The number of “excess deaths” registered by the Civil Registration System (CRS) in Tamil Nadu ever since the COVID-19 pandemic hit (from April 2020 to May 2021) is 6.2 times the official reported figure of 24,232 deaths. But in data accessed by The Hindu, the CRS recorded the number of deaths due to COVID-19 as 35,807 (14,652 in 2020 and 21,155 till May 2021), possibly adjusted over the months, an increase of nearly 47% in the deaths reported in the State health bulletin.
After omitting deaths due to causal factors unrelated to COVID-19, it is estimated that there were 1,61,581 excess deaths amounting to an undercount factor of 4.5 for the pandemic period — April 2020 to May 2021. In the second wave (April and May 2021) alone, the CRS registered 20,158 COVID-19 deaths, but we found that this was undercounted by a factor of 3, as the estimated excess deaths for this period were 60,773. The undercount factor for 2021 was 3.7.
Excess deaths in Tamil Nadu were calculated based on the month-wise number of deaths registered by the CRS from January 2018 to May 2021, besides utilising year-wise data from 2015.
Data accessed by The Hindu included cause-wise deaths registered in the CRS and medically certified deaths data (close to 45% of deaths were medically certified in the State as of latest data from 2019).
Causes such as heart disease and heart attacks, diabetes mellitus, unclassified, liver disease, bronchitis, pneumonia, cerebro-vascular issues constituted more than 80% of all deaths registered in 2020 and 2021, increasing from 72% and 73% in 2018 and 2019, suggesting that there was a fall in other causes overall compared to COVID-related or similar causality. Deaths due to cancer for example fell from 3% in 2018 and 2019 to 2.6% and 1.9% in 2020 and 2021 so far. The inability to access standard care for chronic conditions over a period of two years, it is suspected, could have led to higher mortality over this period among patients who had co-morbidities.
Gender ratio
Gender-wise, the proportion for male and female people among the dead remained the same (60%-40%) before (2018 and 2019) and during the pandemic years (2020 and 2021).
Both the undercount figures, adjusted for unrelated causal factors and registered death count (3.7, 3) and unadjusted (6.5, 5.3) numbers, for 2021 and the second wave (April 2021-May 2021) respectively are, however, much less than the corresponding figures from CRS data estimated for Madhya Pradesh and Andhra Pradesh (42 and 43, 34 and 31.4) recently. The unadjusted figure for Tamil Nadu was also similar to that of Karnataka — an estimated five times the actual death count for 2021. But these figures were still higher than the undercount estimated by the WHO for COVID-19 deaths globally — two to three times and more than 1.6 times for the U.S., Latin America and Europe in 2020.
Also read | Interpreting deaths in Chennai
Raw data from the Greater Chennai Corporation on deaths show that the undercount factors (based on official deaths and not CRS adjusted figures) were 5.6, 4.1, 5.6 compared to 6.5, 6.2 and 5.3 for the State for the periods April 2020-May 2021, January to May 2021 and April-May 2021 respectively. This suggests that undercounting was lower in the city limits overall, but improvements in registration in the rest of the State led to similar numbers during the second wave.
Excess death calculations were recently estimated for Madhya Pradesh and Andhra Pradesh (Scroll), Karnataka (The Newsminute) based on CRS data and deaths registered in municipal corporations in Hyderabad, Kolkata and Chennai (The Hindu) recently.
The inclusion of causal data along with the CRS registrations in Tamil Nadu helped in estimating the excess deaths in a granular manner. Releasing CRS data on death registrations along with causal factors nation-wide from all States will go a long way in estimating the actual number of deaths due to the pandemic in the country and measure the true impact of COVID-19.
Differences of opinion
“We need to understand that there are two different things at play — death certification, and medical certification of death. As far as registration of deaths, there is no major issue in the State. As far as medical certification goes, it is indeed an evolving process — driven by ICMR guidelines. But in many cases there have been differences of opinion about the underlying cause of death. For instance, doctors are conflicted whether a person had died due to complications from Parkinsonism, and has also tested positive for COVID-19. So medical certification is an evolving process, at best — guidelines are also shifting,” explains Health Secretary J. Radhakrishnan.
However, he adds that Tamil Nadu has an established mechanism of facilitating death audit, and a State-level reconciliation committee constituted for the express purpose of reconciling death data (COVID-related). “The government has been clear about revealing the proper figures — whether it is related to deaths or positive cases. Reconciliation has been an important part, we even indicate such deaths in the daily bulletin we put out. In the field, health staff have also been overwhelmed, which might result in a lag in counting/certifying deaths,” Dr. Radhakrishnan said.
(With inputs from Vignesh Radhakrishnan)