Tracking Missing Deaths: An Exploratory Study on the Mortality Impact of COVID-19 in Kozhikode City, India.

Background: The debate over the extent of the mortality impact of COVID-19 in India is still unsettled.

Objectives: This article contributes to the debate, seeking to explore the true mortality impact of the pandemic, by answering four interrelated questions. First, is there any discrepancy between recorded and actual death count? Second, if so, how large it is? Third, what is the extent of misclassification of COVID-19 mortality, and fourth, what is the magnitude of deaths that could be indirectly linked to COVID-19?

Materials and methods: To answer the questions, we explored three sources of data-all-cause mortality data from the civil registration system, records maintained at the burial grounds/cemeteries and crematoriums, and a household survey. The data collection period was between August 2021 and November 2021. The instrument used for data collection of verbal autopsies was built on the instrument proposed by the World Health Organization for adult mortality.

Results: The results revealed that deaths due to various causes including COVID-19 increased considerably at some points in 2020-2021 compared to the base year 2019 in the study setting. Notably, 5.5% of the noninstitutional deaths were unreported at the time of the survey and many deaths were plausibly misclassified, leading to undercounting of COVID-19 deaths. Overall, about half of our sampled deaths (48%) had either direct or indirect attribution to the pandemic.

Conclusion: The extent of undercounting of pandemic-related deaths is likely to be either similar or worse in other states. To get reliable state and national estimates, policymakers should conduct a large-scale study.