Estimates of pandemic excess mortality in India based on civil registration data

Banaji, M.; Gupta, A.

Background: The COVID-19 pandemic has had large impacts on population health. These impacts are less well understood in low-and middle-income countries, where mortality surveillance before the pandemic was patchy. Although limited all-cause mortality data are available in India, interpreting this data remains a challenge. Objective: We use existing data on all-cause mortality from civil registration systems of twelve Indian states comprising around 60% of the national population to understand the scale and timing of excess deaths in India during the COVID-19 pandemic. Methods: We characterize the available data, discuss the various reasons why these data are incomplete, and estimate the extent of coverage in the data. Comparing the pandemic period to 2019, we estimate excess mortality in twelve Indian states, and extrapolate our estimates to the rest of India. We explore sensitivity of the estimates to various assumptions, and present optimistic and pessimistic scenarios along with our central estimates. Results: For the 12 states with available all-cause mortality data, we document an increase of 28% in deaths during April 2020-May 2021 relative to expectations from 2019. This level of increase in mortality, if it applies nationally, would imply 2.8-2.9 million excess deaths. More limited data from June 2021 increases national estimates of excess deaths during April 2020-June 2021 to 3.8 million. With more optimistic or pessimistic assumptions, excess deaths during this period could credibly lie between 2.8 million and 5.2 million. We find that the scale of estimated excess deaths is broadly consistent with expectations based on seroprevalence data and international data on COVID-19 fatality rates. Moreover, there is a strong association between the timing of excess deaths, and of recorded COVID-19 deaths. Contribution: We show that the surveillance of pandemic mortality in India has been extremely poor, with around 8-10 times as many excess deaths as officially recorded COVID-19 deaths. Our findings highlight the utility of all-cause mortality data, as well as the significant challenges in interpreting such data from LMICs. These data reveal that India is among the countries most severely impacted by the pandemic. It is likely that in absolute terms India has seen the highest number of pandemic excess deaths of any country in the world.