Prabhat Jha is the world’s foremost expert on mortality in India, and is founding director of the Centre for Global Health Research in Toronto and professor of disease control at the University of Toronto. Jha led the Million Death Study in collaboration with the Registrar General of India that produced verbal autopsy-led cause-of-death estimates from 2001 to 2013 in India.
“The Kerala reports are based on civil registration, which can miss deaths. In particular there are reports that the proportion of home deaths rose in Kerala in the last year, so this might be part of the explanation,” said Jha, who has been advocating for India to conduct a rapid household sample survey to ascertain the level and causes of mortality in 2020. “The reported 10% drop in overall mortality in 2020 from 2019 in Kerala needs to be confirmed by the Sample Registration System.”
“If [drop in overall mortality] is true, the 10% lower deaths at all ages is not due to lower accidents, as these are only 10% of all deaths. And if true, this would be important to understand what’s going on as Kerala with its older age distribution than India could have had more Covid-19 deaths than observed,” Jha said, adding, “Overall, Kerala does have a better public health system and the more widespread testing and contact tracing and isolation may have played a role in keeping deaths low.”
In Mumbai, on the other hand, the increase in adult deaths is most likely on account of undiagnosed Covid-19, Jha said. “The absolute number of extra adult deaths is about 25,000, while for Maharashtra overall, the cumulative Covid deaths by January 1, 2021, were about 50,000. I suspect then that the excess deaths in Mumbai were mostly [from] Covid, with no clear offsetting increases or decreases in other causes. But this would need detailed data to be released,” he said.
All of this once again becomes important as the second wave of Covid-19 infections gathers steam in India. While cities like Mumbai and Pune have returned to daily new cases comparable to or surpassing their first peaks, daily reported deaths are still some distance behind. So does this mean that the second wave is resulting in fewer deaths?
It’s too soon to declare that the second wave is less deadly, particularly since cases are growing far faster than the first time around, said Murad Banaji, lecturer of mathematics at Middlesex University, U.K., who has been closely tracking India’s Covid-19 numbers.
Deaths can take some time after cases start rising to show up for several reasons, he told IndiaSpend. For one, when active infection is low, a statistically large enough pool of infected people needs to develop for deaths to start occurring. Then, deaths usually take weeks after the confirmation of a case to show up in the data. Finally, cases might first occur among less vulnerable groups like young people, and take some time to spread to the elderly where deaths are more likely to occur, he said. “It would be incredibly premature to declare based on the current data that mortality is lower in this wave,” Banaji said.
It still does appear that at least in parts of India, mortality from Covid-19 has been substantially lower than in the rest of the world. “The few cities in India which have reported on overall deaths by week regardless of cause do show a big increase in overall deaths when Covid-19 deaths rose, suggesting that much of the increase in overall deaths are likely to have been from Covid-19,” Jha said.
The degree of under-reporting of Covid deaths varies, but Jha believes that it is in the range of 10-20% in big cities like Mumbai and Delhi, and not say 100% or so. Based on this presumption, India could have more deaths from Covid-19 than its official count, but relatively low undercounting would not dramatically alter the Indian picture.
Further, India has reported substantially lower Infection Fatality Rates–deaths relative to total infections–than many other countries; the last official estimate put India’s IFR at under 0.1%, while the United States Centre for Disease Control pegs the U.S. IFR at 0.65%. But in rural India, the truth is that we simply don’t know what is happening with Covid-19 infection and deaths, he said.
If fatality rates truly have been lower in India, what could explain it? Observations from Vietnam and Thailand suggest some cross-immunity, perhaps from other circulating bat coronaviruses in the region, said Jha, and this is worth studying in India. Another possible explanation for India is widespread low-grade Covid-19 infection, he said.
“My sense is that we’ll know the real toll of the pandemic (and the potential impact on other causes of death) only years from now, when the patient work of counting the dead and describing causes is more complete,” Jha said, “Better antibody studies in the whole of India would help. Till then, we’ve got to try to use the limited data to track the epidemic.”
And for now, Covid-19 vaccination must ramp up, Kurian and Jha both say.