The many challenges in estimating deaths

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 The many challenges in estimating deaths

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  • Two arguments: 
    1. The total number of deaths caused by Covid is debatable and a challenge to determine accurately. Official number reported on August 26 was 59,449 which is believed to be way below the real number. Two scientists multiplied this number by 5 (since about 21% of all registered deaths are medically certified) and provided an estimate which has also been questioned.
    2. Is there merit in making data about Covid-19 related deaths public? 
  • Urgency of the need of the estimate: 
    1. It helps get a sense of the magnitude of the burden but this number alone cannot inform public health strategies.
    2. The infection rate is high and the number gest outdated fast.
    3. But the estimate is important and helps in being better prepared for estimations in the future.
  • Two pieces of info: a) Count of all deaths, b) Cause of death in all cases
  • Two kinds of challenges: a) System-related, b) Covid-specific issues
  • Three sources for cause of death: 
    1. Civil registration scheme: According to the 2018 report, a good 86% of all deaths were registered out of which 34% were through hospitals. But this source may not provide accurate information about the cause of death since it’s reported by a member of the family at the time of registration. 
    2. Medical certification cause of death (MCCD): According to the 2018 Office of the Registrar General of India (ORGI), 1.45 million or 21% of all deaths were medically certified. But MCCD primarily reports urban deaths and Covid-19 has largely affected urban areas till now where medical certification is better. There are also quality issues with death certification. 
    3. Sample registration system: This provides good quality mortality surveillance where all identified deaths are noted by a trained doctor using standard procedures. But this occurs for a small representative population of about 40,000 per year. Due to delays this information is not made public.
  • India-specific challenges in determining Covid-19 mortality:
    1. Covid-19 death registrations are far from accurate due to lockdowns, travel restrictions and tendency to hide deaths due to the stigma associated with Covid. These challenges will intensify as Covid-19 moves to rural areas. 
    2. There is delay in availability of data even after registration since most systems are not electronic. Thus ORGI 2020 data even if made public may not be very useful. 
  • Determining Covid-19 mortality is a challenge globally:
    1. Access and use of test availability is limited. Using clinical features to identify Covid-19 deaths in the absence of testing may not be accurate and hence result in miscalculation. 
    2. Identifying indirect deaths due to Covid-19 is also an issue. Societal and health system disruptions during the pandemic add to deaths from causes such as suicides, non-communicable diseases, tuberculosis, and even heart conditions in some cases if heart patients contract Covid-19. 
  • Covid-19 issues are similar to those of influenza: Reporting influenza-related deaths has also been a challenge. An estimate of 2009 swine flu deaths indicated real mortality was 15 times higher than globally reported cases. For years, influenza estimates have been determined using indirect modelling approach which provides a range, not a number. 
  • Excess mortality: This is the number of deaths above the expected during ‘normal’ times. First, expected number of deaths in ‘normal’ times using past mortality records are calculated and then 2020 mortality data is used to estimate the number of deaths beyond the number during ‘normal’ times. This approach includes direct and indirect deaths. Also, accident and pollution-linked deaths during lockdowns are lower than in ‘normal’ times. 
  • Summary: Estimating true Covid-19 mortality is a challenge due to various system-related and Covid-19 specific factors. System-related gaps have existed for a long time and should be fixed urgently. 
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