3 reasons why India could be underreporting COVID-19 deaths

When it comes to COVID-19 deaths, the ground reality in India’s second wave seems far worse from what is captured by official statistics. We explain three reasons for the alleged underreporting of deaths

By Anuja Venkatachalam

In India’s fight against a second wave of COVID infections, it has been alleged that there are grave discrepancies in the official death statistics reported by the government. Field visits made by journalists and interviews with crematorium staff, hospital staff and local government officials suggest that COVID-19 deaths are being substantially underreported in many states.

On the ground, it seems far more people are getting cremated or buried under COVID-19 protocols than is reported by state and central governments.

Since the early days of the pandemic, India’s low fatality rate has been championed as a success of the health system. In an official statement released on 30 August 2020, India’s low COVID-19 fatality rate was attributed to the “timely and effective clinical management of patients in critical care”. A similar statement was made during the second wave of infections, when the Health Minister, Mr Harsh Vardhan stated, “India still has one of the lowest COVID mortality rates in the world, but each death is painful”.

Official statistics released by the Ministry of Health and Family Welfare show that India has the lowest number of deaths among countries with the highest prevalence of COVID-19, surpassing even the most developed economies of the world.

The picture that we get from the official statistics is evidently contrary to what is being reported on the ground.

Why then, is there an underreporting of COVID-19 deaths?

3 reasons can explain why

1. Deaths in India are rarely medically certified

The Indian Registration of Births and Deaths Act of 1969 mandates that all births and deaths be registered within 21 days of occurrence.

Institutional deaths or deaths that occur inside a hospital are directly reported to government authorities by the facility, and non-institutional deaths which occur outside a health institution are required to be reported by family members of the deceased.

At the time of registration, a Medical Certification of Cause of Death (MCCD) issued by a medical practitioner is required to be submitted to the concerned municipality. The certificate declares the immediate, antecedent, and underlying causes for death, and is, therefore, critical in the record-keeping of deaths in India.

Empirical data, however, shows that only 21.1% of deaths registered are medically certified. Moreover, this number has been on the decline since 2016 with states such as Uttar Pradesh and Jharkhand certifying less than 5% of deaths registered.

The Million Death Study conducted by the Centre for Global Health Research in collaboration with the Registrar of India found that most deaths in India, particularly those occurring in rural areas occur at home without medical attention. In an effort to collect data on these “missing” deaths, the study conducted verbal autopsies through in-person surveys, covering 2.4 households across India.

Data, therefore, indicates that systemic failures in record-keeping could hinder the accurate reporting of COVID-19 deaths unless carefully monitored by state health departments.

2. Suspected, probable and clinically diagnosed cases are excluded from the count of confirmed deaths

The guidelines for recording COVID-19 deaths in India have been issued by ICMR and the Centre for Disease Informatics and Research in adherence with the World Health Organization.

A death is accounted for as a COVID death if the deceased tested positive for the virus, irrespective of whether they were symptomatic or asymptomatic.

There are, however, deaths associated with suspected and probable cases. In both cases, the deceased is expected to have shown symptoms of COVID-19, but with inconclusive test results. Additionally, there are deaths associated with symptomatic patients who tested negative but were clinically diagnosed with COVID-19.

The current death statistics reported by the Ministry of Health and Family Welfare only include confirmed deaths, and therefore do not account for symptomatic patients whose test results were negative, pending or inconclusive. In the US, for example, the CDC includes suspected and probable deaths in their public reporting on COVID-19.

3. India isn’t testing enough people

The accurate reporting of COVID-19 deaths is hugely dependent on testing. If people die without getting tested for COVID-19, their deaths are not recorded as COVID deaths, causing the true number of deaths to be underreported.

India has one of the lowest rates of testing with only 211,913 people tested for every 1 million population.

What are countries doing to accurately report deaths from COVID?

As death registrations have a time lag from the occurrence of the death, governments can report revised death estimates that include late registrations.

Epidemiologists also use the “excess deaths” statistic to support the number of confirmed deaths. Excess deaths measure the difference between actual death registrations during the pandemic and expected death registrations under normal conditions. The excess is then attributed to the pandemic, given that they were not expected under normal circumstances.

Many countries including the United States, United Kingdom, Brazil, Mexico and Japan have reported excess death estimates from the first year of the pandemic. The US CDC reported that between 567,743 – 690,138 excess deaths occured in 2020. Similarly, Brazil and Mexico reported a 63% and 27% increase in deaths during the COVID-19 pandemic.

These estimates expose the challenges in reporting deaths across the globe, and particularly in countries such as India that have pre-existing limitations in monitoring and reporting deaths. In order to derive the true cost of COVID-19 on the lives of Indians, the government must undertake similar measures to calibrate death data.

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