The complex and evolving picture of COVID-19-related mortality highlights the need for data to guide the response. Yet many countries are struggling to maintain their data systems, including the civil registration system, which is the foundation for detailed and continuously available mortality statistics. We conducted a search of country and development agency Web sites and partner and media reports describing disruptions to the civil registration of births and deaths associated with COVID-19 related restrictions.We found considerable intercountry variation and grouped countries according to the level of disruption to birth and particularly death registration. Only a minority of the 66 countries were able to maintain service continuity during the COVID-19 restrictions. In the majority, a combination of legal and operational challenges resulted in declines in birth and death registration. Few countries established business continuity plans or developed strategies to deal with the backlog when restrictions are lifted.Civil registration systems and the vital statistics they generate must be strengthened as essential services during health emergencies and as core components of the response to COVID-19. (Am J Public Health. Published online ahead of print April 15, 2021: e1-e9. https://doi.org/10.2105/AJPH.2021.306203).

During an epidemic, rapid mortality surveillance provides essential information to formulate an evidence-based response. Weekly counts of deaths are a key indicator of overall epidemic impact and trajectory.1,2 Enumeration of all deaths, when compared to historically expected mortality, produces a picture of excess death, capturing both the direct burden of the epidemic and its indirect mortality burden, caused by disruptions to the access, use and provision of health-care services. Such actionable public health intelligence can overcome the ambiguities of just measuring cases and deaths linked to the infectious disease causing the epidemic. Measuring excess death would therefore be useful in the countries’ response to the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE: To describe household-level risk factors for secondary Influenza-like illness (ILI), an important public health concern in the low-income population of Bangladesh. METHODS: Secondary analysis of control participants in a randomized controlled trial evaluating the effect of handwashing to prevent household ILI transmission. We recruited index-case patients with ILI-fever (<5 years); fever, cough or sore throat (≥5 years)-from health facilities, collected information on household factors, and conducted syndromic surveillance among household contacts for 10 days after resolution of index-case patients' symptoms. We evaluated the associations between household factors at baseline and secondary ILI among household contacts using negative binomial regression, accounting for clustering by household. RESULTS: Our sample was 1491 household contacts of 184 index-case patients. 71% reported that smoking occurred in their home, 27% shared a latrine with 1 other household, and 36% shared a latrine with >1 other household. A total of 114 household contacts (7.6%) had symptoms of ILI during follow-up. Smoking in the home (RRadj 1.9, 95% CI 1.2, 3.0) and sharing a latrine with 1 household (RRadj 2.1, 95% CI 1.2, 3.6) or >1 household (RRadj 3.1, 95% CI 1.8-5.2) were independently associated with increased risk of secondary ILI. CONCLUSION: Tobacco use in homes could increase respiratory illness in Bangladesh. The mechanism between use of shared latrines and household ILI transmission is not clear. It is possible that respiratory pathogens could be transmitted through fecal contact or contaminated fomites in shared latrines. This article is protected by copyright. All rights reserved.

RATIONALE: There is little evidence for the efficacy of handwashing for prevention of influenza transmission in resource-poor settings. We tested the impact of intensive handwashing promotion on household transmission of influenza-like illness and influenza in rural Bangladesh. METHODS: In 2009-10, we identified index case-patients with influenza-like illness (fever with cough or sore throat) who were the only symptomatic person in their household. Household compounds of index case-patients were randomized to control or intervention (soap and daily handwashing promotion). We conducted daily surveillance and collected oropharyngeal specimens. Secondary attack ratios (SAR) were calculated for influenza and ILI in each arm. Among controls, we investigated individual risk factors for ILI among household contacts of index case-patients. RESULTS: Among 377 index case-patients, the mean number of days between fever onset and study enrollment was 2.1 (SD 1.7) among the 184 controls and 2.6 (SD 2.9) among 193 intervention case-patients. Influenza infection was confirmed in 20% of controls and 12% of intervention index case-patients. The SAR for influenza-like illness among household contacts was 9.5% among intervention (158/1661) and 7.7% among control households (115/1498) (SAR ratio 1.24, 95% CI 0.92-1.65). The SAR ratio for influenza was 2.40 (95% CI 0.68-8.47). In the control arm, susceptible contacts <2 years old (RRadj 5.51, 95% CI 3.43-8.85), those living with an index case-patient enrolled ≤24 hours after symptom onset (RRadj 1.91, 95% CI 1.18-3.10), and those who reported multiple daily interactions with the index case-patient (RRadj 1.94, 95% CI 1.71-3.26) were at increased risk of influenza-like illness. DISCUSSION: Handwashing promotion initiated after illness onset in a household member did not protect against influenza-like illness or influenza. Behavior may not have changed rapidly enough to curb transmission between household members. A reactive approach to reduce household influenza transmission through handwashing promotion may be ineffective in the context of rural Bangladesh. TRIAL REGISTRATION: ClinicalTrials.gov NCT00880659.