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. Updates from States and the MoHFW are our immediate source of COVID-19 deaths. The same should also be available at the end of the year when the MCCD reports are collated. The latest MCCD report is available for 2017.
Change in the top 10 States with COVID-19 deaths after adjustment for prevailing coverage of death registration and medical certification of cause of death till 8 a.m. IST on July 31, 2020.
Death registration and MCCD
Do the reported COVID-19 deaths reflect the true picture? Before we get into this, 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. Outside designated COVID-19 facilities, there could be many instances of suspected COVID-19 being the cause of death (testing not done or results not available); this may not be captured. This is possible in the context of a prevailing systemic under-registration of deaths and the poor coverage of MCCD. This may be more pronounced in rural and semi-urban areas where there is poor access to health facilities and/or qualified medical doctors. 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.
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This estimated COVID-19 deaths per million population is higher than Russia (96 per million, 100% MCCD of total deaths), similar to South Africa (137 per million, 92% MCCD) and lower than the U.S. (477 per million, 100% MCCD), Brazil (440 per million, 99% MCCD), Mexico (362 per million, 100% MCCD), Peru (588 per million, 57% MCCD), Chile (498 per million, 95% MCCD), Spain (608 per million, 95% MCCD) and Iran (202 per million, 90% MCCD). Most of the above countries (but for Peru) have a high MCCD coverage. Hence, we do not need to adjust the reported COVID-19 deaths of these countries.
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Within India, we calculated State-wise estimated COVID-19 deaths by multiplying the reported COVID-19 deaths with the multiplication factor for the respective State . The top 10 States based on estimated COVID-19 deaths (ranging from 347 per million population to 114) in decreasing order are Delhi, Maharashtra, Gujarat, Andhra Pradesh, Nagaland, Madhya Pradesh, Uttarakhand, West Bengal, U.P. and Tamil Nadu. If we go by reported COVID-19 deaths, then Nagaland, Madhya Pradesh, Uttarakhand, West Bengal and Uttar Pradesh do not find a mention in the top 10.
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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.
COVID-19 deaths per million population is a straightforward metric but this entirely depends on the timing of the epidemic in the given geographic region. The deaths per million increase as the epidemic progresses. Therefore, inter-country or inter-State comparisons have to be made and interpreted considering the stage of the epidemic.
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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.
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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. 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. Also, for triangulation of data, we urge the MoHFW to release monthly or quarterly bulletins of national and State-wise deaths reported under CRS and MCCD. 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. We also recommend the MoHFW to monitor the proportion of COVID-19 deaths coded with ‘suspected COVID-19’ as the cause of death.
