COVID-19 deaths may be higher than reported

COVID-19 deaths may be higher than reported

By, Hemant Deepak Shewade and Giridara Gopal Parameswaran are community physicians by training. Hemant works for an international NGO and is based in Bengaluru. Giridara works at the All India Institute of Medical Science, Delhi. This piece along with graphs can be accessed online at www.thehindu.com

Context

• As on July 31, India had the third highest burden of COVID-19 globally (based on total reported cases).
• According to the Union Ministry of Health and Family Welfare (MoHFW), there were 35,747 reported COVID-19 deaths and 5,45,048 active cases.
• India had 26 COVID-19 deaths per million population.
• This has been cited to substantiate the low mortality in the country. As per Indian Council of Medical Research guidelines, if it is medically certified that the underlying cause of death is suspected or confirmed COVID-19, then that death should be recorded and reported as a COVID-19 death.
• The States update the number of COVID-19 deaths to the MoHFW based on the updates received from cities and districts. The reported COVID-19 deaths have to be updated in the medical certification of cause of death (MCCD) web portal.

Death registration and MCCD

• We need to understand the prevailing coverage of death registration and MCCD in India.
• According to the latest vital statistics of India based on the Civil Registration System (CRS, 2018), 86% of the total deaths were registered of which 22% had a medically certified cause of death (MCCD report, 2017).
• This means 18.9% (0.86*0.22) of the total deaths were medically certified with a cause of death.
• The key reason for this is that only 34% received institutional medical attention at the time of death (CRS, 2018).
• Another reason is that not all hospitals (including public and private hospitals in rural and urban areas) have been brought under the coverage of MCCD.
• Errors, missing details or issues in the quality of MCCD have also been reported.
• This proportion of total deaths that are medically certified with a cause of death varies from State to State. It is less than 10% in Nagaland (1.5%), Bihar (2.4%), Jharkhand (2.6%), Uttarakhand (5%), Uttar Pradesh (5%) and Madhya Pradesh (7.4%); more than 60% in Delhi (60.7%) and Puducherry (63.7%); and 100% in Goa.
• The COVID-19 deaths compiled by States predominantly include deaths occurring in COVID-19-designated facilities among reported COVID-19 cases.
• Hence, suspected COVID-19 deaths occurring at home or during transit or in non-COVID hospitals may not be reported.
• This is possible in the context of a prevailing systemic under-registration of deaths and the poor coverage of MCCD.
• Hence, we need to adjust for the prevailing under-registration of deaths and poor coverage of MCCD to arrive at the correct estimate of COVID-19 deaths.

Estimated COVID-19 deaths

• To adjust for the prevailing under-registration of deaths and poor coverage of MCCD, we multiplied the reported COVID-19 deaths by a multiplication factor. It was 5.29 for India and calculated as the inverse of 18.9% (the coverage of MCCD among total deaths based on the 2018 CRS and 2017 MCCD reports).
• This gave a total of 1,88,938 estimated COVID-19 deaths taking the deaths per million population to 138. This is in contrast to the widely prevailing notion that deaths are very low in India.
• This estimated COVID-19 deaths per million population is higher than Russia (96 per million, 100% MCCD of total deaths), etc.
• Madhya Pradesh, West Bengal, U.P., Bihar and Jharkhand constitute 43% of the national population.
• These States with <12% MCCD coverage and less than 10,000 COVID-19 tests per million population contribute to 38% of the total estimated COVID-19 deaths.
• If we go by reported COVID-19 deaths, then these States contribute to a mere 12% of total reported COVID-19 deaths. This clearly shows the extent to which cases and deaths could be missed.
• In India, many media reports have highlighted that when suspected COVID-19 was the cause of death (testing not done or results not available), it was erroneously not reported as COVID-19 death.
• Hence, even among the registered deaths, the COVID-19 deaths appear to be under-reported. Therefore, the estimated COVID-19 deaths calculated by us, despite the adjustment, are an underestimate.

Considering adjustments

• We call upon the MoHFW to consider the adjustments suggested before arriving at the COVID-19 deaths and before making inter-State and inter-country comparisons.
• The States with a relatively high estimated COVID-19 death per million population and low testing need to be focused upon.
• These are also the States that have poor healthcare infrastructure.

Way forward

• Additionally, this is an opportunity to improve MCCD. Reporting of deaths with suspected COVID-19 as the cause needs to be encouraged and ensured from COVID-19 facilities, non-COVID-19 facilities and homes.
• The current COVID-19 reporting mechanism is very different from the MCCD reporting. Therefore, we request that it is ensured that the reported COVID-19 deaths are promptly captured in the MCCD web portal.
• Data under CRS will enable us to compare the deaths registered before and during the epidemic and help understand how close are the reported and estimated COVID-19 deaths to the true picture.