New Delhi: Last Wednesday, Darur Kattimani Dharmanna, an 84-year-old resident of Davanagere city in Karnataka, was going about his chores when he began showing the first symptoms of Covid-19. Dharmanna experienced mild cold, fever and a runny stomach. The octogenarian was admitted to Bapuji hospital in the city the same day after his virus test came out positive.
But his oxygen levels depleted quickly and despite an early admission and treatment, he passed away within six days on September 28 due to multiple organ failure.
Dharmanna’s grandson Gowd Kiran Kumar said his grandmother, Darur Rajamma, 76, also tested positive for coronavirus, although she remained asymptomatic throughout. Kumar’s grandparents live with his maternal uncle and his wife, who is a public health officer. She had quarantined herself a week before Kumar’s grandparents got the infection.
“Even at 84, my grandfather was fit, active and did not have any serious health complications or disease. We expected him to easily live till 100. This has been a rude awakening and we must all realise that if we don’t continue to be alert, many homes in the country may lose their elderly,” Kiran Kumar said.
Dharmanna’s tryst with the coronavirus infection and eventual death is just one instance of the 1,00,000 Covid-19 deaths reported in the country officially. It has taken India over six and a half months since the first death to reach this unfortunate milestone. The rise in fatalities though has been rapid since August and particularly high in September.
The country recorded over 1,000 deaths per day through all of September, except for one day, September 28, when 776 deaths were reported. As a result, deaths that were reported in September (33,390), accounted for over a third of all deaths in the country.
The mortality caused by novel coronavirus and the issues surrounding it have been debated hotly over the nine months of the pandemic in India. Doctors and healthcare workers have grappled with the different ways in which the disease causes death while the methods adopted by some states to record these deaths have also raised questions of under-reporting.
India is second in the world, behind United States of America, in terms of cumulative tally of Coronavirus infections (63,12,584) and is currently reporting the highest number of daily cases in the world per day. The country’s low-mortality rate, though, has made it stand out among countries with a high cumulative and active case load. As on Thursday, India’s case fatality ratio (the proportion of individuals diagnosed with a disease who die from that disease) was 1.56 per cent.
Experts suggest that its infection fatality ratio (the proportion of deaths among all infected individuals) may be even lesser. With the absence of a large-scale studies on epidemiological dynamics of infections and mortality of Covid-19, the jury is still out on the reasons behind low-mortality. Experts though have offered some plausible explanations.
Jayaprakash Muliyil, epidemiologist and former principal of Christian Medical College, Vellore, argued that Vitamin D, lower obesity and undercounting might be some of the potential reasons for low-mortality. Vitamin D plays a crucial role in the body’s immunological response against infectious diseases in general and people in tropical countries like India get plenty of it, he said, unlike the western countries. “Vitamin D is an important substances which initiates immunological response and our obesity levels are much more less than in the USA, these factors are in favour of India, but these are certainly not the complete answers the question of low-mortality due to Covid-19,” Muliyil said.
Dr.Giridhar R Babu, an epidemiologist with the Public Health Foundation of India think-tank said that low-mortality rates have been seen in the entire South Asia region and demography seems to have played an important role in India. “The main reason seems to be younger age of Indians, in addition, as usual, most low and middle income countries have problems of under-reporting, but not so high that our overall estimates will be way beyond what we are seeing,” Babu said.
Under-reporting of deaths
With the emergence of a new infectious disease, it was crucial for the state health departments and central government to follow a fresh protocol to accurately and adequately capture deaths occurring due to Covid-19. The Indian Council of Medical Research (ICMR) rolled out detailed guidelines to record Covid-19 related deaths in India. The guidelines were explicit in stating that prior co-morbid conditions such as asthma and diabetes were not be considered as underlying cause of death as they may have not directly caused death due to Covid-19. It also specified that mode of death, such as organ failure and heart failure, too, were not to be considered as cause of death.
Howevr, the record of some states in following these guidelines has not been up to the mark. At different points during the pandemic, there have been instances in Maharashtra, Gujarat, Madhya Pradesh and Assam, where clear cases of Covid-19 deaths were not counted in the official records.
Under-reporting of Covid-19 deaths is also possible because official medical certification of deaths is generally low in India. As per the central government’s ‘Medical Certification Cause of Death Report, 2017’ published in 2019, only 22 per cent of deaths were medically certified in the country.
Dr Avinash Supe, who is part of the deaths audit panel formed by Maharashtra government, said there were some issues regarding recording of deaths in April and May, which were rectified and data reconciled data on deaths. “Any patient who has died after testing positive for Covid-19 is considered a Covid-19 death except in cases of suicide, homicide or burns,” he said.
“Under normal circumstances too, we have a poor system of capturing disease events. What we are counting now are deaths among Covid-19 positive persons. But if you see the first national sero-survey, it said that we missed 80-120 cases per detected coronavirus case. So for over six million cases we have now, the infections might be over 450 million. Taking all this account, for the known denominator, the death rate is low,” said Dr T Jacob John, a veteran virologist.
Dr Babu said there would have to be a reconciliation of deaths happening due to Covid-19 and other deaths that are recorded. “A reconciliation exercise has to be done at the level of urban local bodies of the deaths reported at deaths recorded in the medical system and those recorded in as part of civil registrations,” he said.
Lessons learnt so far
Throughout the pandemic, Maharashtra has accounted for the most cases (13.84 lakh) and Covid-19 deaths (36,662). But the state’s public health officials have also learnt valuable lessons from managing the thousands of infections and even from those who have departed due to Covid-19. Dr Supe explained that in Maharashtra, the number of cases grew rapidly compared to the rest of India and the infection spread from Mumbai and Pune to other regions. Dr Supe feels the initial mystery of the disease and the dangers it posed were not well understood and the burden on health system was immense.
“Initially, the mortality rate was high due to late detection of cases and delayed admissions. There is improvement in that area but the stigma of the disease persists. We have noticed in Mumbai that prior co-morbid conditions are playing a big role in mortality. There is a high incidence of diabetes and hypertension in the city and these conditions are complicated by the Covid-19 disease. The mortality rate is likely to remain between 2-3 per cent due to these conditions in the population,” Dr Supe said.
Dr T Jacob John felt that by and large, the steps taken by doctors and medical fraternity at their own level were more effective than what the government did. “The government should have issued clinical guidelines through Medical Council of India and not ICMR. The chief efforts to curb mortality have been driven by the medical fraternity. By consulting between themselves, helping each and making decisions on their own, the fraternity took steps to prevent Covid-19 deaths,” Dr.John said.
Meanwhile, talking of the experience of his family, Kiran Kumar said that people need to stop being casual about the disease. “It is a peculiar disease because some get severely ill, some don’t develop any disease. The younger generation needs to consciously protect themselves and the elderly.”