Coronavirus | Opeds and editorials

The many challenges in estimating deaths

There is a debate on the number of deaths in India caused by COVID-19. The official number as on August 26 was 59,449. Nobody believes this number to be true, yet nobody has an alternative number. So, when two young scientists conjured up a specific estimate of 1,88,939 deaths on July 31 based on an ingenuously simple approach (multiply the reported deaths by five) in an article in these pages, they were criticised. There is also a campaign by activists asking the government to put COVID-19 deaths-related data in the public domain. Before we discuss the merit of these two arguments, we need to be clear about the urgency of the need of this estimate. While knowing the number of COVID-19 deaths is a good indicator of burden, this alone is not of much use in planning our current public health strategies, for which case fatality rates or infection fatality rates are far more useful. Also, as the pandemic is far from over, this estimate becomes outdated almost the instant it is generated. Despite this, there is no question that such an estimate needs to be generated, if only for academic purposes. It also gives us an opportunity to be better prepared for such estimations in future.

There are two kinds of challenges in estimating the number of deaths due to COVID-19 – the first is related to weaknesses in our mortality surveillance system; the second to COVID-19-specific issues. It might also be relevant to point out that even for other diseases, estimating the number of deaths is a problem.

 

Counting deaths

In an ideal world, we would be able to count all deaths and have a certified cause of death in all the cases. In the real world, we have neither. According to the Civil Registration Scheme report for 2018, 86% of all deaths were registered, with 34% being through hospitals. However, this would not be a good source for cause of death as it is as reported by the next of kin at the time of registration.

The second source of cause of death is the medical certification of cause of death (MCCD). As per the report released by the Office of the Registrar General of India (ORGI) in 2018, 1.45 million deaths (21% of all registered deaths and hence, multiplication by five suggested by the scientists) were medically certified. MCCD has an urban bias and there are also issues related to quality of death certification by doctors. The scientists mentioned above ignored the fact that COVID-19 has largely been an urban phenomenon till now, where medical certification coverage is much better, and also did not address COVID-19-specific issues.

The third and final source for cause of death is the Sample Registration System. Here good quality mortality surveillance is carried out in a small representative population. All identified deaths are noted by a trained worker using standard procedures to generate information which is reviewed by a doctor to arrive at a cause of death. This occurs in a small number of deaths (40,000-45,000) nationally per year. However, due to delays in the process, this information is available in the public domain only till 2013.

Coronavirus | 444 deaths added to Chennai’s COVID-19 toll

Impact of the pandemic

In addition, COVID-19 has adversely impacted death registrations due to lockdowns, travel restrictions as well as social stigma resulting in people hiding these deaths. As COVID-19 moves to rural areas, these challenges are going to worsen. Also, as many of these systems are not yet fully electronic, there will be a delay in the availability of these data even after registration. Thus, it is quite likely that the data available with the ORGI for 2020 will need evaluation for its usefulness for estimation procedures, even if made public. I have always supported efforts to put publicly funded data in the public domain. Yet, I would caution against uncontrolled access in this case.

Identifying COVID-19-specific mortality is a challenge across the globe. An approach of using reported death data would be applicable if all those who developed COVID-19 were tested and their deaths certified. However, there are serious limitations of test availability due to restrictive criteria for access and use, even for people with symptoms. Without testing of all suspected cases, healthcare providers have to rely on clinical features to label a death as being due to COVID-19. Our inability to differentiate these from other causes of death may result in misclassification. Without testing, it is going to be difficult for a doctor to differentiate between COVID-19 and, say, influenza. The second issue is related to defining indirect deaths caused by COVID-19. Due to societal and health system disruptions, the pandemic is likely to contribute to deaths from other causes — suicides, non-communicable diseases, tuberculosis. Also, think of a person who had a compromised heart which was worsened when she suffered a COVID-19 infection, precipitating a heart attack, which otherwise would not have occurred now. In a sense, this is also a death caused by COVID-19 as it initiated the final sequence of events leading to death. However, a doctor would certify this as a cardiac death as one cannot ever be sure that COVID-19 initiated the process. How do we include this in our estimate? All these factors will have to be considered when we estimate COVID-19-related deaths.

Coronavirus | Delhi municipal count puts COVID-linked funerals at double the death toll

So, what is the way out? Almost all the issues mentioned for COVID-19 are also applicable to influenza. For the swine flu pandemic of 2009, an estimate published in The Lancet in 2012 indicated that the real mortality was 15 times higher than the globally reported laboratory-confirmed cases. For many years, influenza-associated mortality has been estimated using an indirect modelling approach based on the concept of ‘excess mortality’. An estimate for influenza mortality in India using the same approach based on above data sources has been generated by my team. Such exercises always give you a range and not a single estimate.

Excess mortality

Even countries with near-complete registration of deaths in normal times have acknowledged that their officially recorded COVID-19 death tolls might be underestimates and they are now focusing on excess mortality – the number of deaths above that expected during ‘normal’ times. This approach first statistically defines the ‘expected’ number of deaths in a given period in a given population using past mortality records and then uses the 2020 mortality data to estimate increase in rates of death beyond what would be expected if SARS-CoV-2 had not circulated. The ‘excess death’ approach would include deaths directly (pneumonia or other respiratory conditions) as well as indirectly caused by the pandemic or its interventions (cardiac conditions). It will have to be acknowledged here that lockdowns may have had a preventive effect on some other deaths, notably road accidents and pollution-linked deaths. Depending on the availability of data and analytic capacity, this can lead to a real-time measurement of excess mortality or it could be an exercise done at the end of the epidemic.

Data | Is India undercounting its COVID-19 deaths?

Thus, the estimation of ‘true’ mortality due to COVID-19 is likely to pose significant methodological and systemic challenges. However, sufficient technical capacity exists in the country to do so. It should be noted that deficiencies in mortality surveillance have existed for a long time. There is no denying that these need to be addressed urgently.

Anand Krishnan is a Professor at the Centre for Community Medicine at the AIIMS, New Delhi

This article is closed for comments.
Please Email the Editor

Printable version | Apr 15, 2021 8:45:42 AM | https://www.thehindu.com/opinion/op-ed/the-many-challenges-in-estimating-deaths/article32537264.ece

In This Package
Examination priorities: On annual exams amid the pandemic
The secrecy around deaths after vaccination
Indian universities need immediate vaccination
Lessons from COVID-19
The second wave: On why new COVID-19 vaccines should be cleared
Weighing in on the saga of a vaccine
Rising poverty: On pandemic-induced disparities
A booster shot for India’s vaccination plan
Allaying concerns: On public trust and vaccination programmes
A moral test: On the vaccine divide
Efficacious too: On Covaxin
Sustaining the drive: On COVID-19 vaccination phase 2
Vaccine inequities: On need to vaccinate all above 45
Addressing vaccine reluctance and policy hesitancy
Redefining the exit plan for COVID-19
Boosting confidence: On need for efficient use of COVID-19 vaccine stocks
Opening up the vaccine market
Origin and spread: On the source of SARS-CoV-2
New questions: On COVID-19 infecting one-fifth of Indian population
A year on, mind the gaps in the pandemic response
Should Board exams be conducted in one go this year?
No to vaccine nationalism, yes to global cooperation
Tempered optimism: On India’s sliding COVID-19 graph
The best shot against COVID-19
More vaccines than takers
Managing the rollout: On addressing vaccine hesitancy
Injecting confidence: On India’s COVID-19 vaccination drive
Vaccine optimism and the scientific uncertainty link
Building trust in vaccines
The debilitating side-effect of a flawed vaccine trial
Gearing up: On vaccines and public trust
A hurried gamble: On vaccines and transparency
The second dose: On COVID-19 vaccine
A constant vigil: On the new coronavirus strain in India
Unmasked, reflections on the pandemic and life
Caution pays: On Centre’s COVID-19 surveillance guidelines
Towards an effective vaccination distribution policy
Essential dry run: On COVID-19 vaccination drive
COVID-19 and limits of political accountability
The purpose of a vaccine
Clear the fog, draw up a clear vaccination policy
Rein in the vaccine nationalism, the profiteering
In vaccine race last lap, the key steps for India
The storage tale of two vaccines
T-cell immunity and COVID-19
COVID-19, climate and carbon neutrality
Signs of easing: On India’s COVID-19 fight
Has India passed the COVID-19 peak?
Sooner, better: On indigenously developed COVID-19 test kits
The battered Puja economy
Outline of a pandemic fight, by and for citizens
Pandemics and the collective consciousness
Vaccines with a global common good guarantee
Saving lives under the long shadow of the pandemic
Until vaccine: On Unlock 5
The challenge of changing health behaviour
Weighing the costs: On COVID-19 vaccine
The slow and frustrating journey of recovering from COVID-19
Health worker safety deserves a second look
Unlocking campuses: On UGC’s revised academic calendar
Recovery from COVID-19 can be a struggle
Uniting to combat COVID-19
Coronavirus fears and preconception advice
An agriculture-led revival as flawed claim
A necessary pause: On the COVID-19 vaccine race
The uncertainties over COVID-19 numbers
The challenges in counting the dead
COVID-19 deaths may be higher than reported
You are reading
The many challenges in estimating deaths
Alone at the top: On India’s COVID-19 numbers
The participants we need in Phase 3 trials
Differential impact of COVID-19 and the lockdown
More than a vaccine, it is about vaccination
COVID-19 and a country club India must leave
A quest for order amid cyber insecurity
Adopting a public systems approach to COVID-19
Milestone of a million: On India’s COVID-19 numbers
Testing times: On university exams
Predictions, pandemics and public health
It’s time to flatten the pandemic stereotyping
Viral outrage only spikes the data
Sending the right message
Needed: Clear testing data
The social contract needs to be rewritten
The pandemic is about eyes shut
Joblessness and opportunity in Tamil Nadu
Green-lighting ecological decimation amidst a pandemic
COVID-19 has no religion
A case for extension: On rural jobs scheme
Surely, even if slowly: On a COVID-19 vaccine
Bend it like Italy: On flattening the COVID-19 curve
Promise and delivery: On India’s first COVID-19 vaccine
States hold the key: On Unlock 2.0
PCR testing is a double-edged sword
Science vs nonsense: On Patanjali’s COVID-19 claim
Shut and open: On tennis during the pandemic
The perils of follow the leader syndrome
The many questions about Favipiravir
In new lockdown, a second chance for Tamil Nadu
United front in Delhi: On Kejriwal government-Centre camaraderie
A prescription of equitable and effective care
Multilateralism post COVID-19
Making public transport safe during COVID-19
A better rate: On COVID-19 recovery
Look back in relief: On the migrant labour crisis
Needed, a transfusion for public health care
Wrong priorities: On keeping religious places open during a pandemic
Crossing the line: On Delhi’s decision to limit health services
Profit, not profiteering: On regulation of COVID-19 testing charges
In Persian Gulf littoral, cooperative security is key
Paging the private sector in the COVID fight
Curves and recoveries: On India’s coronavirus numbers
India’s Parliament is missing in action
Axing the economy’s trunk
Scripting a new narrative for COVID control
Open with caution: On Unlock 1
It’s time for a universal basic income programme in India
The waning of subaltern solidarity for Hindutva
Export blocks: On India’s trade amid the pandemic
A moment to trust the teacher
The echo of migrant footfalls and the silence on policy
Enjoying the fruits of their labour
Helping supply chains recover
The heavy burden of social suffering
An effective lockdown
The lockdown has highlighted stark inequalities
Will sport be the same in empty stadia?
Cinema after COVID-19
The eternal longing for the distant home
Working safely: On workplaces during the pandemic
A hole in the whole: On health sector woes
China, better prepared for the post-COVID world
How public health boosts an economy
Keep it retrospective
Backing the ‘angels in white coats’
Standstill: On opening of stadia for training
Flawed stimulus is justice denied
We need social physicians
A callous response
Peaking: On India’s coronavirus tally
Farm gate in focus: On amending Essential Commodities Act
A question of quarantine: On migrant workers and other travellers
TASMAC tribulations: On Tamil Nadu liquor sale
The pandemic and the challenge of behaviour change
One for the poor: On Centre’s corona package
Lockdown syndrome: On virus-induced economic crisis
Are India’s labour laws too restrictive?
Stop the return to laissez-faire
States cannot be left to the Centre’s mercy
Local motif: On Modi’s call for self-reliance
Liquidity lifeline: On Nirmala’s MSME package
A plan to revive a broken economy
Provide income support, restore jobs
Perilous state: On State finances
COVID-19 and the path ahead
Reaffirm cooperative federalism
Riding roughshod over State governments
Tragedy on the tracks: On the killing of 16 migrant workers
Coming to terms: On India refusing to admit community transmission
The trends shaping the post-COVID-19 world
The epidemic and ensuring safety in courts
Responding to COVID-19 at the grassroots
The face of exploitation
Contempt for labour: On dilution of labour laws
Slower growth and a tighter fiscal
Back home: On return of Indian expatriates
Blame game: On Donald Trump’s anti-China rhetoric over COVID-19
Resuscitating multilateralism with India’s help
A war-like state and a bond to the rescue
Fear and loathing in the land of the free
Everyone wants a good stimulus
Rent control amidst pandemic
Slow release: On lockdown 3.0
No comfort in numbers: On Bengal’s coronavirus cases
Pandemics without borders, South Asia’s evolution
India’s disease surveillance system needs a reboot
No relief for the nowhere people
BRICS against COVID-19
Recovering early: On India’s COVID-19 patients
It’s about food, nutrition and livelihood security
Taiwan’s coronavirus protocol shows how it is done
Needed: a pandemic patent pool
Getty Images/iStockphoto
Plasma therapy is no silver bullet
Take care of yourself too, fellow journalists
Strategic shift: On home isolation of mild coronavirus cases
Coping with today, planning for tomorrow
No end in sight: On India’s coronavirus strategy
Vividly imagining the life of migrant workers
A task for South Asia
Privacy concerns during a pandemic
Unlocking justice in the lockdown
Safe return: On migrant worker distress
The outline of another pandemic combat strategy
Pandemic and panic: On Tamil Nadu’s five-city lockdown
Protecting the poor from becoming poorer
Did SARS-CoV-2 begin from a lab?
Protection for protectors: On safety of healthcare workers
Rapid failures: On antibody testing kits
The COVID-19 paradox in South Asia
Fishing in troubled waters during a pandemic
How will India emerge out of the lockdown?
Making doctors wash hands
Locked out of cities, homes and livelihoods
Script of unity: On coronavirus and social prejudices
Exploiting a pandemic: On Trump’s immigration policy
The village is still relevant
A time for planetary solidarity
There may be no going back
No transparency in West Bengal
Focus on the curve: On India’s COVID-19 numbers
Economy in lockdown: On India’s worst case scenario
A shot of hope with a game changing vaccine
Caught in the heightened arc of communal polemics
Singing the corona tune
Helping a lending hand: On RBI’s second lockdown stimulus
A season of change: On IMD forecast system
A virus, social democracy, and dividends for Kerala
Across the gulf: On stranded Indian workers
Virtual reality: On telemedicine
A blueprint to revive the economy
A case to use JEE-Main instead of JEE-Advanced this year
Will the aviation industry recover from the pandemic?
Data-driven reporting during COVID-19
Stress test: On revised lockdown guidelines
Disastrous decision: On Trump halting funds to WHO
Cease the distractions, seize the moment
Getting the containment strategy in India right
In India’s response, a communications failure
Harmonising with nature
End the harassment of farmers now
A narrowing window: On extension of lockdown
Corona bond: On Eurozone COVID-19 rescue package
Halting the march of rumours
Polls during a pandemic
The pandemic and the contours of a health response
Economic liberalisation and its faults
Invasive, alien, most fearsome
Trade in tatters: On the global slump
Wanted, a collective national endeavour
Disingenuous and no antidote
COVID-19 and the crumbling world order
Women’s safety during lockdown
Lives and livelihoods: On economy after lockdown
Stage fright: On denying community transmission
Team India and winning the pandemic battle
In time of need: On hydroxychloroquine export
Will COVID-19 affect the course of globalisation?
Finding a scapegoat in WHO
Curating news for children during pandemic
A time for extraordinary action
For better use: On MPLADS funds
Needed, greater decentralisation of power
A key arsenal in rural India’s pandemic fight
Preparing for exit: On lifting the lockdown
Sanctions and pandemic: On America’s Iran policy
‘A script of action, responsibility and compassion’: Chief Minister Ashok Gehlot writes on Rajasthan’s fight against COVID-19
Taking a long view of the pandemic fight
Ten questions posed by the virus
A different economic approach
Why healthcare workers above 60 should be ‘benched’
Enemy at the gates: On Kerala-Karnataka border row
Reducing farm distress during a pandemic
Why everyone should wear masks
The criticality of community engagement
A niggardliness that is economically unwarranted
The spectre of a post-COVID-19 world
Light and sound: On Narendra Modi’s 9-minute light ceremony
A million and counting: On global coronavirus spread
Safe forests, safe people: On diseases of animal origin
Quarantine and the law
Making the private sector care for public health
Looking east to contain COVID-19
Limits to rugged individualism
Uncritical endorsement: On exodus of migrant workers and the Supreme Court
Beyond the blame game: On the Tablighi Jamaat episode
A long road: On India’s 21-day coronavirus lockdown
The missing notes: On politics and the fight against COVID-19
China’s zero: On China’s lead in containing coronavirus
Unprecedented step: On Wuhan lockdown
The return of the expert
Lessons from Hubei
A pandemic in an unequal India
Faith can’t override public health
Devising a people-centric response to COVID-19
Karnataka CM writes on how the State is fighting the pandemic
Tamil Nadu CM writes on how the State is stopping the pandemic in its tracks
The hunt for a cure begins with telling the truth
COVID-19 and a city’s anatomy
Long live the nation-state
The COVID cycle
Coronavirus | The worst of times, the best of times
It’s also a fight against punitive measures
The age of the neoliberal virus
The deep void in global leadership
Thinking national, acting local
Every man is a part of the main
Beyond social distancing to fight COVID-19
Next Story