Is India counting all COVID deaths?

During the week between April 18 and 25, India reported 2.24 million new coronavirus cases, the highest number recorded by any country in a seven-day period. It also logged 16,257 deaths, almost double the 8,588 deaths recorded the previous week, according to Health Ministry data.   

India has been logging global daily records of over 300,000 cases for the last five days. The country saw 352,991 daily new infections and 2,812 COVID-related deaths in the past 24 hours. 

Altogether, 195,123 people have died while 17.3 million people have been infected with the virus in India.

These numbers are staggering, but experts and epidemiological modelers believe that the real number of COVID fatalities could be much higher than the deaths recorded by health departments nationwide.

"The distressing scenes of patients dying in ambulances and bodies burning on pyres outside crematoriums and even on pavements across cities and towns clearly show that the tragedy is far greater," Anoop Saraya, a private doctor, told DW.

'The true numbers are being suppressed'

India's relatively low fatality rate doesn't tell the whole story and suspicions abound that there's substantial undercounting in several states.

Suspected cases are not being added to the final count and deaths from the infection are being credited to underlying health conditions, point out observers.

"There appears to be a wide discrepancy between official records of deaths attributed to COVID-19 and reports of cremations and burials that are many multiples of what might normally have been expected," Gautam Menon, a professor of physics and biology at Ashoka University, told DW.

"These discrepancies suggest that the true numbers are being suppressed," the health expert said. "The actual number of deaths from COVID-19 may be 5 to 10 times the official numbers. Together with under-reporting of cases and the large test positivity ratios we are seeing across the country, the true scale of the pandemic may be far worse than the numbers would suggest."

Surging cases lead to delayed results

Shahid Jameel, a virologist and director of the Trivedi School of Biosciences at Ashoka University, also maintains that the real death toll is higher than the recorded one, based on reports from cremations and burial sites.

He pointed out that the surging demand for COVID tests has created backlogs, causing labs that issued results within hours to now take days to deliver them.

"One problem that is happening is that test results are taking too long to come. It has happened to my cousin in Uttar Pradesh. He was tested on April 13 and his test result has still not come," Jameel told DW.

"And his will not be reported as a COVID death even though he had all symptoms, including a very high lung infection score and high inflammation markers in blood. There are thousands of cases like that."

Poor registration of deaths

In smaller towns like Surat, Kanpur and Ghaziabad, which have been reporting a high number of COVID deaths, mass cremations have been taking place in open spaces because of a dearth of crematorium space and deaths far exceeding official figures.

Although many countries have struggled to record the precise number of COVID deaths, in India, the problem has been compounded by the lack of an effective death registration system in many parts of the nation.

Most deaths in the country are not assigned a cause by a trained medical professional, making data on case fatality ratio unreliable.

"Because death registration is poor in India, the government will have little data to respond to the impact of COVID-19 on large sections of the population who live in rural areas," Jacob John, a renowned virologist, told DW.

Had these deaths been monitored through a registration system, they could have influenced the scale and geographic targeting of government relief measures as well as healthcare system responses.

"Unfortunately, we don't have a public health system at all in this country. The cause of deaths is seldom recorded," John said.

Undercounting deaths outside hospitals?

In the absence of a reliable death registration system, the government's Integrated Disease Surveillance Program (IDSP) has been collecting data on COVID cases and deaths from testing laboratories and hospitals.

However, the IDSP's major drawback is that it has no way of tracking deaths outside hospitals.

"In the current scenario, India's soaring official COVID-19 count may just represent the tip of an iceberg. Because of low testing rates outside big cities, the actual caseload, and deaths, could be anything from 10 to 30 times higher," Vikas Bajpai of the Progressive Medicos and Scientists Forum told DW.

Positivity, too, has been high with nearly one in five in the country and one in three in Delhi who have been tested turning out COVID positive.

"Far better reporting of COVID-19 deaths is needed. Daily or weekly reporting of the total death counts by age and sex as well as by each municipality would help track if there is a spike in presumed COVID-19 deaths," Prabhat Jha of the Center for Global Health Research in Toronto told DW.