While data from the Health Ministry of India suggest that the national recovery rate has reached 92% and the case fatality rate is down to 1·49%, experts have time and again questioned shortcomings and lack of clarity and classification of COVID-19 deaths in India.

With the COVID-19 toll soaring across India, there has been a major debate about India’s reported missing COVID-19 deaths. As per several reports, the country of 1.5 billion people is underreporting the COVID-19 death and thus presenting a low fatality rate picture in the public domain.

At the time of filing this story, India stands at 8.3 million COVID-19 cases with 123,611 deaths. The total number of recovered patients stands at 7.65 million, and if we calculate the percentage, the mortality rate is 1.49%, while the national recovery rate stands at 92.09%, according to the Union Health Ministry’s data.

However, experts have questioned shortcomings and lack of clarity in vital registration, testing practices, and classification of COVID-19 deaths in India.

Though the health ministry maintains that the steady rise in recoveries has ensured a low case fatality rate, Dr. Murad Banaji, a renowned mathematician with an interest in disease modelling at Middlesex University London points out that the recovery rate is not a useful measure of the effectiveness of strategies to combat COVID-19.

According to him, “Everyone knows that most people recover, and also know typically how long this takes! In fact, in a long-running epidemic, we expect the recovery rate to be high, regardless of whether the epidemic has been well-handled or not,” he said.

While there are a number of news reports on the undercounting of COVID-deaths in India and in some cases, on a very large scale, there are also discrepancies in the data reported so far. For example dramatic differences in fatality rates between states such as Chhattisgarh and Bihar which appear to be badly hit but have reported only 2,266 and 1,108 COVID-19 deaths, respectively.

Also, the findings of the first national population-based serosurvey conducted by the Indian Council of Medical Research (ICMR) have raised several questions about the coronavirus data reporting in India. ICMR researchers conducted the survey from May 11 to June 4 — across 400 districts — most of them in rural India, to gauge the spread of the infection.

“The ICMR paper on the first national serosurvey implicitly acknowledges underreporting as the paper itself suggests that only fatalities for the high case-load stratum where “death reporting was more robust” should be regarded as reliable,” he said.

Banaji further added that the paper did not even calculate the fatality rates using all the data available to them. “When we calculate, the fatality rates are almost three times the raw values that can be calculated from the data in the paper. And ICMR seems to be acknowledging that up to two-thirds of fatalities had not been reported by early June,” he added.

In fact, the report published in the Indian Journal of Medical Research on September 10 raised more questions than offering help in mitigating the pandemic. Besides, what’s worth highlighting from the findings of the report is the fact that 0.73% of adults in India were exposed to the novel coronavirus, translating to 64 lakh infections by early May. This is in stark contrast to India’s cumulative caseload on May 7 which stood at 52,592.

Thus, there is a huge gap between ICMR and the Ministry of Health & Family Welfare (MoHFW) numbers. This is another reason why experts are raising doubts about the authenticity of data reporting of COVID-19 in India. Also, it is still unclear how suspected or probable COVID-19-attributable deaths are being included in mortality estimates.

“There are big differences between states — and even between different districts in the same state — in both testing strategies and death reporting,” said Banaji who is of the view that most Indian states are not reporting suspected COVID deaths, and therefore, the reported death figures in such a scenario depend heavily on the extent of testing.

“We should expect that more deaths will be missed when testing is low – there is a higher likelihood of a COVID patient dying without being tested,” he added.

If we talk about possible fault lines, there are a variety of different ways in which deaths can go missing. “For example, some states/districts choose explicitly — and wrongly — to exclude most deaths of COVID-19 patients with comorbidities or data may get lost in transit between different levels of government which appears to have occurred in Tamil Nadu, or suspected COVID-19 fatalities may not have been tested at all,” explained Banaji.

Meanwhile, experts have also expressed their concern about the underreporting of COVID-19 deaths in India in the latest Lancet report.

“Of course there is undercounting as we have weak health surveillance systems,” said Oommen C Kurian of the Observer Research Foundation, a Delhi-based think tank. “But the question is about the scale of undercounting.”

The report also highlights that more than 65% of the total COVID-19 deaths reported in India so far are from just four states, Maharashtra, Tamil Nadu, Karnataka, and Delhi.

Also, it has been reported that two states, Gujarat and Telangana, appear to have undercounted heavily. In Vadodara, Gujarat, even as the caseload leaped by a whopping 329%, the number of deaths grew by just 49% in the last two months. Further, there have been reported discrepancies between the official toll from the virus and counts from crematoria and burial grounds in some cities which points towards inconsistencies in data being collected and reported in India.

Public pressure about alleged undercounting did push a few states to review their COVID-19 mortality data. As a result, several states added ‘missing’ deaths later. For example, Tamil Nadu has added backlogs of 400-plus deaths. So did Maharashtra. Even West Bengal, which earlier used to exclude all deaths due to comorbidities from COVID deaths has finally started adding it to their tally.

But, if we go by Banaji’s own estimates, which are based on modelling and tracking fatality rates, if not more, at least 2 – 3 COVID fatalities have gone unrecorded for each recorded fatality in the country. “There is certainly a huge variation in this figure between states. And where there is serosurvey data, we have a more reliable indication of the number of “missing deaths” – deaths which we would expect to see based on infection levels and age structure, but which do not appear in the figures,” he added.

And even though experts do expect India to have a considerably lower fatality rate than the European and North American countries because of the young population, yet the low fatality rate that we are seeing in India cannot be explained by age alone. “Underreporting clearly plays a major part,” said Banaji.