BACKGROUND: The burden of COVID-19 in low-income and conflict-affected countries remains unclear, largely reflecting low testing rates . In parts of Yemen, reports indicated a peak in hospital admissions and burials during May-June 2020 . To estimate excess mortality during the epidemic period, we quantified activity across all identifiable cemeteries within Aden governorate (population approximately 1 million) by analysing very high-resolution satellite imagery and compared estimates to Civil Registry office records .
METHODS: After identifying active cemeteries through remote and ground information, we applied geospatial analysis techniques to manually identify new grave plots and measure changes in burial surface area over a period from July 2016 to September 2020 . After imputing missing grave counts using surface area data, we used alternative approaches, including simple interpolation and a generalised additive mixed growth model, to predict both actual and counterfactual (no epidemic) burial rates by cemetery and across the governorate during the most likely period of COVID-19 excess mortality (from 1 April 2020) and thereby compute excess burials . We also analysed death notifications to the Civil Registry office over the same period .
RESULTS: We collected 78 observations from 11 cemeteries . In all but one, a peak in daily burial rates was evident from April to July 2020 . Interpolation and mixed model methods estimated ≈1500 excess burials up to 6 July, and 2120 up to 19 September, corresponding to a peak weekly increase of 230% from the counterfactual . Satellite imagery estimates were generally lower than Civil Registry data, which indicated a peak 1823 deaths in May alone . However, both sources suggested the epidemic had waned by September 2020 .
DISCUSSION: To our knowledge, this is the first instance of satellite imagery being used for population mortality estimation . Findings suggest a substantial, under-ascertained impact of COVID-19 in this urban Yemeni governorate and are broadly in line with previous mathematical modelling predictions, though our method cannot distinguish direct from indirect virus deaths . Satellite imagery burial analysis appears a promising novel approach for monitoring epidemics and other crisis impacts, particularly where ground data are difficult to collect.
Index: COVID-19, epidemiology, geographic information systems, public Health