MADURAI: "Robust cause of death information in a population is useful for understanding disease burden estimations, and explains trends in the health of populations. It is useful for evaluation and planning of health services and programmes. Good cause of mortality statistics also aids in identifying research questions of public health significance," reads the Indian Council of Medical Research (ICMR) guidelines for appropriate recording of COVID-19 related deaths in India. However, the district-level discrepancies in the COVID data are in contradiction to the aforementioned statement.
The New Indian Express accessed a month-wise break up of death certificates issued by the Madurai Municipal Corporation and by nine government hospitals in the district. It must be noted that while the total number of deaths in the district will include deaths from local bodies aside from the Corporation, the discrepancies are indicative. The district – and State – recorded its first Covid death on March 25, 2020 when a 54-year-old man from Anna Nagar in Madurai passed away due to the disease.
However, in the first wave of the pandemic, the number of Covid deaths and cases peaked in July 2020. According to the State media bulletins, the district recorded 204 Covid deaths that month. The number of death certificates issued by the Corporation and the GHs also peaked in that month, 2,857. In comparison, the Corporation and Ghs issued a total of 1,571 death certificates for the previous non-pandemic year of 2019, suggesting a huge rise in deaths to the tune of 1,286. At least some of these deaths may be related to Covid, while others may be related to limited access to healthcare due to the pandemic and must be investigated.
Similarly, in the second wave, deaths and cases peaked in May 2021. The number of death certificates issued by the Corporation and GHs also peaked that month with a total of 3,553 death certificates being issued. In comparison, they issued 1,734 death certificates in the non-pandemic year of 2019, suggesting 1,819 more deaths had occurred. The media bulletin just recorded 394 Covid deaths for the entire district in that month.
Between January and April 2021, when all Covid norms were relaxed and the State was busy with election campaigns, 7,655 death certificates were issued by the Madurai Corporation and the nine GHs. According to the State bulletin, only 66 persons were said to have died of Covid in the district in that period. In comparison, for that period in 2019, 7,055 death certificates were issued by the Corporation and Ghs, suggesting perhaps less discrepancies in the accounting of deaths in that period.
Anecdotally too, TNIE learned that many Covid deaths may have gone unaccounted for in the city. According to hearse drivers, for instance, in the first wave, when the lockdown restrictions prevented people from stepping out, the number of deaths caused by road accidents were nearly nil. “To our surprise, there were hardly any natural deaths. Most of the deaths were only the Covid and Covid related cases. After the lockdown restrictions were lifted, the scene changed."
Sources from the crematoria in Thathaneri and Moolakarai said that they had handled 40 to 60 casualties on a daily basis when cases were at a peak. The crematoria were also ordered to function round-the-clock and additional gasifiers were installed. "According to the medical records, the cause of death would predominantly be viral pneumonia, pneumonia, suspected Covid-19 and clinical Covid-19, while only less than five cases were declared dead due to Covid-19," said the workers. However, Covid protocol was followed for all such deaths.
As per the ICMR guidelines for Medical Certification of Cause of Death (MCCD), code U07.1 is used by the hospital authorities to call it a COVID death if the person was RT-PCR positive (with symptoms, without symptoms, has comorbidities).
Code U07.2 is used to report a death as 'clinically-epidemiologically diagnosed COVID-19', if the patient tests negative but has symptoms. It is marked 'suspected COVID' when test results are awaited and the patient has symptoms. The term 'probable Covid' is used for those whose test results are inconclusive but the patient has the symptoms.
Responding to this, City Health Officer and the Deputy Director of Health Services (in-charge) Dr P Kumaragurubaran told TNIE that that the civic body follows only the guidelines issued by the ICMR in accounting the number of Covid and crematoria data could not be used to record Covid deaths, as many from other districts might cremate the bodies in their respective native districts. Only the hospital records on MCCD would be considered."
Further, when the test results of a 'suspected Covid' patient turns positive after the patient dies, the number would be added into the next day's Covid death data, he said, adding, "Not all deaths of patients with comorbid conditions who test positive would be recorded as Covid death. Only those who die due to 'complications related to Covid' would be brought under Covid death data."
Some discrepancies in the recording of new cases have also been noticed. For instance, while the daily bulletin shows Madurai as recording 21 cases between February 9 and 28 and 456 cases in March 2020, the April data brought only 6 cases of March into its account.
The other 471 cases went totally unaccounted for. Even when one assumes there were only 6 cases in March, 484 cases went missing between March 2020 and May 2021.
Commenting on such errors in the data, another senior official said that local bodies would send a figure to Chennai but the bulletin would have a different figure. "Once a Nagercoil resident gave swabs for testing at Chennai. His contact details were registered in Chennai. Later when he was in Ooty, he gave the swabs again, as he was symptomatic. But he got admitted at the ESI Hospital in Coimbatore. This case was recorded under Nagercoil in the bulletin. But when such patients die, the death certificate should be issued only by the respective local body where the patient was treated," the official said.