Excess mortality from COVID 19 in Costa Rica: a registry based study using Poisson regression

Abstract

Background: Official death toll related to COVID-19 has been considerably underestimated in reports from some Latin American countries. This study aimed to analyze the mortality associated with the COVID-19 pandemic in Costa Rica between March 2020 and December 2021.

Methods: A registry based study based on 2017-2021 data from the National Institute of Statistics and Census was designed (N = 128,106). Excess deaths were defined by the WHO as "the difference in the total number of deaths in a crisis compared to those expected under normal conditions"; and were estimated using a Poisson regression, and mortality and years of potential life lost (YPLL) rates were calculated.

Findings: The COVID-19 pandemic represented 15% of the deaths in Costa Rica between March 2020 and December 2021. The mortality rate related to COVID-19 was 83 per 100,000 person-years. Between March and July 2020 (low-incidence period), observed number of deaths was 9%-lower than expected, whereas it was 15% and 24% higher than expected between July 2020 and March 2021 (high incidence period - no vaccination), and between March 2021 and December 2021 (high incidence period - progressive vaccination) respectively. Between July 2020 and December 2021, excess deaths observed and COVID-19 deaths reported were comparable (7461 and 7620 respectively). Nevertheless, there were more deaths than expected for conditions that predispose to COVID-19 deaths. YPLL and mortality rates increased with age, but significant excess deaths were observed in all age-groups older than 30-39 years. No large differences were noted by districts' socioeconomic characteristics although excess death rate was lower in rural compared to urban areas.

Interpretation: Reporting of deaths was only slightly underestimated. In the pre-vaccination period, mortality rate and YPLL rates increased with age, being highest in people aged 60 years or older and justifying the decision to initially prioritize vaccination of older individuals.

Funding: The study was supported by the University of Costa Rica and the Agencia Costarricense de Investigaciones Biomédicas - Fundación Inciensa.

Keywords: Costa Rica; Covid-19; Excess deaths; Middle income country; Mortality; YPLL.

Fig. 1

Evolution of mortality in Costa Rica between 2017 and 2021 according to different periods of the pandemic outbreak.

Fig. 2

Absolute difference between observed and expected mortality by cause of deaths and period. For each cause of death: first bar (left) represents period 1, second bar (middle) represents period 2, third bar (right) represents period 3. Green bar: observed mortality was significantly lower than expected mortality (p < 0.05). Red bar: observed mortality was significantly higher than expected mortality (p < 0.05). Grey bar: observed mortality was not significantly different than expected mortality (p < 0.05).