COVID-19 mortality effects of underlying health conditions in India: a modelling study

  1. Paul Novosad
  2. Radhika Jain
  3. Alison Campion
  4. Sam Asher

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Abstract

To model how known COVID-19 comorbidities affect mortality rates and the age distribution of mortality in a large lower-middle-income country (India), and to identify which health conditions drive differences with high-income countries.

Design

Modelling study.

Setting

England and India.

Participants

Individual data were obtained from the fourth round of the District Level Household Survey and Annual Health Survey in India, and aggregate data were obtained from the Health Survey for England and the Global Burden of Disease, Risk Factors and Injuries Studies.

Main outcome measures

The primary outcome was the modelled age-specific mortality in each country due to each COVID-19 mortality risk factor (diabetes, hypertension, obesity and respiratory illness, among others). The change in overall mortality and in the share of deaths under age 60 from the combination of risk factors was estimated in each country.

Results

Relative to England, Indians have higher rates of diabetes (10.6% vs 8.5%) and chronic respiratory disease (4.8% vs 2.5%), and lower rates of obesity (4.4% vs 27.9%), chronic heart disease (4.4% vs 5.9%) and cancer (0.3% vs 2.8%). Population COVID-19 mortality in India, relative to England, is most increased by uncontrolled diabetes (+5.67%) and chronic respiratory disease (+1.88%), and most reduced by obesity (−5.47%), cancer (−3.65%) and chronic heart disease (−1.20%). Comorbidities were associated with a 6.26% lower risk of mortality in India compared with England. Demographics and population health explain a third of the difference in share of deaths under age 60 between the two countries.

Conclusions

Known COVID-19 health risk factors are not expected to have a large effect on mortality or its age distribution in India relative to England. The high share of COVID-19 deaths from people under age 60 in low- and middle-income countries (LMICs) remains unexplained. Understanding the mortality risk associated with health conditions prevalent in LMICs, such as malnutrition and HIV/AIDS, is essential for understanding differential mortality.

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  1. Version published to 10.1136/bmjopen-2020-043165
  2. ScreenIT

    SciScore for 10.1101/2020.07.05.20140343: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    NIH rigor criteria are not applicable to paper type.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: Thank you for sharing your code and data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    The key limitation of this study is that there are virtually no data on the COVID-19 mortality risks associated with health conditions that are more common in LMICs than in high income countries, such as protein calorie malnutrition, micronutrient deficiency, and HIV/AIDS.4 If these conditions make individuals more susceptible to severe infections, then population health may indeed exacerbate the severity of COVID-19 in LMICs. Understanding the extent to which health conditions endemic to poor countries affect COVID-19 severity is an urgent priority, particularly as policy responses increasingly focus on identifying and isolating high risk individuals.27 Our analysis is also constrained by the limited and changing evidence on risk factors for COVID-19 severity. Based on the availability of existing measures, our model assumed that health condition relative risks are age-invariant. However, data from New York’s epidemiological surveillance system suggest that hypertension and diabetes may contribute more to mortality at younger ages,28 which would exacerbate the burden of illness among the young in LMICs. Further, if illness severity and the quality of prior medical management of pre-existing health conditions change mortality risk for the same diagnosis across contexts, applying HRs from England may understate mortality risk in India. Finally, hazard ratios which are not conditioned on infection may reflect infection risk in addition to disease severity risk and thus may not ...

    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.

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  3. Version published to 10.1101/2020.07.05.20140343v1 on medRxiv