Because clinically severe cases are more likely to be recognised and tested 16, mortality data have been viewed as a more reliable datastream for cross-country comparisons and for tracking epidemics 17. Under-ascertainment of COVID-19 symptomatic cases has been recognised as an issue in many high and low-income settings, due to factors such as limited testing capacity and the non-specific symptoms of mild disease 15. One alternative (or concurrent) explanation, which has garnered less attention within the scientific literature despite numerous reports in the media 13, 14, is that COVID-19 related deaths have been substantially under-ascertained in some countries. Consequently, alternative explanations have been sought to understand the heterogeneity in the magnitude of COVID-19 epidemics, including the effects of climate 8, population density 9, inter-pathogen effects 10, younger populations 11 and BCG vaccination 12 on COVID-19 transmission or clinical severity. Additionally, many settings with very low observed mortality are now reporting that cases and hospital bed demand are falling despite no notable change in implemented interventions or behaviour change, which may suggest that the epidemic has passed its peak 7. These observations are hard to reconcile with contemporaneous reports of hospitals becoming overwhelmed in these settings 5, 6.

Sudan, Syria, and Yemen, have reported no sharp increases in mortality of the scale predicted by multiple modelling studies, even where interventions were limited 3, 4. However, a number of conflict-affected countries in Africa and West Asia, e.g. The majority of countries have responded to the threat by implementing various non-pharmaceutical interventions, with many opting for society-wide suppression measures in an effort to prevent unacceptable loss of life 2. The COVID-19 pandemic is a major global threat, with 25,327,098 cases and 848,255 deaths confirmed as of 1 September 2020 1. Nature Communications volume 12, Article number: 2394 ( 2021) Imperial College COVID-19 Response Team,.Leveraging community mortality indicators to infer COVID-19 mortality and transmission dynamics in Damascus, Syria

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