What Explains India’s Low COVID-19 Death Rate?

The number of diagnosed cases is not same as infected ones - not just in India but in many countries.

Updated
Coronavirus
5 min read
India's COVID-19 case fatality rate is 3.3%, lower than the global CFR.
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India, a country with the second largest population in the world has a case fatality of 3.2% as of 1 May according to the data released by the Union Health Ministry. Is this the impact of the hard lockdown measures? Or are we simply not reading the numbers right?
As of May 1
As of May 1
(Source: FIT)

Out of the nearly 40,000 confirmed cases, 1,301 people or 3.2% have died so far in India as of 3 May. The developed countries such as the US, UK, Italy and Spain, which are testing more than India, have a much higher CFR.

FIT reached out to experts to understand the low numbers. They point to a host of factors, including India's historically abysmal death reporting - only 22% deaths here are medically certified.

Low CFR Doesn't Mean Virus is Less Deadly

Since Case Fatality Rate (CFR) is calculated by dividing the number of deaths by the number of confirmed cases, it goes without saying, if, for the same numbers of confirmed cases, deaths increase, the CFR would be high and that would evidently become distressing news for many. But is that the only event which should alarm us? Unfortunately, no.

The first and foremost thing to understand is that the CFR is not the same as Infection Fatality Rate (IFR). CFR gives us the rate of the number of people dying out of the diagnosed cases and IFR gives us the rate of the number of people dying out of the infected people. The number of diagnosed cases is not same as infected - not just in India but in most countries.

This is simply because of the lack of testing globally. Some countries are indeed doing much better. India, however, has one of the lowest numbers of testing. The US test rate as of 1 May is 19,311 per million population, UK (13, 286), Italy (32, 735), Spain (31, 126) and India (654) according to the data collected by Statista.

Only around 3.5-4% percent of those who India tests yield into positive cases which again is lower than the US, UK, Italy and Spain.

Unless, we don't test more - both PCR and antibody tests - we will not know the severity of death rate.

A recent Financial Times analysis of 14 countries found that the fatality rate may have been 60 percent higher than the number reported.

Reasons Why India's CFR Could Be an Underestimation

Virus strain becoming more severe in some parts of the world due to mutation is an unproven theory as reported by FIT earlier.

An expert dealing with COVID-19 patients in Maharashtra who doesn't want his identity to be revealed told FIT, "I am not sure if the death rate is really low. From my experience, I can say it is exactly like what people must be experiencing in the US or UK."

He adds,

“We have a poor reporting system in our country. Many deaths go unreported. So if the person dies before the test is done, they will die as a suspected case but it will not be counted in the fatality rate. We don’t do postmortems for suspected COVID-19 patients. It’s not encouraged because it’s risky.”

There are some other crucial factors that could possibly lead to low fatality rate:

  • Deaths due to the coronavirus mostly take place after a few weeks of contracting the virus when the infection becomes severe, so the current number of deaths could actually be telling us the deaths for the earlier reported (At least 2-3 weeks ago) number of cases.

  • Many coronavirus related deaths - especially at home - are not reported or are reported as other kinds of deaths such as influenza-like illnesses. Medical experts from the COVID-19 hospitals tell us that when dead patients are brought to the hospital, they are not tested for COVID-19 even if there is a suspicion. Another doctor from Mumbai tell us that around 60-70 TB patients are visiting the hospitals with coronavirus like symptoms but it's hard to differentiate without testing more.

  • India's median age is 28, much lower than a country like Italy. Further, India has only 6% of people above the age of 65. The health ministry in early April had said, of the total tested cases, 47% are below age 40, 34% are between age 40 and 60 and 19% are above 60 years. The fact that India has more young population and is testing young more too, might be contributing to keeping the death rate low as it has already been established than the virus is more deadly for old generation - especially the ones with comorbidities.

  • Some experts believe that the weather conditions, humidity, universal BCG vaccination and resistance to many viral infections could be helping Indians dealing with coronavirus better. However, as reported by us earlier, there is no definitive proof that hot weather can reduce the effect of virus or BCG vaccination helps against coronavirus

  • The early lockdown imposed by India may have helped keep the levels low. However, experts believe this is temporary.

Shiva Ayyar, Head of Critical Care at Bharati Hospital, Bharatiya Vidyapeeth Medical College, Pune told FIT,

"The mortality rate in India should be understood to be deceptive. Deaths are significantly underreported here. Due to abysmally low levels of testing the denominator number of diagnosed cases is also low. Suspected cases leading to death are not counted, again contributing to low deaths. The number of cases in India does appear to be low now but this may change over time as the lockdown is lifted."

On Maharashtra's case-fatality rate, he says, "It's a fallacy because it depends on the stage of the epidemic we are in and the number of tests we are doing."

FIT also reached out to Dr Shahid Jameel, Virologist & CEO of Wellcome Trust/DBT India Alliance who says, "Deaths can be measured with more certainty than infected cases. But, we are underestimating deaths because a lot of deaths are not counted as COVID-19 deaths or they may be dying at home. World over, the deaths are either underestimated or overestimated. The cumulative figure that we have today for deaths is for infections that happened on an average of 15-20 days ago."

One may want to look at India's all-cause mortality since the COVID-19 outbreak and compare it with previous months but the lockdown has reduced overall deaths occurring due to accidents, pollution, hospital deaths, etc - this is in addition to the fact that in India total medically certified deaths are only 22%. So, we can't possibly reach a sound conclusion by looking at that number.

Dr Shahid also says,

"There is a misplaced feeling that after the lockdown, everything will be fine. But it won't be. Lockdown has only slowed down the outbreak. We keep forgetting history. If we look at the 1980 flu outbreak, most deaths happened in the second wave and third wave. But since India imposed lockdown early in the first phase, it may experience more mortality in the second phase. It is a very distinct possibility."

He also suggests that between different locations, the transmission and deaths will be very different so local models should be performed based on the local data and possibilities.

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