https://ojs.wpro.who.int/ 1WPSAR Vol 13, No 4, 2022 | doi: 10.5365/wpsar.2022.13.4.964

Original Research

C
oronavirus disease 2019 (COVID-19) was first
reported as clusters of unexplained pneumonia
in late December 2019 in Wuhan, China, and

was found to be caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2). The World
Health Organization (WHO) declared COVID-19 a public
health emergency of international concern on 30 January
2020.1

Fiji’s first COVID-19 case was imported on
15 March 2020 and resulted in a small local outbreak of
18 cases. Over the next year, 50 additional imported cas-
es were reported without any community transmission.
By 14 November 2020, 70 cases of confirmed COVID-19
had been reported, including two deaths.2 There were no
other cases until 15 April 2021, 364 days after the last
reported, locally acquired case, when travellers tested

positive for COVID-19 in government quarantine in a
hotel. A subsequent locally acquired case of COVID-19
occurred when a hotel worker at the quarantine facility
inadvertently had close contact with the infected travel-
lers, and this marked the start of the second wave of the
COVID-19 outbreak in Fiji. The sequencing of the local
case’s specimen confirmed a SARS-CoV-2 Pango lineage
B.1.617.2 variant – that is, the Delta variant – which at
that time was classified as a variant of concern by WHO.1

During the same period in WHO’s Western Pacific
Region, 10 of the 21 Pacific Island countries and territo-
ries reported cases of COVID-19: some had only imported
cases contained in quarantine facilities (i.e. the Republic
of the Marshall Islands, Samoa, the Solomon Islands and
Vanuatu) and others had large-scale outbreaks (i.e. French
Polynesia, Guam, New Caledonia, the Commonwealth of

a Ministry of Health and Medical Services, Suva, Fiji.
b Ministry of Lands and Mineral Resources, Suva, Fiji.
c World Health Organization Representative Office for the South Pacific, Suva, Fiji.
Published: 23 November 2022
doi: 10.5365/wpsar.2022.13.4.964

Objective: There is limited published information about deaths due to coronavirus disease 2019 (COVID-19) in Fiji, the
World Health Organization’s Western Pacific Region and low- and middle-income countries. This report descriptively analyses
deaths directly associated with COVID-19 in Fiji by age group, sex, ethnicity, geographical location, vaccination status and
place of death for the first 7 months of the 2021 community outbreak.

Methods: A retrospective analysis was conducted of deaths directly associated with COVID-19 that occurred from 15 April to
14 November 2021 in Fiji. Death rates per 100 000 population were calculated by utilizing divisional population estimates
obtained from medical zone nurses in 2021.

Results: A total of 1298 deaths relating to COVID-19 were reported, with 696 directly associated with COVID-19 and
therefore included in the analysis. Of these, 71.1% (495) were reported from the Central Division, 54.6% (380) occurred
among males, 75.6% (526) occurred among people of indigenous (iTaukei) ethnicity and 79.5% (553) occurred among
people who were unvaccinated. Four deaths were classified as maternal deaths. The highest percentage of deaths occurred
in those aged ≥70 years (44.3%, 308), and the majority of deaths (56.6%, 394) occurred at home.

Discussion: At-risk populations for COVID-19 mortality in Fiji include males, iTaukei peoples, and older (≥70 years) and
unvaccinated individuals. A high proportion of deaths occurred either at home or during the first 2 days of hospital admission,
potentially indicating both a reluctance to seek medical care and a health-care system that was stressed during the peak of
the outbreak.

Descriptive analysis of deaths associated
with COVID-19 in Fiji, 15 April to
14 November 2021
Nashika Sharma,a Dashika Balak,a Shaneel Prakashb and Julia Maguirec

Correspondence to Nashika Sharma (email: nashika92@gmail.com)

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Sharma et alCOVID-19 deaths in Fiji

testing for COVID-19 was implemented for all deaths
occurring during the study period.

A descriptive analysis was conducted for deaths
directly associated with COVID-19. Death rates per
100 000 population were calculated by age group,
sex, ethnicity and geographical location using division
population estimates obtained from medical zone nurses
in 2021. Note that the administrative boundaries (e.g.
provincial boundaries) differ slightly from the medical
division boundaries, hence medical zone demographic
data were used.

RESULTS

A total of 1298 deaths relating to COVID-19 were re-
ported during the study period. Of these, 696 were cat-
egorized as being due to COVID-19 and were included
in the analysis. For the first 4 months of the outbreak,
deaths directly associated with COVID-19 primarily
occurred in the Central Division; they later spread to
the Western Division and then to the Eastern Division
(Fig. 1).

Most deaths (71.1%, 495/696) were reported from
the Central Division, and 54.6% (380/696) occurred
among males, 75.6% (526/696) occurred among people
of iTaukei ethnicity and 79.5% (553/696) occurred
among unvaccinated people (Table 1). Although deaths
were reported across all age groups, the median age of
deaths due to COVID-19 was 67 years, and the highest
percentage of deaths occurred in those aged ≥70 years
(44.3%, 308/696). The death rate per age group–spe-
cific population increased with age (Table 1).

Four deaths were classified as maternal deaths,
all of which occurred during the postpartum period at
divisional hospitals between 4 and 6 days from the date
of admission (data not shown). Three maternal deaths
occurred in the Central Division, while one death oc-
curred in the Western Division. The mean age of those
categorized as a maternal death was 36.5 years (median,
35 years), and all women in this group were reported to
be unvaccinated.

The majority of deaths directly associated with
COVID-19 occurred at home (56.6%, 394/696), and
of these 53.8% (212/394) were among males, 86.3%
(340/394) were among iTaukei people and 50%

the Northern Mariana Islands, and Wallis and Futuna).
The remaining 11 Pacific Island countries and territories
remained COVID-free by closing their international bor-
ders and accepting only citizens and emergency support
workers into their country or territory.1

There is limited published information regarding
deaths due to COVID-19 in Fiji, the Western Pacific
Region and low- and middle-income countries.3–5 This
report provides a descriptive analysis of the first 7
months of the 2021 outbreak for deaths directly associ-
ated with COVID-19 in Fiji by age group, sex, ethnicity,
geographical location, vaccination status and place of
death.

METHODS

We conducted a retrospective study of deaths directly as-
sociated with COVID-19 that occurred during the second
wave of community transmission in Fiji between 15 April
and 14 November 2021.

SARS-CoV-2 infection was identified using reverse
transcription polymerase chain reaction (RT-PCR) test-
ing. During this period, all RT-PCR samples were sent to
the Fiji Centre for Communicable Disease Control, also
known as Mataika House, which is Fiji’s national public
health laboratory for analysis and reporting. Deaths were
classified as either directly associated with COVID-19
(i.e. due to COVID-19) or indirectly associated with
COVID-19 (i.e. people with COVID-19 infection at the
time of death).6 Classification was determined by the at-
tending physician at the medical facility or by a mortality
review panel, with COVID-19 categorized as a primary or
secondary cause of death based on the case definition
used by the Fiji Ministry of Health and Medical Services,7
clinical records, medical history from relatives and results
of COVID-19 investigations.

For each death directly associated with COVID-19,
the Ministry of Health and Medical Services obtained
the following information: age, sex, ethnicity, residential
address, place of death, COVID-19 test type, date the
specimen was collected for laboratory testing, date the
specimen was tested, date of death, hospitalization
status, date of hospital admission, COVID-19 vaccination
status and dates of vaccination doses. In the analyses,
deaths were classified as occurring at home or at a health
facility (i.e. a health centre or hospital). Postmortem

WPSAR Vol 13, No 4, 2022 | doi: 10.5365/wpsar.2022.13.4.964https://ojs.wpro.who.int/ 3

COVID-19 deaths in Fiji Sharma et al

95/200) and 0.5% (1/200) occurring at a health centre.
In the Eastern Division, one death occurred at home; no
deaths were reported in the Northern Division during the
study period.

DISCUSSION

Our study describes deaths directly associated with
COVID-19 occurring in Fiji during its second wave of com-
munity transmission in 2021. Most of these deaths occurred
among males, people aged ≥70 years and those living in
the Central Division (the most populous division in Fiji).

Geographically, the deaths directly associated with
COVID-19 followed a similar pattern to that of the cases,
occurring first in the Central Division, then the Western
Division and later in the Eastern Division.8 The delayed
spread of cases through the country can be attributed to
the restriction of movement across the major divisional
borders and from areas with localized outbreaks. With
cases initially concentrated in the Central Division, the
remaining divisions had the opportunity to prepare their
health systems for an influx of cases and also rapidly
increase vaccination coverage to prevent widespread dis-
ease transmission.

(197/394) were among people aged ≥70 years. Of the
43.4% (302/696) of deaths that occurred in a hospital
or health-care setting, 56.3% (170/302) were among
males, 61.6% (186/302) were among iTaukei people and
36.8% (111/302) were among people aged ≥70 years
(Table 2). Of the deaths that occurred in the hospital or
health-care setting, 44.0% (133/302) occurred within 1
day of admission, 9.3% (28/302) occurred 2 days after
admission and 46.7% (141/302) occurred ≥3 days after
admission. Early in the outbreak when there were fewer
cases, less than half of deaths occurred at home; how-
ever, during the peak of the outbreak (15 July–12 August)
more than 60% of deaths occured at home rather than in
a health facility (Fig. 2). From September onwards, this
proportion decreased as the number of cases and deaths
decreased.

The place of deaths directly associated with
COVID-19 (i.e. at home or at a health centre or hospital)
varied by division. In the Central Division, most deaths
occurred at home (60.2%, 298/495), with the remaining
occurring in hospitals (35.2%, 174/495) and at health
centres (4.6%, 23/495). Conversely, in the Western
Division, most deaths occurred in hospitals (52.0%,
104/200), with slightly fewer occurring at home (47.5%,

Fig. 1. Deaths directly associated with COVID-19 by geographical division, Fiji, 15 April to 14 November 2021
(N = 696)

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Central Division Western Division Eastern Division

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Sharma et alCOVID-19 deaths in Fiji

Table 1. Characteristics of 696 people whose death
was directly associated with COVID-19, Fiji,
15 April to 14 November 2021

Table 2. Characteristics of 696 people whose death was
directly associated with COVID-19 by place of
death, Fiji, 15 April to 14 November 2021

a higher rate of respiratory intubation and a longer length
of hospital stay.9 Although there is limited information
about the relationship between sex and COVID-19, the
literature has highlighted the importance of understand-
ing the role of comorbidities, immune system responses
and sex hormones as drivers of COVID-19 mortality.9,10

During our study period, deaths directly associated
with COVID-19 were reported in all age groups. However,
the number and rate of COVID-19 deaths were highest
in those aged ≥70 years, highlighting that COVID-19
mortality increases with age.11–13 A paper by Jergović
et al. emphasized that the loss of immune function and
reduced protection from infectious agents that occur with
age are factors associated with increased disease severity
and mortality from COVID-19.12

The deaths directly associated with COVID-19 in our
study population occurred predominantly among unvac-
cinated people, who accounted for 79.5% of deaths,
whereas 18.7% of those who died had received one dose
of vaccine and 1.9% had received two doses. This is
similar to other studies, highlighting that mortality from

In this study, more than half of the deaths directly
associated with COVID-19 were among males, which is
consistent with other studies, demonstrating that male
sex is associated with higher mortality.9,10 A paper by
Nguyen et al. additionally reported that male sex is not
only associated with a higher rate of mortality but also with

Characteristic

Deaths directly associated
with COVID-19 (N = 696)

No. (%)
Rate/100 000

population

Sex

Male 380 (54.6) 42.9

Female 316 (45.4) 35.7

Age (years)

Median (IQR) 67.0 (21.0) NA

Mean (SD) 65.6 (15.9) NA

Age group

<20 9 (1.3) 2.7

20–29 9 (1.3) 6.3

30–39 22 (3.2) 16.4

40–49 58 (8.3) 56.3

50–59 120 (17.2) 132.4

60–69 170 (24.4) 327.3

≥70 308 (44.3) 1079.2

Ethnicity

iTaukei 526 (75.6) NA

Fijian of Indian
descent

139 (20.0) NA

Other 31 (4.5) NA

Place of death

Hospital or
health-care setting

302 (43.4) NA

Home 394 (56.6) NA

Vaccination status

Unvaccinated 553 (79.5) NA

One dose 130 (18.7) NA

Two doses 13 (1.9) NA

Geographical division

Central 495 (71.1) 123.4

Western 200 (28.7) 56.3

Eastern 1 (0.1) 2.6

Northern 0 (0.0) 0

IQR: interquartile range; NA: not applicable; SD: standard deviation.

Characteristic

No. (%) of deaths

At home
(n = 394)

In hospital or
health-care

setting
(n = 302)

Sex

Male 212 (53.8) 170 (56.3)

Female 182 (46.2) 132 (43.7)

Age group (years)

<20 3 (0.8) 6 (2.0)

20–29 3 (0.8) 6 (2.0)

30–39 10 (2.5) 12 (4.0)

40–49 22 (5.6) 36 (11.9)

50–59 61 (15.4) 59 (19.5)

60–69 98 (24.9) 72 (23.8)

≥70 197 (50.0) 111 (36.8)

Ethnicity

iTaukei 340 (86.3) 186 (61.6)

Fijian of Indian descent 39 (9.9) 100 (33.1)

Other 15 (3.8) 16 (5.3)

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COVID-19 deaths in Fiji Sharma et al

Fig. 2. Deaths directly associated with COVID-19 by place and date of death, Fiji, 15 April to 14 November
2021 (N = 696)

outcomes.18–22 Three separate studies conducted in the
United States of America and Scotland found that severe
complications known to be associated with COVID-19
in pregnancy (such as admission to a critical care unit,
perinatal mortality and developing severe or critical
COVID-19 infection) were more common in pregnant
women who were unvaccinated at the time they were
diagnosed with COVID-19 than in vaccinated pregnant
women.23–25 Therefore, this highlights the importance
of vaccinating pregnant women to reduce the severe
maternal and neonatal health outcomes associated with
COVID-19.

We found that although all ethnicities in Fiji were at
risk of contracting and dying from COVID-19, indigenous
populations (i.e. iTaukei) had a disproportionately higher
rate of death from the disease. A review of the literature
shows that globally indigenous populations seem to have
higher rates of infection, more severe disease, higher
rates of hospitalization, and poorer health and health
outcomes from COVID-19.26–28 Although there is limited
knowledge about the relationship between ethnicity and
COVID-19 morbidity and mortality, research suggests
that pre-existing social, economic, political and cultural

COVID-19 is higher in the unvaccinated population than
the vaccinated population.14–17 COVID-19 vaccinations
have successfully reduced the incidence and severity
of, and hospitalization and deaths from, COVID-19.14–17

Although many countries are utilizing different vaccines
and booster regimens, it is evident that COVID-19 vac-
cinations have the potential to reduce morbidity and
mortality.15–17 The Fiji national COVID-19 vaccination
programme commenced on 6 April 2021, with 61 667
individuals aged >18 (approximately 10% of the eligible
population) receiving their first dose of vaccine by the end
of April 2021; by 14 November 2021, 599 423 (97% of
the eligible population) had received their first dose and
553 943 (89.6%) had received their second dose.

During the study period, four maternal deaths were
reported. We have limited antenatal, intrapartum and
postpartum information about these maternal deaths, so
it is difficult to draw meaningful associations with other
studies conducted around the world; however, a review
of the literature highlights that pregnant women are at
higher risk of severe COVID-19 infection; of needing
caesarean delivery, intensive care admission and invasive
ventilation; and of having adverse maternal and neonatal

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Death at home Death at health facility within 1 day of admission or test
Death at health facility ≥2 days after admission or test % deaths at home (7-day moving average)

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Sharma et alCOVID-19 deaths in Fiji

There were some limitations to this study. The clas-
sification of deaths depended on the assessment of the
attending physician and, therefore, there was potential
for misclassification. If the death occurred outside a
health-care facility (e.g. at home), there may have been
a delay in receiving the death certificate; therefore, there
is potential for delayed reporting or underreporting of
deaths during our study period. We were also unable
to calculate mortality rates by ethnicity due to a lack
of recent population data. In this study, deaths directly
associated with COVID-19 were reported by geographi-
cal divisions; however, it would be valuable to analyse
deaths by urban, periurban and rural settings because
some communities have poorer access to health-care
services, water, hygiene and sanitation and, as a result,
are reported to have poorer health and health outcomes.
It would also be interesting to assess the common signs
and symptoms, and severity of COVID-19 disease, as
well as underlying comorbidities, especially since about
80% of all deaths that occur in Fiji are due to noncom-
municable diseases.32 However, this information is not
reported in the Medical Cause of Death Certificates,
and a detailed review of inpatient data and clinical notes
would be required. Occasionally, the clinical severity of
disease was classified on the death certificate, but the
investigative team was unsure how physicians classified
the severity and whether all physicians in Fiji utilized
standard definitions. Therefore, this information was
not analysed. Understanding the common comorbidities
among those who died from COVID-19 would help to
highlight populations that are at risk for severe outcomes
in Fiji, and understanding the severity of disease would
provide a way to assess the required levels of health-care
preparedness, health-care delivery and future clinical
and public health forecasting in a developing country like
Fiji. Information on the common signs and symptoms
of COVID-19 experienced within our population can be
utilized to increase knowledge and awareness among our
frontline and allied health-care workers and can also be
used to develop risk communication material to increase
knowledge of and awareness about COVID-19 among our
population.

In addition, understanding the patterns of disease
among other at-risk populations would be useful, such as
individuals with underlying mental health disorders or ill-
nesses, those who are immunocompromised, those who
have a disability, and residents of aged-care facilities, as
well as low-income or unemployed individuals, unhoused

determinants of health are important factors in the health
and health outcomes of indigenous populations.26

Therefore, it is important to collect timely, relevant, high-
quality and disaggregated data to better understand the
needs of vulnerable and at-risk populations and to ensure
that COVID-19 response and mitigation measures are
delivered in a way that ensures health equity and health
equality.29

We found that the majority of deaths directly associ-
ated with COVID-19 occurred at home (56.6%). While the
reason for this is not clear, it is important to understand
a population’s health-seeking behaviours and the factors
that drive these behaviours. Two studies conducted in
Pakistan and Viet Nam examined health-seeking behav-
iours and factors that altered these during the COVID-19
pandemic.30,31 They found that individuals increased
self-medication with unprescribed drugs, decreased
their hospital visits and had an increased preference for
visiting private general practitioners, traditional healers
and unregistered clinics rather than visiting govern-
ment facilities. The main factors that limited or altered
health-seeking behaviours, or both, during the pandemic
included fears of being stigmatized, of whole families
being transferred to quarantine facilities and of disclosing
past activities to contact tracing teams, and these fears
were enhanced by misinformation, panic and uncertain-
ties that spread over social media platforms.30,31 The
two countries in these studies are developing countries,
and these findings may be applicable to the context in
Fiji. It is also important to consider the immense and
unprecedented stress placed on the health-care system
in Fiji during the peak of the outbreak, and its impact
on the system’s ability to provide adequate and timely
services to people with COVID-19. Indeed, we found that
a high proportion of deaths occurred at home or soon
after hospital admission, but this may be due to multiple
factors, such as a limited ability to identify people with
deteriorating health, limited availability of transportation
to hospital and limited bed capacity to treat patients
within the hospital, rather than a lack of health-seeking
behaviour. As the outbreak progressed, strategies were
implemented to increase the ability of the health system
to identify those most at risk of severe disease and place
them into an appropriate care pathway. More research on
health-seeking behaviours and the factors that drive these
behaviours within the context of Pacific Island countries
and territories is pivotal for informing future pandemic
response and mitigation measures.30,31

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COVID-19 deaths in Fiji Sharma et al

2. COVID-19 updates. Suva: Fiji Ministry of Health and Medical Ser-
vices; 2022. Available from: https://www.health.gov.fj/covid-19-up-
dates/, accessed 19 April 2022.

3. Wang D, Gee GC, Bahiru E, Yang EH, Hsu JJ. Asian-Americans and
Pacific Islanders in COVID-19: emerging disparities amid discrimi-
nation. J Gen Intern Med. 2020;35(12):3685–8. doi:10.1007/
s11606-020-06264-5 pmid:33009656

4. McElfish PA, Purvis R, Willis DE, Riklon S. COVID-19 disparities
among Marshallese Pacific Islanders. Prev Chronic Dis. 2021;18:E02.
doi:10.5888/pcd18.200407 pmid:33411668

5. Cha L, Le T, Ve’e T, Ah Soon NT, Tseng W. Pacific Islanders in the
era of COVID-19: an overlooked community in need. J Racial Ethn
Health Disparities. 2022;9(4):1347–56. doi:10.1007/s40615-
021-01075-8 pmid:34169488

6. International guidelines for certification and classification (coding)
of COVID-19 as cause of death. Geneva: World Health Organiza-
tion; 2020. Available from: https://www.who.int/publications/m/
item/international-guidelines-for-certification-and-classification-
%28coding%29-of-covid-19-as-cause-of-death, accessed 19 July
2022.

7. Criteria for testing for COVID-19 for Fiji. Suva: Fiji Ministry of
Health and Medical Services; 2020. Available from: https://
www.health.gov.fj/wp-content/uploads/2020/06/CRITERIA-FOR-
TESTING-FOR-COVID-19-FOR-FIJI_upload.pdf, accessed 19 July
2022.

8. Statement by the Permanent Secretary for Health & Medical
Services, Dr James Fong – 05.01.22. Suva: Fijian Government;
2022. Available from: https://www.fiji.gov.fj/Media-Centre/Speech-
es/English/STATEMENT-BY-THE-PERMANENT-SECRETARY-FOR-
HEA-(116), accessed 1 August 2022.

9. Nguyen NT, Chinn J, De Ferrante M, Kirby KA, Hohmann SF,
Amin A. Male gender is a predictor of higher mortality in hospi-
talized adults with COVID-19. PLoS One. 2021;16(7):e0254066.
doi:10.1371/journal.pone.0254066 pmid:34242273

10. Mukherjee S, Pahan K. Is COVID-19 gender-sensitive? J Neuroim-
mune Pharmacol. 2021;16(1):38–47. doi:10.1007/s11481-020-
09974-z pmid:33405098

11. Xu K, Wei Y, Giunta S, Zhou M, Xia S. Do inflammaging and coagul-
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individuals, and members of the lesbian, gay, bisexual,
transgender and queer communities; however, this
information was not available. Having these data would
allow health promotion activities to be targeted to reduce
morbidity and mortality in these groups.

This retrospective analysis of deaths directly as-
sociated with COVID-19 that occurred in Fiji during the
second wave of the pandemic (15 April to 14 November
2021) found that at-risk groups included male, indigenous
(iTaukei), older (≥70 years) and unvaccinated individu-
als. Therefore, we conclude that individuals belonging to
these risk groups in Fiji should adhere to the recom-
mended COVID-19 precautions and preventive measures
to avoid becoming infected with SARS-CoV-2, and we
recommend that future public health prevention strate-
gies, health promotion activities, risk communication
materials and public health policies for COVID-19 in Fiji
are tailored to these at-risk populations. Strategies should
include providing education about the signs and symp-
toms of severe and progressing COVID-19, and increasing
the capacity of health systems to identify and respond to
a rapid influx of deteriorating patients.

Acknowledgements

We thank Dr Eric Rafai, the Head of Research at the Fiji
Ministry of Health and Medical Services, for providing
the team with guidance and direction throughout the
research process.

Conflicts of interest

The authors have no conflicts of interest to declare.

Ethics statement

This study was approved by the Human Health Research
Ethics Review Committee of the Ministry of Health and
Medical Services, Fiji (FNHRERC: 59/2021).

Funding

This study was self-funded.

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