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Original article

COVID-19 mortality in Belgrade

Nataša Rosić1, Milena Šantrić Milićević2
  • Institute of Public Health of Belgrade, Belgrade, Serbia
  • Faculty of Medicine University of Belgrade, Institute of Social Medicine, Center-School of Public Health and Health Management, Belgrade, Serbia

ABSTRACT

Introduction: Mortality data are the most reliable indicators of the number of lives that a community has lost due to COVID-19 and represent the minimum data necessary for public health decision-making.

Aim: The aim of the study is to describe the basic characteristics of population mortality from COVID-19 in Belgrade in 2020.

Methods: The unit of observation in this cross-sectional study for the description of mortality from COVID-19 in 2020 was the population of Belgrade (total, by sex, and by age intervals). COVID-19 was analyzed as the main cause of death (ICD-10: U071, U072). The number and the structure of deaths (%), the crude death rate (per 1,000 population) and the specific death rate (per 100,000 population) were analyzed. The data sources for the study were official statistics on vital events of the Statistical Office of the Republic of Serbia.

Results: In 2020, 10.5% of the total number of deaths were due to COVID-19, and the majority of deaths was from the male contingent of Belgrade residents. The mortality rate due to COVID-19 was 158.78 per 100,000 population (211.7 for males and 111.4 for females). COVID-19 was the second leading cause of death in Belgrade.

Conclusion: The results of this study indicate the existence of premature mortality in Belgrade. In 2020, COVID-19 was the second leading cause of death among the male residents of Belgrade, while in female residents, it was the third leading cause of mortality. This research provides evidence that can contribute to the international discussion about societal losses caused by the COVID-19 pandemic.


INTRODUCTION

At the press briefing held on March 11, 2020, Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) pointed out that the number of COVID-19 cases outside China had rapidly increased thirteen-fold, and that, due to the tripled number of affected countries, the WHO was declaring a pandemic of the new infectious disease - COVID-19 [1].

COVID-19 is a disease caused by several lesser-known variants of coronavirus, which makes the complete description of the clinical course and the prognostic aspects of the disease, in children and adults, more difficult [2]. Sufficient knowledge is also lacking as to the incubation period of COVID-19 [3], its origin, epidemiological presentation, length of transmission in the population, and spectrum of clinical manifestations [4],[5],[6].

In most countries, including Serbia, public healthcare measures for preventing the spread of COVID-19 are being implemented. These measures are based on previous experience of respiratory pathogen transmission from human to human, and include isolation and quarantine, curfew, the closing of businesses and schools, physical distancing, limited social interaction, improved respiratory hygiene, wearing face masks and gloves (not limited only to medical masks and gloves), and the application of efficient and safe vaccines.

So far, we have almost daily been receiving updates on the different estimates of the losses that the COVID-19 has caused, from the local to the global level. Health losses are most frequently expressed in mortality indicators. In the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD - 10) [7], according to the International guidelines for certification and classification (coding) of COVID-19 as cause of death [8], death caused by COVID-19 is defined as “a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g., trauma)”. It is also important to note that the guidelines state that “there should be no period of complete recovery from COVID-19 between illness and death”

These guidelines were published on April 16, 2020, for the purpose of the surveillance of identified or unidentified but clinically-epidemiologically diagnosed COVID-19 cases, or probable COVID-19 cases, i.e., possible/suspected cases of COVID-19. Based on these guidelines, a new chapter was added to the ICD-10 - Chapter XXII with U00-U89 Codes for special purposes, where COVID-19 is coded as:

  • U07.1 COVID-19, virus identified; and
  • U07.2 COVID-19, virus not identified.

It is important to emphasize that the Statistical Office of the Republic of Serbia data state that all registered deaths in Chapter XXII, in 2020 were only deaths caused by COVID-19, i.e., all deaths in the entire U00-U89 group were caused by COVID-19.

Mortality data are the most reliable indicators of the number of lives that a community has lost due to COVID-19, and they represent the minimum data necessary for public health decision-making. Analyses and comparisons of mortality indicators may inform decision makers and help them in formulating public health recommendations and measures for promoting the care for the health and lives of the population. Between January 3, 2020, and September 3, 2021, the World Health Organization [9] registered more than 218 million confirmed COVID-19 cases worldwide as well as 4.5 million COVID-19 deaths, while in Serbia, more than 769 thousand confirmed cases and 7,322 deaths were registered.

AIM

The aim of the study is to describe the basic characteristics of population mortality from COVID-19 as the main cause of death, in Belgrade, in 2020.

METHODS

In this paper, a descriptive cross-sectional study was applied for analyzing mortality from COVID-19 as the main cause of death, in the population of Belgrade, in 2020. The unit of observation in the study was the population of Belgrade, observed in total, by sex, and by age intervals. Overall mortality, as well as mortality from COVID-19 as the main cause of death was observed. In the ICD-10, Chapter XXII, Codes for special purposes (U00-U89), there were only deaths with the main cause of death – COVID-19 (U07.1, U07.2). The data sources for the study were the electronic databases on population of the Statistical Office of the Republic of Serbia [10]. Indicators such as the absolute number of deaths, the average age at death (mean value and measures of variability), the structure of deaths (%), the death rate (crude death rate per 1,000 population and specific death rate per 100,000 population) were used for descriptive analysis of mortality.

RESULTS

In Belgrade, in 2020, a total of 25,526 people died, of whom 51.1% female (13,063) and 48.9% male (12,463). The greatest number of deaths in the population of Belgrade was in the age group 85 years and older (6,582) of whom 38.8% (2,557) male and 61.2% (4,025) female individuals. In the same year, the number of deaths caused by COVID-19 (group U00-U89, i.e., U07.1 and U07.2 ) was 2,690 or 10.5% of the total number of deaths, i.e., 13% of the total number of deceased male residents and 8% of the total number of deceased female residents. The proportion of COVID-19 as the cause of death in relation to other groups of causes of death differs across age intervals, i.e., groups. It should be noted that in the age groups 20 - 24 years and 25 - 29 years, COVID-19 alone, as compared to other groups of causes of death, was the cause of death for 33.3% of men and 28.6% of women. In men, in the age groups 70 - 74 years and 45 - 49 years, COVID-19 was, in relation to other causes of death, present in 16% and 15.8% of deaths, respectively.

When only individuals who had died from COVID-19 are observed (Figure 1), almost two thirds of the deceased persons were male, i.e., 63% or 1,693 deceased male individuals, while 37% or 997 were female individuals. In 2020, the greatest number of people dying from COVID-19 (ICD-10: U071, U072) was in the age group 70 – 74 years (480 or 17.8% persons deceased from COVID-19 in total), followed by the age groups 80 - 84 years (17.3%), 85 years and older (16.8%), and 65 - 69 years (14.4%). The greatest number of men deceased due to COVID-19 was in the age group 85 years and older (20.4%), followed by the age group 80 - 84 years (20.2%), and the age group 70 - 74 years (17.5%).

In Belgrade, in 2020, the crude mortality rate was 15.1 per 1,000 population, while the mortality rate due to COVID-19 was 158.75 per 100,000 population (Figure 2). The crude mortality rates for both sexes were similar (16.33 for men and 13.93 for women).

Specific death rates due to COVID-19 differ by sex: the frequency of the death rate due to COVID-19 is almost twice as high in men as compared to women (211.68 for men and 111.43 for women) (Figure 2).

The crude death rate for both sexes enters the double digits in the age group 60 - 64 years (16.29 per 1,000 population) and triple digits in the age group 80 - 84 years (106.24 per 1,000 population) (Figure 3).

05f01

Figure 1. Deaths (%) due to COVID-19 in Belgrade, 2020, by sex

05f02

Figure 2. Distribution by sex of the crude mortality rate (per 1,000 population) and the specific mortality rate due to COVID-19 (per 100,000) in Belgrade, 2020

05f03

Figure 3. Age distribution of the crude mortality rate (per 1,000 population) and the specific mortality rate due to COVID-19 (per 100.000) in Belgrade, 2020

05f04

Figure 4. Age distribution of the crude mortality rate (per 1,000 population) and the specific mortality rate due to COVID-19 (per 100,000) in Belgrade, 2020

The distribution of the specific rate indicates that COVID-19 significantly affected younger adults. The specific death rate due to COVID-19 for both sexes enters the double digits in the age group 35 - 39 years (11.73 per 100,000 population), triple digits in the age group 55 - 59 years (111.43 per 100,000 population), and it becomes higher than 1,000 in the age group 80 - 84 years (1062.18 per 100,000 population) and older (Figure 3).

Crude death rates in male and female residents have similar distribution across age groups (Figure 4). The crude death rate in men enters the double digits in the age group 55 - 59 years (13.69 per 1,000 population), and the triple digits in the age group 80 – 84 years (125.99 per 1,000 population), while in women it is in the double digits in the age group 60 - 64 years (10.97 per 1,000 population), and in the triple digits in the age group 85 and older (194.64 per 1,000 population) (Figure 4).

Table 1. Centers for Disease Control (CDC) data on monthly COVID-19 cases and deaths, from March 2020 - May 2021

05t01

Specific death rates due to COVID-19 in male and female residents do not have similar distribution across age groups (Figure 4). The specific death rate due to COVID-19 in men enters the double digits in the age group 35 - 39 years (19.61 per 100,000 population), the triple digits in the age group 50 - 54 years (111.52 per 100,000 population), and exceeds 1,000 in the age group 75 - 79 years (1108.91 per 100,000 population) and older, while in women it is in the double digits in the age group 25 - 29 years (11.11 per 100,000 population), and enters the triple digits in the age group 60 - 64 years (116.14 per 100,000 population) and older (Figure 4).

In Belgrade, in 2020, the ICD-10 group U00-U89, where deaths were registered only due to COVID-19 (U07.1, U07.2) represents the third leading cause of death, with a rate of 158.75 per 100,000 population, after ‘Diseases of the circulatory system’ (I00-I99), which are in the lead, with a rate of 672.42 per 100,000 population, and ‘Tumors’ (C00-D48), which are the second leading cause of death, with a rate of 314.85 per 100,000 population.

The ranking of the five leading diagnoses as main causes of death for residents of Belgrade in 2020 (Table 1), differs between sexes: COVID-19 (U07.1, U07.2) is the second leading cause of death for both sexes (158.75 per 100,000 population), and for men only (211.68 per 100,000 population), however it is the third leading cause of death for women only (111.43 per 100,000 population). The leading causes of death for men and women are ‘All other forms of heart disease’ (I26-I51). However, while ‘Cerebrovascular diseases’ (I60-I69) are the third leading cause of death in men, they are the second leading cause of death in women. ‘Ischemic heart diseases’ (I20-I25) and ‘Malignant neoplasms of the trachea, bronchus and lung’ (C33-C34) are in the fourth and fifth place for both sexes.

DISCUSSION

According to the data of the Statistical Office of the Republic of Serbia, in Belgrade, in 2020, the population was 1.7 million. In the same year, 2,690 Belgrade citizens died from COVID-19, and the majority of deaths was from the male contingent of residents. The COVID-19 pandemic has become fatal for men aged 35 years and older and for women older than 50 years.

Similar results were obtained in studies carried out worldwide, including Europe [11],[12]. Although globally [13] precise evaluations of the effects of COVID-19 on the ranking of causes of death in 2020 are lacking, there are such assessments for individual countries. It has been assessed that, in 2020, COVID- 19 was the third leading cause of death in Belgium (180.9 per 100,000 population), Scotland (150.7 per 100,000 population), Portugal (131.57 per 100,000 population), Spain (127.7 per 100,000 population), United States of America (122.7 per 100,000 population), Sweden (118.8 per 100,000 population), Holland (81.7 per 100,000 population), and Germany (68.4 per 100,000 population) [11],[12]. As is the case in our study, it has been estimated that COVID-19 was the second leading cause of death in some European countries [12], for instance in England and Wales (124.9 per 100,000 population) and France (94.3 per 100,000 population), but it was the fifth leading cause of death in Denmark (37.6 per 1,000 population), and in the ninth place in Norway (10.7 per 100,000 population). At the level of Serbia, in 2020, from diseases that can be connected to COVID-19, 10,356 people died (8.9% of all deaths, i.e., 6,629 men and 3,727 women), and these diseases are in the third place after ‘Diseases of the circulatory system’ (which are in the first place with 47.3% of all deaths) and ‘Tumors’ (which are in the second place with 18.3% of all deaths) [14].

In Belgrade, in 2020, the average life expectancy of live-born individuals, according to abridged approximate mortality tables, was estimated at 72.31 years for men and 78.18 years for women [10]. Although the greatest number of deaths from COVID-19 was in the age group 70 - 74 years, specific mortality rates for COVID-19 show that this disease has taken the lives of much younger men and women, thus contributing to premature mortality.

In Belgrade, according to the percentual proportion in overall mortality for both sexes, COVID-19 was the second leading cause of death. In the previous two years, the official data on vital events of the Statistical Office of the Republic of Serbia show that, in Belgrade, ‘All other forms of heart disease’ were in the first place as the leading cause of death; ‘Cerebrovascular diseases’ were in the second place; ‘Ischemic heart diseases’ were in the third place, while ‘Malignant neoplasms of the trachea, bronchus and lung’ were the fourth leading cause of death. In 2018, ‘Respiratory diseases’ were the fifth leading cause of death, while in 2019, ‘Hypertensive diseases’ were in the fifth place [10]. In 2020, COVID-19 disrupted the ranking of these diseases and inserted itself in the second place.

Our research, performed on the example of a number of European countries, including Serbia, has confirmed previous estimates of the vulnerability of older residents with comorbidities [15]. Relatedly, it is assumed that COVID-19 has prematurely taken the lives of persons who would probably have died during the year (but at a later time) [16]. Bearing this in mind, it would be of value to perform research according to the Burden of Disease methodology at the national and subnational levels (in Serbia and in Belgrade, for instance), as has already been done in some countries [17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35].

According to clinical evidence [4], patients with the most severe form of COVID-19 were most frequently older people with comorbidities, among which the ones most frequently mentioned were chronic diseases, such as heart diseases, diabetes, pulmonary diseases and renal insufficiency, as well as obesity as a risk factor. These are probably the reasons why COVID-19 has displaced some causes of death from the list of five leading causes of death in Belgrade. Also, other, non-clinical factors may contribute to the ultimate effects of COVID-19. Amongst them are mobility [36],[37],[38], the level of preparedness and readiness of the healthcare system to respond to service demands during the pandemic [39], the method of the surveillance of contacts during the epidemic [40], behavioral and social factors which support wide population testing [41],[42] adherence to measures of social distancing [43], etc. The existence of strong family bonds and support networks should be included amongst these factors [44], as they most probably explain the Latin American Mortality Paradox in [45].

From the socio-medical aspect our study analyzes a vital event – mortality during a specific period in one community. The results of the study indicate the occurrence of premature mortality from COVID-19 during 2020, despite the implementation of preventive measures. Adequate, consistent and timely implementation of a combination of public health and clinical measures may prevent the occurrence of the disease and mitigate the effects of the COVID-19 pandemic on the population. Many studies have already demonstrated the benefits from health promotion and from applying protective and preventive measures, as well as disease control measures, such as wearing masks and protective gloves, adhering to the recommended physical distance, isolation, social distancing, curfew, boosting immunity, providing healthcare, observing healthcare recommendations, and vaccination [45],[46],[47],[48].

In addition to baseline and clinical research, public health studies are also necessary in order to demonstrate the efficiency of the application of all the above-mentioned measures in Belgrade and contribute to the conclusions on how much the application of these measures has contributed to the prevention of disease and premature deaths in Belgrade.

For more efficient decision-making, in addition to research on mortality, it is also necessary to carry out socio-medical studies which would assess how well healthcare institutions are staffed and equipped with other resources necessary for the prevention, treatment, and rehabilitation of COVID-19 patients, as well as studies that would evaluate the accessibility, use, and quality of health services offered to COVID-19 patients and other persons with suspected COVID-19 infection. With the lack of such research during the pandemic, as well as the lack of professional assessments of the incidence, prevalence and survival of COVID-19, observed through the age and sex distribution in the population, the interpretation of the overall burden of COVID-19 in the population remains a challenge for the community, while mortality data remain the most relevant data for professional consideration.

Due to the limitations of the study, such as the small number of analyzed variables, it is not possible to draw wider conclusions on mortality. In order to gain a broader understanding of COVID-19 mortality and suspected COVID-19 mortality, additional information is necessary, which would enable, for instance, the analysis of deaths in relation to the location of death (at healthcare facilities or outside healthcare facilities), in relation to the type of community (urban or other), in relation to the level of education of the patient, their employment status, ethnicity, health status, type of healthcare coverage, as well as in relation to the use of health services, i.e., the level of equipment of the healthcare facilities where they had died. Other limitations are related to the data themselves. Official data was used in the study only on U07.1 and U07.2 as the main cause of death, and not on immediate, previous or other causes of death related to COVID-19 [7],[8]. Since, during the COVID-19 pandemic, postmortems have not been performed to the same extent as before the pandemic, it is not possible to determine with certainty the extent of the underregistration of U07.1 and U07.2 death cases. It is necessary to analyze to which extent were doctors, especially those registering the deaths, familiar with the guidelines on the use of U07.1 and U07.2 codes for the main cause of death, how well do they understand the significance of the proper classification of the cause of death, and whether they are able to successfully distinguish among the main, previous, immediate and other causes of death. Also, original data refer only to deceased citizens of Belgrade and the results of the study cannot be generalized to refer to other communities.

The advantages of this study lie in the fact that it shows processed data originating from death certificates in the Dem-2 form, which have gone through the system of mortality control at the regional offices of the Statistical Office of the Republic of Serbia, at institutes of public health, and at the statistical Office of the Republic of Serbia. Results of the study may be useful in order to focus special attention, in the coming period, on vulnerable groups, in order to maintain and improve their life expectancy. What remains is to determine, in studies applying the Burden of Disease methodology, how many years of life has the population of Belgrade lost due to premature death from COVID-19 (Years of Life Lost Due to COVID-19), as well as how many years of life have been spent with disability due to COVID-19 (Years Lived with Disability Due to COVID-19) [17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34].

CONCLUSION

The results of the study indicate the existence of premature death of Belgrade residents from COVID-19. In 2020., according to specific mortality rates, COVID-19 was the second leading cause of death in Belgrade male residents and the third leading cause of death in female residents. This research provides evidence that can contribute to the international discussion about societal losses caused by the COVID-19 pandemic.

1 Tedros Adhanom Ghebreyesus

  • Conflict of interest:
    None declared.

Informations

September 2021

Pages 236-247
  • Keywords:
    mortality rates, COVID-19, causes of death, Serbia
  • Received:
    13 August 2021
  • Revised:
    14 September 2021
  • Accepted:
    15 September 2021
  • Online first:
    30 September 2021
  • DOI:
  • Cite this article:
    Rosić N, Šantrić-Milićević M. COVID-19 mortality in Belgrade. Serbian Journal of the Medical Chamber. 2021;2(3):236-47. doi: 10.5937/smclk2-33540
Corresponding author

Nataša Rosić
Belgrade City Institute of Public Health
54a Bulevar despota Stefana, 11000 Belgrade, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


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34. Jo MW, Go DS, Kim R, Lee SW, Ock M, Kim YE, et al. The burden of disease due to COVID-19 in Korea using Disability-Adjusted Life Years. J Korean Med Sci. 2020;35(21):e199.[CROSSREF]

35. Yi-Hsuan C, Chi-Tai F, Yu-Ling H. Effect of Non-lockdown Social Distancing and Testing-Contact Tracing During a COVID-19 Outbreak in Daegu, South Korea, February to April 2020: A Modeling Study. Int J Infect Dis. 2021;110: 213-221.[CROSSREF]

36. Adam K. Second wave of Covid-19 in Europe leads to new restrictions but no national lockdowns. [Internet]. Washington Post. https://www.washingtonpost.com/world/europe/covid-europe-second-wave/2020/10/12/8aacfadc0c66-11eb-b404-8d1e675ec701_story.html. [Published 12 October 2020]. [Accessed on 9 August 2021].

37. Wright A, Salazar A, Mirica M, Volk LA, Schiff GD. The invisible epidemic: neglected chronic disease management during COVID-19. J Gen Intern Med. 2020;35(9):2816-2817.[CROSSREF]

38. Bennhold KA. German exception? Why the country’s coronavirus death rate is low. [Internet]. The New York Times. https://www.nytimes.com/2020/04/04/world/europe/germany-coronavirus-death-rate.html. [Published 4 April 2020]. [Accessed on 9 August 2021].

39. Beaumont P. Coronavirus testing: How some countries got ahead of the rest. [Internet]. The Guardian. https://www.theguardian.com/world/2020/apr/02/coronavirus-testing-how-some-countries-germany-south-koreagot-ahead-of-the-rest.[Published 2 April 2020]. [Accessed on 9 August 2021].

40. Barone E. Why some people are waiting weeks for their COVID-19 test results. [Internet]. Time. https://time.com/5878732/covid-19-testing-delays/. [Published 12 October 2020]. [Accessed on 9 August 2021].

41. Ruiz JM, Steffen P, Smith TB. Hispanic mortality paradox: a systematic review and meta-analysis of the longitudinal literature. Am J Public Health. 2013;103(3):e52-e60.[CROSSREF]

42. Abraído-Lanza AF, Dohrenwend BP, Ng-Mak DS, Turner JB. The Latino mortality paradox: a test of the “salmon bias” and healthy migrant hypotheses. Am J Public Health. 1999;89(10):1543-1548.[CROSSREF]

43. European Centre for Disease Prevention and Control. Prevention and control of COVID-19. [Internet]. [Accessed on 9 August 2021]. Available on: https://www.ecdc.europa.eu/en/all-topics-z/coronavirus/threats-and-outbreaks/covid-19/prevention-and-control-covid-19

44. Covid-19 Prevention Network. [Internet]. [Accessed on 9 August 2021]. Available on: https://www.coronaviruspreventionnetwork.org/

45. Doroshenko A. The Combined Effect of Vaccination and Nonpharmaceutical Public Health Interventions—Ending the COVID-19 Pandemic.JAMA Netw Open. 2021;4(6):e2111675.[CROSSREF]

46. Mishra D, Maurya RR, Kumar K, Munjal NS, Bahadur V, Sharma S, et al. Structurally modified compounds of hydroxychloroquine, remdesivir and tetrahydrocannabinol against main protease of SARS-CoV-2, a possible hope for COVID-19: Docking and molecular dynamics simulation studies. J Mol Liq. 2021;335:116185.[CROSSREF]

47. Brooks JT, Butler JC. Effectiveness of mask wearing to control community spread of SARS-CoV-2.JAMA. 2021;325(10):998-9.[CROSSREF]

48. Maria N, Rapicavoli RV, Alaimo S, Bischof E, Stasuzzo A, Broek J, et al. Rapid Identification of Druggable Targets and the Power of the PHENotype SIMulator for Effective Drug Repurposing in COVID-19. Res Sq. 2021 Apr:rs.3.rs-287183.[CROSSREF][Preprint].


REFERENCES

1. WHO Director-General’s opening remarks at the media briefing on COVID-19 - March 2020. [Internet]. [Accessed on 8 August 2021]. Available on: https:// www.who.int/director-general/speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-on-covid-19---11-march-2020

2. Kupferschmidt K, Cohen J. Will novel virus go pandemic or be contained? Science. 2020;367(6478):610-611.[CROSSREF]

3. Linton NM, Kobayashi T, Yang Y, Hayashi K, Akhmetzhanov AR, Jung SM, et al. Incubation Period and Other Epidemiological Characteristics of 2019 Novel Coronavirus Infections with Right Truncation: A Statistical Analysis of Publicly Available Case Data. J Clin Med. 2020 Feb 17;9(2):538.[CROSSREF]

4. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. [Erratum in: Lancet. 2020 Jan 30;]. Lancet. 2020;395(10223):497-506.[CROSSREF]

5. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.[CROSSREF]

6. Chan JF, Yuan S, Kok KH, To KKW, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;95:514–523.[CROSSREF]

7. Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”, World Health Organization. Međunarodna statistička klasifikacija bolesti i srodnih zdravstvenih problema, 10. Revizija. Knjiga 2. Priručnik za upotrebu. Beograd: Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”, 2010.

8. Međunarodne smernice za potvrđivanje i klasifikaciju (šifriranje) Kovid-19 kao uzroka smrti. [Internet]. [Accessed on 9 August 2021]. Available on: https:// www.batut.org.rs/download/Uputstvo_Uzrok_Smrti_COVID-19%20SZO.pdf

9. WHO Coronavirus (COVID-19) Dashboard. [Internet]. [Accessed on 4 September 2021]. Available on: https://covid19.who.int/

10. Republika Srbija. Republički zavod za statistiku Srbije. Stanovništvo. Elektronska baza podataka. [Internet]. https://www.stat.gov.rs/.

11. Woolf SH, Chapman DA, Lee JH. COVID-19 as the leading cause of death in the United States. JAMA.2021;325:123-4.[CROSSREF]

12. Soneji S, Beltrán-Sánchez H, Yang JW, Mann C. Population-level mortality burden from novel coronavirus (COVID-19) in Europe and North America. Genus. 2021;77:7. [CROSSREF]

13. WHO. The top 10 causes of death. Dostupno na: https://www.who.int/newsroom/fact-sheets/detail/the-top-10-causes-of-death. [Pristupljeno 09.08.2021.].

14. Republika Srbija, Republički zavod za statistiku. Vitalni događaji 2020. Saopštenje SN 40 2021;180. [Internet]. [Accessed on 4 September 2021]. Available on: https://publikacije.stat.gov.rs/G2021/pdf/G20211180.pdf

15. Wyper GMA, Assunção R, Cuschieri S, Devleesschauwer B, Fletcher E, Haagsma JA, et al. Population vulnerability to COVID-19 in Europe: a burden of disease analysis. Arch Public Health. 2020;78,47. [CROSSREF]

16. The Institute for Health Metrics and Evaluation. Estimation of the excess mortality due to COVID-19. [Internet]. http://www.healthdata.org/ node/8660. Objavljeno 13. 5. 2021.

17. Gémes K, Talbäck M, Modig K, Ahlbom A, Berglund A, Feychting M, et al. Burden and prevalence of prognostic factors for severe COVID-19 in Sweden. Eur J Epidemiol. 2020;35(5):401-409.[CROSSREF]

18. John D, Narassima MS, Menon J, Jammy GR, Banerjee A.  Estimation of economic burden of COVID-19 using disability-adjusted life years (DALYs) and Productivity Losses in Kerala, India: a model-based analysis.  BMJ Open. 2021;11:e049619.[CROSSREF]

19. Salinas-Escudero G, Toledano-Toledano F, García-Peña C, Parra-Rodríguez L, Granados-García V, Carrillo-Vega MF. Disability-adjusted life years for the COVID-19 pandemic in the Mexican population. Front Public Health. 2021:9;6 86700.[CROSSREF]

20. Fan CY, Fann JC, Yang MC, Lin TY, Chen HH, Liu JT, et al. Estimating global burden of COVID-19 with disability-adjusted life years and value of statistical life metrics. J Formos Med Assoc. 2021:S0929-6646(21)00234-5.[CROSSREF]

21. He M, Li X, Tan Q, Chen Y, Kong Y, You J, et al. Disease burden from COVID-19 symptoms among inpatients at the temporary military hospitals in Wuhan: a retrospective multicentre cross–sectional study. BMJ Open. 2021;11(5):e04 8822.[CROSSREF]

22. Quast T, Andel R, Gregory S, Storch EA.  Years of life lost associated with COVID-19 deaths in the USA during the first year of the pandemic. J Public Health. 2021; u štampi.[CROSSREF]

23. Vasishtha G, Mohanty SK, Mishra US, Dubey M, Sahoo U. Impact of COVID-19 infection on life expectancy, premature mortality, and DALY in Maharashtra, India. BMC Infect Dis. 2021;21:343.[CROSSREF]

24. Lagerweij G, Schimmer B, Mooij S, Raven S, Schoffelen A, de Gier B, et al.  State of Infectious Diseases in the Netherlands, 2019.  RIVM-Rapport 2020-0048.[CROSSREF]

25. Rommel A, von der Lippe E, Plass D, Ziese T, Diercke M, An der Heiden M, et al.  The COVID-19 disease burden in Germany in 2020—years of life lost to death and disease over the course of the pandemic.  Dtsch Arztebl Int. 2021;118:arztebl.m2021.0147.[CROSSREF]

26. Zhao J, Jin H, Li X, Jia J, Zhang C, Zhao H, et al. Disease burden attributable to the first wave of COVID-19 in China and the effect of timing on the cost-effectiveness of movement restriction policies. Value Health. 2021; u štampi.[CROSSREF]

27. Pifarré I Arolas H, Acosta E, López-Casasnovas G, Lo A, Nicodemo C, Riffe T, et al.  Years of life lost to COVID-19 in 81 countries.  Sci Rep.  2021;11:3504.[CROSSREF]

28. Ortiz-Prado E, Simbaña-Rivera K, Barreno LG, Diaz AM, Barreto A, Moyano C, et al.  Epidemiological, socio-demographic and clinical features of the early phase of the COVID-19 epidemic in Ecuador.  PLOS Negl Trop Dis. 2020;15(1):e0008958.[CROSSREF]

29. Mitra AK, Payton M, Kabir N, Whitehead A, Ragland KN, Brown A.  Potential Years of Life Lost due to COVID-19 in the United States, Italy, and Germany: an old formula with newer ideas.  Int J Environ Res Public Health. 2020;17(12):4392.[CROSSREF]

30. Oh IH, Ock M, Jang SY, Go DS, Kim YE, Jung YS, et al.  Years of Life Lost attributable to COVID-19 in high-incidence countries.  J Korean Med Sci. 2020;35(32):e300.[CROSSREF]

31. Bell D, Schultz Hansen K, Kiragga AN, Kambugu A, Kissa J, Mbonye AK. Predicting the impact of COVID-19 and the potential impact of the public health response on disease burden in Uganda. Am J Trop Med Hyg. 2020; u štampi.[CROSSREF]

32. Tchole AIM, Li ZW, Wei JT, Ye RZ, Wang WJ, Du WY, et al.; Cheeloo EcoHealth Consortium (CLEC). Epidemic and control of COVID-19 in Niger: quantitative analyses in a least developed country.  J Glob Health.  2020;10(2):020513.[CROSSREF]

33. Nurchis MC, Pascucci D, Sapienza M, Villani L, D’Ambrosio F, Castrini F, et al.  Impact of the burden of COVID-19 in Italy: Results of Disability-Adjusted Life Years (DALYs) and productivity loss.  Int J Environ Res Public Health. 2020;17:4233.[CROSSREF]

34. Jo MW, Go DS, Kim R, Lee SW, Ock M, Kim YE, et al. The burden of disease due to COVID-19 in Korea using Disability-Adjusted Life Years. J Korean Med Sci. 2020;35(21):e199.[CROSSREF]

35. Yi-Hsuan C, Chi-Tai F, Yu-Ling H. Effect of Non-lockdown Social Distancing and Testing-Contact Tracing During a COVID-19 Outbreak in Daegu, South Korea, February to April 2020: A Modeling Study. Int J Infect Dis. 2021;110: 213-221.[CROSSREF]

36. Adam K. Second wave of Covid-19 in Europe leads to new restrictions but no national lockdowns. [Internet]. Washington Post. https://www.washingtonpost.com/world/europe/covid-europe-second-wave/2020/10/12/8aacfadc0c66-11eb-b404-8d1e675ec701_story.html. [Published 12 October 2020]. [Accessed on 9 August 2021].

37. Wright A, Salazar A, Mirica M, Volk LA, Schiff GD. The invisible epidemic: neglected chronic disease management during COVID-19. J Gen Intern Med. 2020;35(9):2816-2817.[CROSSREF]

38. Bennhold KA. German exception? Why the country’s coronavirus death rate is low. [Internet]. The New York Times. https://www.nytimes.com/2020/04/04/world/europe/germany-coronavirus-death-rate.html. [Published 4 April 2020]. [Accessed on 9 August 2021].

39. Beaumont P. Coronavirus testing: How some countries got ahead of the rest. [Internet]. The Guardian. https://www.theguardian.com/world/2020/apr/02/coronavirus-testing-how-some-countries-germany-south-koreagot-ahead-of-the-rest.[Published 2 April 2020]. [Accessed on 9 August 2021].

40. Barone E. Why some people are waiting weeks for their COVID-19 test results. [Internet]. Time. https://time.com/5878732/covid-19-testing-delays/. [Published 12 October 2020]. [Accessed on 9 August 2021].

41. Ruiz JM, Steffen P, Smith TB. Hispanic mortality paradox: a systematic review and meta-analysis of the longitudinal literature. Am J Public Health. 2013;103(3):e52-e60.[CROSSREF]

42. Abraído-Lanza AF, Dohrenwend BP, Ng-Mak DS, Turner JB. The Latino mortality paradox: a test of the “salmon bias” and healthy migrant hypotheses. Am J Public Health. 1999;89(10):1543-1548.[CROSSREF]

43. European Centre for Disease Prevention and Control. Prevention and control of COVID-19. [Internet]. [Accessed on 9 August 2021]. Available on: https://www.ecdc.europa.eu/en/all-topics-z/coronavirus/threats-and-outbreaks/covid-19/prevention-and-control-covid-19

44. Covid-19 Prevention Network. [Internet]. [Accessed on 9 August 2021]. Available on: https://www.coronaviruspreventionnetwork.org/

45. Doroshenko A. The Combined Effect of Vaccination and Nonpharmaceutical Public Health Interventions—Ending the COVID-19 Pandemic.JAMA Netw Open. 2021;4(6):e2111675.[CROSSREF]

46. Mishra D, Maurya RR, Kumar K, Munjal NS, Bahadur V, Sharma S, et al. Structurally modified compounds of hydroxychloroquine, remdesivir and tetrahydrocannabinol against main protease of SARS-CoV-2, a possible hope for COVID-19: Docking and molecular dynamics simulation studies. J Mol Liq. 2021;335:116185.[CROSSREF]

47. Brooks JT, Butler JC. Effectiveness of mask wearing to control community spread of SARS-CoV-2.JAMA. 2021;325(10):998-9.[CROSSREF]

48. Maria N, Rapicavoli RV, Alaimo S, Bischof E, Stasuzzo A, Broek J, et al. Rapid Identification of Druggable Targets and the Power of the PHENotype SIMulator for Effective Drug Repurposing in COVID-19. Res Sq. 2021 Apr:rs.3.rs-287183.[CROSSREF][Preprint].

1. WHO Director-General’s opening remarks at the media briefing on COVID-19 - March 2020. [Internet]. [Accessed on 8 August 2021]. Available on: https:// www.who.int/director-general/speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-on-covid-19---11-march-2020

2. Kupferschmidt K, Cohen J. Will novel virus go pandemic or be contained? Science. 2020;367(6478):610-611.[CROSSREF]

3. Linton NM, Kobayashi T, Yang Y, Hayashi K, Akhmetzhanov AR, Jung SM, et al. Incubation Period and Other Epidemiological Characteristics of 2019 Novel Coronavirus Infections with Right Truncation: A Statistical Analysis of Publicly Available Case Data. J Clin Med. 2020 Feb 17;9(2):538.[CROSSREF]

4. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. [Erratum in: Lancet. 2020 Jan 30;]. Lancet. 2020;395(10223):497-506.[CROSSREF]

5. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.[CROSSREF]

6. Chan JF, Yuan S, Kok KH, To KKW, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;95:514–523.[CROSSREF]

7. Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”, World Health Organization. Međunarodna statistička klasifikacija bolesti i srodnih zdravstvenih problema, 10. Revizija. Knjiga 2. Priručnik za upotrebu. Beograd: Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut”, 2010.

8. Međunarodne smernice za potvrđivanje i klasifikaciju (šifriranje) Kovid-19 kao uzroka smrti. [Internet]. [Accessed on 9 August 2021]. Available on: https:// www.batut.org.rs/download/Uputstvo_Uzrok_Smrti_COVID-19%20SZO.pdf

9. WHO Coronavirus (COVID-19) Dashboard. [Internet]. [Accessed on 4 September 2021]. Available on: https://covid19.who.int/

10. Republika Srbija. Republički zavod za statistiku Srbije. Stanovništvo. Elektronska baza podataka. [Internet]. https://www.stat.gov.rs/.

11. Woolf SH, Chapman DA, Lee JH. COVID-19 as the leading cause of death in the United States. JAMA.2021;325:123-4.[CROSSREF]

12. Soneji S, Beltrán-Sánchez H, Yang JW, Mann C. Population-level mortality burden from novel coronavirus (COVID-19) in Europe and North America. Genus. 2021;77:7. [CROSSREF]

13. WHO. The top 10 causes of death. Dostupno na: https://www.who.int/newsroom/fact-sheets/detail/the-top-10-causes-of-death. [Pristupljeno 09.08.2021.].

14. Republika Srbija, Republički zavod za statistiku. Vitalni događaji 2020. Saopštenje SN 40 2021;180. [Internet]. [Accessed on 4 September 2021]. Available on: https://publikacije.stat.gov.rs/G2021/pdf/G20211180.pdf

15. Wyper GMA, Assunção R, Cuschieri S, Devleesschauwer B, Fletcher E, Haagsma JA, et al. Population vulnerability to COVID-19 in Europe: a burden of disease analysis. Arch Public Health. 2020;78,47. [CROSSREF]

16. The Institute for Health Metrics and Evaluation. Estimation of the excess mortality due to COVID-19. [Internet]. http://www.healthdata.org/ node/8660. Objavljeno 13. 5. 2021.

17. Gémes K, Talbäck M, Modig K, Ahlbom A, Berglund A, Feychting M, et al. Burden and prevalence of prognostic factors for severe COVID-19 in Sweden. Eur J Epidemiol. 2020;35(5):401-409.[CROSSREF]

18. John D, Narassima MS, Menon J, Jammy GR, Banerjee A.  Estimation of economic burden of COVID-19 using disability-adjusted life years (DALYs) and Productivity Losses in Kerala, India: a model-based analysis.  BMJ Open. 2021;11:e049619.[CROSSREF]

19. Salinas-Escudero G, Toledano-Toledano F, García-Peña C, Parra-Rodríguez L, Granados-García V, Carrillo-Vega MF. Disability-adjusted life years for the COVID-19 pandemic in the Mexican population. Front Public Health. 2021:9;6 86700.[CROSSREF]

20. Fan CY, Fann JC, Yang MC, Lin TY, Chen HH, Liu JT, et al. Estimating global burden of COVID-19 with disability-adjusted life years and value of statistical life metrics. J Formos Med Assoc. 2021:S0929-6646(21)00234-5.[CROSSREF]

21. He M, Li X, Tan Q, Chen Y, Kong Y, You J, et al. Disease burden from COVID-19 symptoms among inpatients at the temporary military hospitals in Wuhan: a retrospective multicentre cross–sectional study. BMJ Open. 2021;11(5):e04 8822.[CROSSREF]

22. Quast T, Andel R, Gregory S, Storch EA.  Years of life lost associated with COVID-19 deaths in the USA during the first year of the pandemic. J Public Health. 2021; u štampi.[CROSSREF]

23. Vasishtha G, Mohanty SK, Mishra US, Dubey M, Sahoo U. Impact of COVID-19 infection on life expectancy, premature mortality, and DALY in Maharashtra, India. BMC Infect Dis. 2021;21:343.[CROSSREF]

24. Lagerweij G, Schimmer B, Mooij S, Raven S, Schoffelen A, de Gier B, et al.  State of Infectious Diseases in the Netherlands, 2019.  RIVM-Rapport 2020-0048.[CROSSREF]

25. Rommel A, von der Lippe E, Plass D, Ziese T, Diercke M, An der Heiden M, et al.  The COVID-19 disease burden in Germany in 2020—years of life lost to death and disease over the course of the pandemic.  Dtsch Arztebl Int. 2021;118:arztebl.m2021.0147.[CROSSREF]

26. Zhao J, Jin H, Li X, Jia J, Zhang C, Zhao H, et al. Disease burden attributable to the first wave of COVID-19 in China and the effect of timing on the cost-effectiveness of movement restriction policies. Value Health. 2021; u štampi.[CROSSREF]

27. Pifarré I Arolas H, Acosta E, López-Casasnovas G, Lo A, Nicodemo C, Riffe T, et al.  Years of life lost to COVID-19 in 81 countries.  Sci Rep.  2021;11:3504.[CROSSREF]

28. Ortiz-Prado E, Simbaña-Rivera K, Barreno LG, Diaz AM, Barreto A, Moyano C, et al.  Epidemiological, socio-demographic and clinical features of the early phase of the COVID-19 epidemic in Ecuador.  PLOS Negl Trop Dis. 2020;15(1):e0008958.[CROSSREF]

29. Mitra AK, Payton M, Kabir N, Whitehead A, Ragland KN, Brown A.  Potential Years of Life Lost due to COVID-19 in the United States, Italy, and Germany: an old formula with newer ideas.  Int J Environ Res Public Health. 2020;17(12):4392.[CROSSREF]

30. Oh IH, Ock M, Jang SY, Go DS, Kim YE, Jung YS, et al.  Years of Life Lost attributable to COVID-19 in high-incidence countries.  J Korean Med Sci. 2020;35(32):e300.[CROSSREF]

31. Bell D, Schultz Hansen K, Kiragga AN, Kambugu A, Kissa J, Mbonye AK. Predicting the impact of COVID-19 and the potential impact of the public health response on disease burden in Uganda. Am J Trop Med Hyg. 2020; u štampi.[CROSSREF]

32. Tchole AIM, Li ZW, Wei JT, Ye RZ, Wang WJ, Du WY, et al.; Cheeloo EcoHealth Consortium (CLEC). Epidemic and control of COVID-19 in Niger: quantitative analyses in a least developed country.  J Glob Health.  2020;10(2):020513.[CROSSREF]

33. Nurchis MC, Pascucci D, Sapienza M, Villani L, D’Ambrosio F, Castrini F, et al.  Impact of the burden of COVID-19 in Italy: Results of Disability-Adjusted Life Years (DALYs) and productivity loss.  Int J Environ Res Public Health. 2020;17:4233.[CROSSREF]

34. Jo MW, Go DS, Kim R, Lee SW, Ock M, Kim YE, et al. The burden of disease due to COVID-19 in Korea using Disability-Adjusted Life Years. J Korean Med Sci. 2020;35(21):e199.[CROSSREF]

35. Yi-Hsuan C, Chi-Tai F, Yu-Ling H. Effect of Non-lockdown Social Distancing and Testing-Contact Tracing During a COVID-19 Outbreak in Daegu, South Korea, February to April 2020: A Modeling Study. Int J Infect Dis. 2021;110: 213-221.[CROSSREF]

36. Adam K. Second wave of Covid-19 in Europe leads to new restrictions but no national lockdowns. [Internet]. Washington Post. https://www.washingtonpost.com/world/europe/covid-europe-second-wave/2020/10/12/8aacfadc0c66-11eb-b404-8d1e675ec701_story.html. [Published 12 October 2020]. [Accessed on 9 August 2021].

37. Wright A, Salazar A, Mirica M, Volk LA, Schiff GD. The invisible epidemic: neglected chronic disease management during COVID-19. J Gen Intern Med. 2020;35(9):2816-2817.[CROSSREF]

38. Bennhold KA. German exception? Why the country’s coronavirus death rate is low. [Internet]. The New York Times. https://www.nytimes.com/2020/04/04/world/europe/germany-coronavirus-death-rate.html. [Published 4 April 2020]. [Accessed on 9 August 2021].

39. Beaumont P. Coronavirus testing: How some countries got ahead of the rest. [Internet]. The Guardian. https://www.theguardian.com/world/2020/apr/02/coronavirus-testing-how-some-countries-germany-south-koreagot-ahead-of-the-rest.[Published 2 April 2020]. [Accessed on 9 August 2021].

40. Barone E. Why some people are waiting weeks for their COVID-19 test results. [Internet]. Time. https://time.com/5878732/covid-19-testing-delays/. [Published 12 October 2020]. [Accessed on 9 August 2021].

41. Ruiz JM, Steffen P, Smith TB. Hispanic mortality paradox: a systematic review and meta-analysis of the longitudinal literature. Am J Public Health. 2013;103(3):e52-e60.[CROSSREF]

42. Abraído-Lanza AF, Dohrenwend BP, Ng-Mak DS, Turner JB. The Latino mortality paradox: a test of the “salmon bias” and healthy migrant hypotheses. Am J Public Health. 1999;89(10):1543-1548.[CROSSREF]

43. European Centre for Disease Prevention and Control. Prevention and control of COVID-19. [Internet]. [Accessed on 9 August 2021]. Available on: https://www.ecdc.europa.eu/en/all-topics-z/coronavirus/threats-and-outbreaks/covid-19/prevention-and-control-covid-19

44. Covid-19 Prevention Network. [Internet]. [Accessed on 9 August 2021]. Available on: https://www.coronaviruspreventionnetwork.org/

45. Doroshenko A. The Combined Effect of Vaccination and Nonpharmaceutical Public Health Interventions—Ending the COVID-19 Pandemic.JAMA Netw Open. 2021;4(6):e2111675.[CROSSREF]

46. Mishra D, Maurya RR, Kumar K, Munjal NS, Bahadur V, Sharma S, et al. Structurally modified compounds of hydroxychloroquine, remdesivir and tetrahydrocannabinol against main protease of SARS-CoV-2, a possible hope for COVID-19: Docking and molecular dynamics simulation studies. J Mol Liq. 2021;335:116185.[CROSSREF]

47. Brooks JT, Butler JC. Effectiveness of mask wearing to control community spread of SARS-CoV-2.JAMA. 2021;325(10):998-9.[CROSSREF]

48. Maria N, Rapicavoli RV, Alaimo S, Bischof E, Stasuzzo A, Broek J, et al. Rapid Identification of Druggable Targets and the Power of the PHENotype SIMulator for Effective Drug Repurposing in COVID-19. Res Sq. 2021 Apr:rs.3.rs-287183.[CROSSREF][Preprint].


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