Establishing reliable, real-time mortality monitoring is an essential element of pandemic preparedness
In form of covid-19 pandemic Moving into its third year with varying intensity, the world is waiting with bated breath to know about its impact. omicron version, Fortunately, South Africa has established an efficient acute mortality monitoring system that will alert us with the earliest evidence of such an impact, if any. It is also reassuring that there has been a spurt in critical response preparedness activities as a result of lessons learned from the past pandemic waves in India. Nevertheless, despite several states announcing ICU bed availability and oxygen supply combined with personal protection through vaccination, the risk of individual susceptibility to the new variant from immune evasion and underlying morbidity remains. Therefore, any evidence of this type of fatality (or lack thereof) from South Africa can only serve as background information, underscoring the need for similar early warning mortality surveillance activities in India.
no reliable guesses
Mortality data is essential for epidemic management from both clinical and public health perspectives to guide patient care, protection of vulnerable population groups, and resource mobilization and allocation. In all countries, data from the COVID-19 death surveillance system is limited due to inadequate access to anti-mortem testing and inconsistent cause attribution. Therefore, the impact of the pandemic is now assessed through an assessment of higher mortality rates (excess deaths observed during the pandemic period compared to those recorded in previous calendar years). For an adequate response, such evaluations require reliable baseline pre-epidemic mortality measures, near-perfect death reporting during the pandemic, and real-time data compilation and release at weekly or monthly intervals. For South Africa, the National Population Register serves as a useful data source, with weekly updates on deaths by gender, age, date of death and place of registration. Deficiencies exist in the completeness and timeliness of reporting, but the mortality monitoring team has established procedures to correct such biases by reporting higher mortality estimates at the national and provincial levels in near real time.
For India, higher mortality estimates are based on epidemiological models, some of which include analysis of month-wise death registration data released by several states. However, these assessment exercises were hindered by the uncertainty in baseline pre-epidemic mortality, potential under-registration in 2021, and the possibility of some delayed registration being included in the data. All of these potential data biases were statistically accounted for by different analysts through different methods and assumptions, resulting in an estimated 2.8 million to 5.2 million deaths between April 2020 and June 2021 . On the other hand, the death toll in the national COVID-19 surveillance program for the period stood at around 4,30,000, which is considered a gross under-count. This 10-fold variation in estimates of COVID-19 mortality in India is clearly not helpful, and the absence of a reliable estimate is a major obstacle to our understanding of the magnitude of pandemic mortality at both the national and global levels.
encouraging trend
Nevertheless, several recent developments have opened up possibilities for better estimation of excess mortality in 2020/2021 as well as for ongoing mortality monitoring and measurement programs in India. Firstly, the Civil Registration System (CRS) report for 2019 indicates a high level of registration completion across India. These data have now been corrected for under-reporting to calculate reliable pre-pandemic mortality estimates based on gender, age and location, as a baseline for evaluating the impact of the pandemic. Thereafter, the rapid release of information on deaths registered by some states in 2021 (briefly summarized by the COVID-19 Mortality Data Report) Hindu) indicates that efficient mechanisms for data compilation are functional in these states. In fact, the Registrar General of India (RGI) issued a circular in November 2017 requiring district and state registrars to submit a summary monthly return of births and deaths registered in their jurisdiction. The circular also declares that “the vital rates generated through CRS are accurate and genuine data which is certified by the registering authority, and therefore legally acceptable, and shall not be allowed to be used for proxy purposes due to paucity of data”. also prevail over other conjectures”. It is likely that these instructions will facilitate the early release of registration data after the second wave. Third, the pandemic has drawn considerable media and public attention to epidemiological data, including mortality, leading to a flurry of data reports to meet this demand. There is now a general expectation of continued public attention to such health data in the times to come.
the road ahead
While an accelerated data release in 2021 bodes well for future availability, the CRS data for 2020 and the provisional data report for 2021 should be released at the earliest, at least to an internal team of analysts. Local statistical capability should also be established in state registration offices for data quality assessment, adjustment for data bias, and basic trend and forecast analysis. Data dissemination protocols need to be standardized using a template for compiling tabular deaths by gender, broad age groups, month of death occurrence and district of usual residence. These variables are included in the CRS death reporting form, therefore enabling such detailed tabulation of each month. A lag period in death reporting in registration units and districts is anticipated, but updated counts in subsequent months are widely accepted in relation to epidemic surveillance. Information on deaths recorded in the National Sample Registration System and other household surveys can be used to estimate the completeness of CRS data using record linkage methods. It should be possible for state registrars to direct such actions with the resources and technical support of local public health/educational institutions. Of course, detailed analysis of annual data that complies with the standard data validation protocol implemented by RGI will still be required for the annual CRS report. But the provisional availability of near real-time monitoring reports will enhance monitoring of the mortality impact of this and future pandemics.
In principle, mortality estimates developed from adjustment to empirical data are locally relevant and therefore more acceptable than modeled estimates. Even in regular times, there has been an undue reliance on epidemiological models to estimate mortality for India, as seen from various recent disease burden estimates. Recent analysis of CRS data has highlighted the brittle nature of the outputs of these models. Furthermore, the gaps identified in CRS data by location, gender and age from detailed analyzes may help guide interventions to improve data quality for the future. In the current environment, establishing reliable, real-time mortality monitoring is an essential element of pandemic preparedness, and immediate steps to build on recent developments in this aspect are the reasons for evidence-based health policy to tackle the pandemic in India. Will carry forward
Chalapathi Rao, Honorary Associate Professor, Research School of Population Health, Australian National University
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