True Covid toll 14.9mn,India count 4.7mn: WHO

At least 4

At least 4.7 million people died in India due to Covid-19 in 2020 and 2021, the World Health Organization said on Thursday, releasing new estimates of the pandemic’s true death toll which, it said, came to about 15 million fatalities worldwide, close to three times the official data released by countries in this period.

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The WHO’s estimate of deaths in India is close to 10 times the 481,000 fatalities recorded officially till the end of 2021. The Indian government issued a rebuttal, objecting to WHO’s assessments by saying that the “process, methodology and outcome” were flawed on several counts.

“These sobering data not only point to the impact of the pandemic but also to the need for all countries to invest in more resilient health systems that can sustain essential health services during crises, including stronger health information systems,” said Dr Tedros Adhanom Ghebreyesus, WHO director-general in a statement.

India, at 4.74 million estimated fatalities, was projected by WHO to have lost the most lives. The second highest projected fatalities was for Russia at 1,072,326, followed by Indonesia at 1,028,565 and the United States at 932,458.

In terms of deaths as percentage of population, India appeared to have fared better – it ranked 33, with 17.1 deaths per million people. Among large countries, Russia had the highest death toll – 36.7 deaths per million placing it on the fifth spot among WHO’s 194 countries. Other countries that fared worse than India included Mexico (24.2 deaths per million), Ukraine (22.7), Poland (20.8), South Africa (20), and Indonesia (18.7).

“We will continue to have consultations and address the concerns India has. And hopefully we can find a mutually acceptable solution,” said Samira Asma, the assistant director-general for Data, Analytics and Delivery for Impact at WHO, during the release of the report on Thursday.

In a statement issued simultaneously, the Indian government outlined four grounds on which it objected to WHO’s assessment: First, mathematical projections are unnecessary since India has a robust death registration system (the data for 2020 from this was released earlier this week); second, some of the source data was obtained from media reports; third, a base used for calculations was itself an estimation and “ignored actual data”; and fourth, there were flaws in WHO’s assumptions about how the disease spread across various parts of the country.

“…WHO has released the excess mortality estimates without adequately addressing India’s concerns,” the statement said.

On May 3, the Union home ministry published the official birth and death registration numbers for 2020, showing a 6.2% increase in the number of deaths recorded in the year compared to 2019 – or 474,806 in absolute terms.

According to WHO’s data, the number of excess deaths in the country in the same period was 832,531. To be sure, the worst of the Covid-19’s impact in India was felt the following year in 2021 when the Delta variant tore through the country, inundating hospitals with more patients than they could handle and triggering an oxygen supply crisis.

Many deaths were estimated to have taken place outside of hospitals, potentially leaving them out of the official statistics – a phenomenon seen in most countries. In order to estimate this, epidemiologists and WHO used a measure known as all-cause excess mortality. The premise for this is that by determining deaths that take place on average, and comparing it with the number of deaths that took place during the pandemic years, can yield excess mortality that can be attributed to Covid-19, whether or not they were recorded officially.

The WHO estimate showed that till August 2020, a period when the country spent most of its pandemic days under a hard lockdown that began in late March, there were approximately 62,000 fewer deaths in India than previous years.

Deaths began to rise from September, 2020, coinciding with the first waves in many states. More than half of the excess deaths, at 2.7 million, took place during the peak of the second nationwide wave in the months of April, May and June in 2021.

The report said most of the excess deaths (84%) are estimated to be concentrated in South-East Asia, Europe, and the Americas. Some 68% of excess deaths are concentrated in just 10 countries globally, it added.

Experts said WHO’s estimates mean that India alone accounts for nearly half of the unreported Covid-19 deaths. “India’s missing deaths of about 4.2 million (that is, 4.7million excess deaths of which 0.5 million were reported) accounts for about half of the global missing deaths at 9 million 15 million is estimated to be the true toll while 6 million are recorded),” said Prabhat Jha, epidemiologist and founding director of the Canada-based Centre for Global Health Research. Jha is also a member of the WHO’s Technical Advisory Group (TAG) of the WHO Covid-19 Mortality Assessment Group.

Jha said even the data released by the government earlier this week appears to support the new estimates, if excess deaths are calculated by taking an average of deaths recorded in past years. “The 2020 deaths should be compared against an average of previous years, not just 2019. So, compared to 2018-19, there were 0.82mn excess deaths [in 2020]. The WHO’s model for 2020 is 0.83mn and our estimate based on household polling but only for 8 months is 0.59mn. So, the CRS (civil registration system) report confirms WHO’s estimate for 2020,” he said, adding: “Data by week or month would be key to release to determine if the 0.82million excess occurred during pandemic weeks. The government should release these”.

Jha’s team made its own assessment of excess deaths, putting India’s true toll at 3.2 million between June 2020 and July 2021 in a study published in the journal Science in January this year.

In a paper released on March 29, TAG said the group uses different methodologies for three groups of countries: those that have “near-complete” data on all-cause mortality, those that have partial data (of some regions, or for some periods), and those that did not have official national all-cause mortality data.

Detailing the methodology, group said for countries in the second tier, which included India, researchers constructed different statistical models to estimate country-specific death tolls. Other than India, this list of nations included Argentina, China, Indonesia and Turkey.

“For India we have data from up to 17 states and union territories... over the pandemic period (out of 36), but this number varies by month,” the paper said. “For India, we use a variety of sources for registered number of deaths at the state and Union territory-level. The information was either reported directly by the states through official reports and automatic vital registration, or by journalists who obtained death registration information through Right To Information requests,” the paper, released on March 29, said.

The researchers mentioned limitations in their approach in the summary findings, including one that appeared to agree with the government’s criticism on one country: “If, over all (local) regions, there are significant changes in the proportions of deaths in the regions as compared to the national total, or large changes in the populations within the regions over time, then the approach will be imprecise”.

But, they also added: “We have carried out sensitivity (for example, we remove different subsets of states and run the model) and cross-validation analyses” to address these shortcomings.