key: cord-0837123-65a9zzad
authors: Kisa, Sezer; Kisa, Adnan
title: Under‐reporting of COVID‐19 cases in Turkey
date: 2020-08-03
journal: Int J Health Plann Manage
DOI: 10.1002/hpm.3031
sha: 0174923467c8aa30f5ab385b33f464cbc932c5b4
doc_id: 837123
cord_uid: 65a9zzad

Having an accurate account of the number of national COVID‐19 cases is essential for understanding the national and global burden of the disease and managing COVID‐19 prevention and control efforts. There is also substantial under‐reporting of COVID‐19 cases and deaths in many countries. In this article, the COVID‐19 under‐reporting problem in Turkey is addressed, and examples and reasons for the under‐reporting are discussed.

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more commonly known as COVID-19, has caused economic and public health disruptions around the world. 1 Addressing the COVID-19 pandemic requires economic and public health coordination at international, national, and local levels. 2 After COVID-19 became the most important public health problem in many countries, the difficulties of conducting cross-country comparisons began to be discussed. There are many challenges in comparing COVID-19 statistics across countries. 3, 4 For example, it takes time to develop reliable tests and criteria for the diagnosis of COVID-19 in the early stages of the disease; many countries use different diagnostic criteria; it is difficult to determine cause of death of those patients display few of the known COVID-19 symptoms; the leaders of some countries do not allow sufficient transparency in the flow of information on the disease; and countries have cultural and lifestyle differences, such as living together as a big family with family elders.

There is also substantial under-reporting of COVID-19 cases and deaths in many countries. For example, the total death tolls in Italy 5 and the Netherlands 6 are more than twice the official reported numbers. In Spain, 7 the United Kingdom (UK), 8 and the United States (US), 9 mortality due to COVID-19 is 10%-60% higher than the officially reported figures. The differences are particularly stark in countries that have been slow to acknowledge the scope of the problem. In March 2020, the Indonesian government attributed 84 deaths in Jakarta to the coronavirus. 10 However, 1600 more people than normal were buried in Jakarta's cemeteries that month, according to city officials.

China has also been accused of under-reporting the extent of the coronavirus outbreak. 11 Health experts question the timeliness and accuracy of China's official data, asserting that the testing system only captured a fraction of the cases in China's hospitals, particularly those in poorly run hospitals. In addition, it is stated that Iran's coronavirus cases are vastly under-reported. 12 The authorities in Indonesia, 10 China, 11 Iran, 12 and Turkey 13 In Turkey, as of May 29, 2020, the total number of tests conducted was 1 928 209, the total number of cases was 169 979, the total number of deaths was 4461, and the total number of recovered patients was 124 369. 14, 15 Only cases with positive polymerase chain reaction (PCR) test results are included in these statistics; suspected/possible cases in hospitals or from ambulatory follow-ups are not included. As such, the reported statistics do not reflect the actual situation in Turkey. The Turkish Medical Association (TMA) reported that more COVID-19 cases and deaths have been reported by physicians in the field and in the local branches of TMA that those reported by the MoH. 15, 16 The Turkish MoH is trying to manage and coordinate the process of combating the epidemic with the Pandemic Science Board (PSB). The biggest criticism of the Pandemic Science Board, mostly coming from clinicians, is that it does not have public health experts and epidemiologists in it. 17,18 Furthermore, it has also been reported by TMA that the MoH has not accepted the participation of the Association of Public Health Experts (APHE), TMA and The analysis of this mortality data suggests that there were deaths in Turkey from COVID-19 before the first reported death in the country in mid-March 2020. 20 TMA and APHE reported that MoH did not use the International Classification of Diseases, Tenth Revision codes (ICD10) recommended by WHO in reporting COVID-19 deaths. 16 In some provinces, infectious disease/natural death has been reported as the cause of death on death certificates of people who died due to COVID-19. 15, 16, 20 Dr. Serdar Savas, former the Vice President of the European Regional Office of the WHO and former deputy undersecretary of the MoH, reported that if the laboratory test results on blood samples taken from patients who have died are still pending, COVID-19 is not listed as cause of death on their death certificates. Therefore, Savas stated that the COVID-19 death figures announced by the Turkish MoH are definitely below the actual figures, and the infected number of people is around one million. 22 Some reasons have been given by the officials to explain the inconsistencies between the official COVID-19 figures for Istanbul and the burial statistics. 5, 18, 20 First, due to testing capacity issues and false negative test results, some patients are registered with a secondary ICD10 code, such as pneumonia or infectious disease, when they die with clinical COVID-19 symptoms. Second, due to travel restrictions, curfews, and other measures, some patients have been buried in Istanbul instead of their hometowns, which has increased the number of deaths recorded in Istanbul. Third, restrictions on access to health services and fears about going to hospitals due to overload of the hospital system have led to a reduced demand for health services, which has, in turn, led to a higher mortality rate.

Meanwhile, there are daily reports of attempts to silence TMA and its regional branches through legal measures to ensure that no one shares COVID-19 data outside the MoH. After TMA-Sanliurfa (a city in the southeast part of the country) President Omer Melik and Secretary General Osman Yüksekyayla shared data on coronavirus cases in Sanliurfa on their social media accounts, they were detained for misleading the public and released under the condition of judicial control. 13 In addition, restrictions were imposed on the social media accounts of the Izmir Medical Chamber. 23 TMA's regional branches started to compare COVID-19 cases and deaths from field workers with MoH data and share differences with the public by using their social media accounts.

This article reports that COVID-19 statistics are being underreported in Turkey. TMA, APHE, and other healthrelated associations are prevented from actively participating in the fight against COVID-19, data sharing by health professionals working in the field is considered a crime, and health associations that comment on the deficiencies of the MoH in the fight against COVID-19 are marginalized.

Under-reporting occurs in every disease outbreak worldwide; however, keeping track of the COVID-19 outbreak in developing countries has been particularly difficult. Having an accurate account of the number of national COVID-19 cases is essential for understanding the national and global burden of the disease and managing COVID-19 prevention and control efforts. As such, associated factors need to be addressed in order to reduce under-reporting.

Reliable reporting enables epidemiologists to predict a disease's trajectory, researchers to develop treatments and vaccines, responders to trace transmission, and the public to protect itself. Full transparency is impossible without public trust, and authoritarian regimes have a steady deficit of public trust. Strong, transparent, and accountable leadership and communication strategies at all levels are crucial in COVID-19 outbreak management to ensure the successful control of epidemic and to prevent secondary problems. When democracy-related indicators are evaluated, it is evident that countries with lower rankings face more COVID-19 under-reporting problems. For example, the Democracy Index (DI) 24 

The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study

COVID-19-we urgently need to start developing an exit strategy

The SARS-CoV-2 outbreak: what we know

Istanbul Death Toll Hints Turkey is Hiding a Wider Coronavirus Calamity Carlotta Gall

Tracking Covid-19 Excess Deaths Across Countries

Global Coronavirus Death Toll could be 60% Higher than

Why Does Spain have the World's Highest Coronavirus Mortality Rate? Miguel Medina-El País-Oriol Güell

Covid-19: Hundreds of UK Care Home Deaths Not Added to Official Toll Robert Booth

Underreporting of Covid-19 Coronavirus Deaths in the U.S. and Europe (update) Joshua Cohen

Indonesia: Little Transparency in Covid-19 Outbreak

Chinese Inquiry Exonerates Coronavirus Whistleblower Doctor Helen Davidson

Iran Bans Printing of All Newspapers, Citing Spread Of Coronavirus

Ttb: Sa glık Bakanlı gı Kovid-19 Ölümlerini Dünya Sa glık Örgütü Kodlarına Göre Raporlamıyor

Erdogan's Covid-19 cover-up Hampers Turkey's coronavirus response

Covid 19'a Ba glı Ölümlerin Yüksekli ginden Endişe Duyuyor

Serdar Savaş: Türkiye'deki Vaka Sayısı 650 Bin Ile 1 Milyon Aralı gında

How to cite this article: Kisa S, Kisa A. Under-reporting of COVID-19 cases in Turkey

No potential conflict of interest was reported by the authors.

All authors have equal contributions.

https://orcid.org/0000-0001-7825-3436