Assessing mortality registration in Kerala: the MARANAM study

Analysis of daily COVID-19 death bulletin data during the first two waves of the COVID-19 pandemic in Thiruvananthapuram district, Kerala, India

Context

Coronavirus disease 2019 (COVID-19) mortality trends can help discern the pattern of outbreak evolution and systemic responses.

Aim

This study aimed to explore patterns of COVID-19 deaths in Thiruvananthapuram district from 31 March 2020 to 31 December 2021.

Setting and Design

Secondary data analysis of COVID-19 deaths in Thiruvananthapuram district was performed.

Materials and Methods

Mortality data were obtained from the district COVID-19 control room, and deaths in the first and second waves of COVID-19 were compared.

Statistical Analysis

We summarised data as proportions and medians with the inter-quartile range (IQR) and performed Chi-square tests to make comparisons wherever applicable.

Results

As on 31 December 2021, 4587 COVID-19 deaths were reported in Thiruvananthapuram district, with a case fatality rate of 0.91%. We observed high mortality among older persons (66.7%) and men (56.6%). The leading cause of death was bronchopneumonia (60.6%). The majority (88.5%) had co-morbidities, commonly diabetes mellitus (54.9%). The median interval from diagnosis to hospitalisation was 4 days (IQR 2-7), and that from hospitalisation to death was 2 days (IQR 0-6). The deaths reported during the second wave were four times higher than those of the first wave with a higher proportion of deaths in the absence of co-morbidities (p < 0.001). The majority of the deceased were unvaccinated. Ecological analysis with vaccine coverage data indicated 5.4 times higher mortality among unvaccinated than those who received two vaccine doses.

Conclusions

The presence of co-morbidities, an unvaccinated status, and delay in hospitalisation were important reasons for COVID-19 deaths. Primary level health providers can potentially help sustaining vaccination, expeditious referral, and monitoring of COVID-19 patients.

Can administrative health data be used to estimate population level birth and child mortality estimates? A comparison of India's Health Information Management System data with nationally representative survey data

•HMIS covers a large proportion of births, but a smaller fraction of child deaths compared to estimates from surveys.•Birth and death coverage in HMIS, while incomplete, has been improving nationally and for many states.•States that have improved HMIS reporting, should be studied for replicating best practices.•HMIS can provide signals for real time policy decisions, if used with due consideration of its limitations.•Including patient socioeconomic and demographic traits in HMIS, could further bolster its utility in population health.

Population perspectives and demographic methods to strengthen CRVS systems: introduction

Civil registration and vital statistics (CRVS) systems and legal identity systems have become increasingly recognized as catalytic both for inclusive development and for monitoring population dynamics spanning the entire life course. Population scientists have a long history of contributing to the strengthening of CRVS and legal identity systems and of using vital registration data to understand population and development dynamics. This paper provides an overview of the Genus thematic series on CRVS systems. The series spans 11 research articles that document new insights on the registration of births, marriages, separations/divorces, deaths and legal residency. This introductory article to the series reviews the importance of population perspectives and demographic methods in strengthening CRVS systems and improving our understanding of population dynamics across the lifecourse. The paper highlights the major contributions from this thematic series and discusses emerging challenges and future research directions on CRVS systems for the population science community.

An alternative estimation of the death toll of the Covid-19 pandemic in India

The absence of reliable registration of Covid-19 deaths in India has prevented proper assessment and monitoring of the coronavirus pandemic. In addition, India's relatively young age structure tends to conceal the severity of Covid-19 mortality, which is concentrated in older age groups. In this paper, we present four different demographic samples of Indian populations for which we have information on both their demographic structures and death outcomes. We show that we can model the age distribution of Covid-19 mortality in India and use this modeling to estimate Covid-19 mortality in the country. Our findings point to a death toll of approximately 3.2-3.7 million persons by early November 2021. Once India's age structure is factored in, these figures correspond to one of the most severe cases of Covid-19 mortality in the world. India has recorded after February 2021 the second outbreak of coronavirus that has affected the entire country. The accuracy of official statistics of Covid-19 mortality has been questioned, and the real number of Covid-19 deaths is thought to be several times higher than reported. In this paper, we assembled four independent population samples to model and estimate the level of Covid-19 mortality in India. We first used a population sample with the age and sex of Covid-19 victims to develop a Gompertz model of Covid-19 mortality in India. We applied and adjusted this mortality model on two other national population samples after factoring in the demographic characteristics of these samples. We finally derive from these samples the most reasonable estimate of Covid-19 mortality level in India and confirm this result using a fourth population sample. Our findings point to a death toll of about 3.2-3.7 million persons by late May 2021. This is by far the largest number of Covid-19 deaths in the world. Once standardized for age and sex structure, India's Covid-19 mortality rate is above Brazil and the USA. Our analysis shows that existing population samples allow an alternative estimation of deaths due to Covid-19 in India. The results imply that only one out of 7-8 deaths appear to have been recorded as a Covid-19 death in India. The estimates also point to a very high Covid-19 mortality rate, which is even higher after age and sex standardization. The magnitude of the pandemic in India requires immediate attention. In the absence of effective remedies, this calls for a strong response based on a combination of non-pharmaceutical interventions and the scale-up of vaccination to make them accessible to all, with an improved surveillance system to monitor the progression of the pandemic and its spread across India's regions and social groups.