Why Audits, Reconciled Death Data Are Still Missing COVID Deaths
Chennai: On the night of June 15, the Brihanmumbai Municipal Corporation (BMC) issued its usual COVID-19 evening bulletin and tweet for Mumbai, then the Indian city with the most COVID-19 cases. The city’s COVID-19 death toll was 2,248, including the 58 new deaths, it announced. By the next morning, the numbers had jumped by about 40%--on June 16, the BMC’s evening bulletin announced 3,165 deaths, including 862 older but previously unreported deaths.
Halfway across the country, a similar story played out in Delhi, currently India’s worst-hit city. On June 15, Delhi’s state health bulletin reported 1,400 deaths including 73 that day. On June 16, there were 93 new COVID-19 deaths but the cumulative total had grown by one-third to 1,837, the bulletin showed.
These increases came about as a result of “death data reconciliation” exercises that at least three states--Maharashtra, Delhi and Tamil Nadu--have undertaken, in order to fix lags, misreporting and other errors in the reporting of COVID-19 deaths by hospitals and municipal corporations. A detailed examination of the COVID-19 deaths data that reach state governments--and in turn, the central government and the public--reveals both areas of concern and hope, as per former health administrators and experts.
Death audit committees’ fuzzy workings
The protocol on recording deaths during the current pandemic comes from the Indian Council of Medical Research (ICMR). It clearly lays down (see box) under what circumstances a death ought to be certified as a COVID-19 death.
However, on the ground, things play out quite differently. Some states such as Tamil Nadu and Delhi have constituted state-level “Death Audit Committees”, which go through the COVID-19 death certificates to determine how many of these are “real” COVID-19 deaths, before announcing a final number daily. Mumbai has death committees at the BMC level, the Mumbai Metropolitan Region and at the state government level.
From their perspective, the committees are essential to reconcile inconsistencies in the data. “We are dealing with municipal corporations governed by a party opposed to ours which is invested in inflating their numbers,” said an advisor to the Delhi government who liaises with the death audit committee, on the condition of anonymity. “The major hospitals are overworked and also not working with us to report the data quickly. So, the committee is essential to scan the certificates and determine which of them really are COVID-19 deaths.”
As with Delhi, the workings of these committees are political and contested in other states too. Following weeks of back-and-forth with the central government over the mode of reporting deaths and the final numbers, West Bengal wound up its Death Audit Committee. In other states, the committees might be less controversial, but they do not readily share data, as we found.
IndiaSpend spoke to members of death audit committees in four states (Maharashtra, Tamil Nadu, Delhi and Uttar Pradesh) and not one agreed to share details of how many cases had come before them and how many they had certified as COVID-19 deaths. Tamil Nadu shot into national headlines after a committee constituted by the state’s Directorate of Public Health examined Chennai city corporation records and found that 236 death certificates that mentioned COVID-19 had not been notified to the state government as COVID-19 deaths. Those deaths had not been automatically added to the city’s or the state’s COVID-19 tally. The process of reconciliation was still on and the state government had set up a nine-member committee to audit all COVID-19 deaths, M. Jagadeesan, Chennai’s Chief Health Officer, told IndiaSpend on June 23.
A similar situation played out in Mumbai: 347 COVID-positive persons undergoing treatment had died, but the BMC labelled them as non-COVID deaths in violation of ICMR protocol. “This happened with the Mumbai district Death Audit Committee. We have asked for all deaths of COVID-19 positive persons except for accidental deaths to be counted as COVID-19 deaths. That reconciliation process is ongoing,” said Avinash Supe, the former dean of Mumbai’s King Edward Memorial (KEM) Hospital who heads a Maharashtra government-appointed committee to audit Mumbai’s deaths.
Ezhilan Naganathan is a consultant physician and diabetologist with Kauvery Hospital in Chennai. He has been attending to COVID-19 patients every day for more than two months. “There is no transparency in the state government’s decisions about which deaths are being declared as COVID-19 deaths. From what we are seeing in the city, we have reason to believe that numbers are being suppressed,” he said.
Prabhat Jha, a professor of global health and epidemiology at the University of Toronto, is a lead investigator of the Million Death Study in India, a project that estimated the ‘true’ causes of mortality in a million households where a death had occurred, using “verbal autopsies”. “During an epidemic, you want to err on the side of overestimating deaths, not underestimating them,” said Jha, adding that there were increasing findings that COVID-19 did not just cause respiratory but also vascular and other deaths. “That’s an argument for sticking to the most liberal definition of a COVID death. If it says anywhere COVID-19 or suspected COVID-19, it should be declared as a COVID death. [This] in turn should mean that the guidelines for each of the state adjudicators or auditors should be unambiguous,” said Jha, who is also the founder and executive director of the Centre for Global Health Research at Unity Health Toronto.
The missing dead
Then there are all those deaths that never make it to the committee.
“At the moment, deaths that take place at home and get a certificate from the local GP [general physician] don’t make it to our committee,” said the advisor to the Delhi government. “Most of these private practitioners, anyway, would not write ‘Suspected COVID-19’ on the death certificate because of the stigma, quarantine and the whole process associated with it.” However, at cremation and burial grounds, some of these suspected cases would be given ‘COVID-19 funerals’ to minimise exposure, sometimes even in deaths not caused by COVID-19, he said. This explains why the suspected COVID-19 death data from burial and cremation grounds was higher than the official toll, he added.
Officials in Mumbai, Delhi and Chennai told IndiaSpend that they had not yet certified any deaths under U07.2, the ICD-10 code for suspected or probable COVID-19 deaths, despite the ICMR guidelines. “All COVID-19 deaths in Delhi are in big institutions only,” a member of the state’s Death Audit Committee insisted. “We have received some forms with U07.2 but we have not yet certified any suspected COVID-19 deaths,” said Chennai’s Jagadeesan. Meanwhile in Mumbai, “all the death certificates right now are with confirmed COVID-19 test and issued by hospitals,” said Rajesh Dere, head of forensics at Mumbai’s Lokmanya Tilak Municipal General Hospital. “We have only been tasked with looking at death reports of those who tested positive for COVID-19,” said Supe, who heads Maharashtra’s Death Audit Committee for Mumbai. The committee had not been asked to even look at suspected or probable COVID-19 cases.
This means that India might be missing many deaths among people who did not or could not get a COVID test. In New York City, for instance, one-fifth of the total deaths are attributed to suspected COVID-19 cases.
Across the world, COVID-19 deaths are being underreported for different reasons, and such audit panels are reconciling the data to provide better estimates, said Jha. “Provided the audit committees are following the WHO procedures and reporting them as per WHO guidelines, COVID-19 deaths need not have a confirmed diagnosis. It is actually a mistake as we have learnt in the Netherlands (which first only reported RT-PCR confirmed deaths and then realised they were missing 20-30% of deaths), France, the UK and belatedly in Canada’s Quebec province,” Jha said. The missed deaths originate in nursing and elder care centres in some countries, and from home deaths in others, Jha said, and the reconciled numbers came as a result of adding these in, and from excess mortality estimates.
“I suspect what’s going on in India is a combination of things: One, the systems followed by the state and hospitals to compile data are different. The second concern is if they are reporting only PCR-confirmed deaths, then they are certainly missing some deaths because not all COVID-19 deaths get tested,” he added.
Towards an Independent audit
In addition to COVID-positive persons clearly dying of respiratory failure in large hospitals, the government should be proactively seeking out those who die at home or outside hospitals, said Naganathan, the consultant physician and diabetologist from Chennai. “In a pandemic, any sudden death of an elderly person or patient with known comorbidities should be investigated, but this is not happening. They are conducting autopsies in medico-legal cases only,” he said, adding, “When patients come to casualty or emergency [wards] in government hospitals, samples are not being taken even if they demonstrate COVID-19 symptoms... only a tentative diagnosis is being given. The government should take another look at all these death certificates.”
The ICMR should come out with clear protocols about testing dead bodies, Dere said. “For example, if they say all bodies should be tested for COVID-19, then we will know clearly what to do,” he said.
“Given India’s low testing rates, non-tested deaths are definitely an area of concern. Remember, we are talking about a situation when only 15-20% of deaths at the best of times are medically certified,” said Keshav Desiraju, India’s former health secretary. What is being reported is from the big cities; in rural areas, death certification is even rarer and the administrative structure for reporting deaths is “messy”, added Desiraju.
So, how can states best audit the data they are receiving to make sure deaths are being accurately reported? The Death Audit Committee is a good arrangement, said Desiraju. Pandemic or not, the death certificate rests on the judgment of the doctor issuing it and that needs oversight, he said. The problem is the current environment. “We suspect now that these committees might conceal some deaths because it has become very political. The occurrence of deaths is seen as a lack of governance. I am sure there is some sort of informal directive that if you can possibly disguise these deaths... do so,” he said.
While the committee is essential, and the fact that it is operating under pressures is also known, the next step should be to empower these committees, said T. Sundararaman, former director of the National Health Systems Resource Centre, a government body that worked as a think-tank for the National Health Mission. Sundararaman is now global coordinator of the People’s Health Movement advocacy group and adjunct faculty in the Department of Humanities and Social Sciences at the Indian Institute of Technology-Madras.
“The committee should have external members from academia or civil society. Since it is performing an audit, it requires some separation from the health establishment. There should be independent committee members who would be willing to exercise their powers, call data and documents on record, see tallies, ask for samples and compare these with recorded deaths,” he suggested. “In the short run, state governments might think they are saving themselves by suppressing the data. But in the long run, they would be the ones who would have to pay, especially when the disease spreads to the districts,” he warned.
This is the second part of an ongoing investigation into India’s COVID-19 mortality. You can read the first part here.
(Rukmini S. is an independent journalist based in Chennai.)
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