Excess mortality in India from June 2020 to June 2021 during the COVID pandemic: death registration, health facility deaths, and survey data
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Abstract
Background
India’s official death totals from the COVID pandemic are widely regarded as under-reports.
Methods
We quantified all-cause excess mortality in India, comparing deaths during the peak of the first and second COVID waves (Jul-Dec 2020 and April-June 2021) with month wise deaths in 2015-19 from three sources: Civil Registration System (CRS) mortality reports from 15 states or cities with 37% of India’s population; deaths in 0.2 million health facilities; and a representative survey of 0.14 million adults about COVID deaths.
Results
During the first viral wave, the median excess mortality compared to CRS baseline was 22% and 41%, respectively, in included states and cities, rising to 46% and 85% during the second wave. In settings with 10 or more months of data across the two waves, the median excess mortality was 32% and 37% for states and cities, respectively. Deaths in health facilities showed a 27% excess mortality from July 2020-May 2021, reaching 120% during April-May 2021. The national survey found 3.5% of adults reported a COVID death in their household in April-June 2021, approximately doubling the 3.2% expected overall deaths. The national survey showed 29-32% excess deaths from June 1, 2020 to June 27, 2021, most of which were likely to be COVID. This translates to 3.1-3.4 million COVID deaths (including 2.5-2.8 million during April-June 2021). National extrapolations from health facility and CRS data suggest 2.7-3.3 million deaths during the year.
Conclusions
India’s COVID death rate may be about 7-8 times higher than the officially reported 290/million population.
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SciScore for 10.1101/2021.07.20.21260872: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization 11 It was adapted to report on COVID symptoms in March 2020, among adults aged 18 years or older, covering about 2100 randomly selected respondents weekly, drawn from nearly 4000 political Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Moreover, our methods are reproducible over time and avoid the limitations of …
SciScore for 10.1101/2021.07.20.21260872: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization 11 It was adapted to report on COVID symptoms in March 2020, among adults aged 18 years or older, covering about 2100 randomly selected respondents weekly, drawn from nearly 4000 political Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Moreover, our methods are reproducible over time and avoid the limitations of model-based estimates. Nonetheless, we faced some limitations. The use of excess mortality has limitations as some causes, notably road traffic accidents and other injuries, might have fallen, particularly during COVID lockdowns. However, these injuries constitute less than 10% of all deaths from 2004-14.4,21 There might also be an excess of some deaths from neglected health service, and there are reports, for example, that maternal mortality has risen during the pandemic months.22 However, changes in causes of death aside from COVID are likely small compared to the sharp increases in COVID deaths, particularly during the second viral wave. The delays in death registration or a backlog of deaths reported suddenly might create an artifact of excess deaths. However, in the case of Andhra Pradesh, 98% of deaths registered in May 2021 took place within the previous 30 days, not earlier time periods. Survey data might represent over-reporting, as the questions asked about deaths beyond the households. However, since the introduction was focused on flu-like symptoms in the respondent’s family or daily contacts, the extent of such over-reporting is likely small. Moreover, we corrected for over-reporting, albeit imperfectly, by subtracting reported rates in non-pandemic weeks and tested this assumption in sensitivity analyses, which suggested that a lowest value of 2.3 million COVID deaths over the study ye...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
Results from scite Reference Check: We found no unreliable references.
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