly mortality rate of children during the 2018–2019 measles outbreak was 161% above the expected value at its peak, and the signal can be detected earlier in children than in the general population. This approach to detect anomalies from expected baseline mortality allows us to delineate the prevalence of COVID-19 at which excess mortality would be detectable with the existing death notification system in Antananarivo. Conclusions: Given current age-specific estimates of the COVID-19 fatality ratio and the age structure of the population in Antananarivo, we estimate that as few as 11 deaths per week in the 60–70 years age group (corresponding to an infection rate of approximately 1%) would detectably exceed the baseline. Data from 2020 will undergo necessary processing and quality control in the coming months. Our results provide a baseline for interpreting this information.

Original languageEnglish (US)
Pages (from-to)338-342
Number of pages5
JournalInternational Journal of Infectious Diseases
StatePublished - Feb 2021

All Science Journal Classification (ASJC) codes

  • Microbiology (medical)
  • Infectious Diseases


  • COVID-19
  • Excess mortality
  • Madagascar
  • Measles


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