What Percentage of Mortality were Medically Certified among Total Registered Mortality in 36 States & UTs of India During 2018-2020 and COVID-19 Mortality Age-Sex Distribution Pattern in India: A Cross Sectional Observational Research Study

Background/Rationale

The most significant event of birth and death must be certified medically / non-medically to prove or support the evidence of existence of birth and death of a particular person legal existence between the certified date / timings of birth and death. Apart from this legal significance, footage of births and mortality is central basic data required for policy and planning about a population group / country such as provisioning of fundamental requirements like food, cloth, housing, health care, transportation, education etc as per Universal Declaration of Human Rights (UDHR) [1]. The national / state programmes planning, management, implementation can be effectual and triumphant only if this statistical information of birth and death is specific, reliable, timely and correct. Hence, the certification / registration of births and mortality are significant as well as necessity of modern era [2]. Not only the registration of birth and death, but also its growth and cause are equally significant [2A]. Statistical data analysis of causes of mortality forms an important morbidity & mortality statistics for National Health Policy and Planning. Medical Certification of Cause of Death (MCCD) serves dual purpose, firstly legal document of mortality for getting insurance benefits etc. such as in several countries and also in India during coronavirus disease-2019 (COVID-19) the Government of India and state governments are providing compensation for COVID-19 deaths provided the deceased death is certified properly [3, 4]. Secondly mortality statistics play an important role in medical research to improve diagnosis and treatment protocols [3]. Registration of Births and Deaths Act ((Act No. 18 of 1969)) in India was passed in the year 1969 making registration of these events mandatory [5]. The Registrar General of India is the highest official who compiles and provides the necessary information about mortality and births arriving in progression from registrars & sub-registrars of district level, Municipal, and Military Cantonments [5]. WHO (World Health Organization), have raised a question mark on the current birth and death registration systems in India, as well as on several global countries, for under reporting of COVID-19 mortality [6, 7]. The researchers pre-print is also available on Impact of Civil Authorities Faulty Mortality Registration on COVID-19 Mortality Count and the researcher quest to know more about the real scenario of birth and death have raised the titled mentioned research question elaborated and explained in this paper [8]. A lack of dedicated public health management cadre as well as corruption and posting scams in some states like Bihar may be responsible for such faulty reporting [9]. The Section 10(2) of the Registration of Births and Deaths Act empowers the State Govt. to put into effect the prerequisite relating to medical certification of cause of mortality in specified areas while Section 10(3) of the Act provides for making a certificate of the cause of mortality by the medical practitioner who has treated / attended the deceased at the time of mortality. In India at present, all the hospitals are not part of the scheme [4]. The Medical Certification of Cause of Death (MCCD) is of enormous use to several key stakeholders of health and other sectors like health planners, policy makers / implementers, researchers and epidemiologists for data -based management with regard to resource distribution, monitoring of indicators for performance / output etc., identifying the top priorities for state / national health or other programs such as Ayushman Bharat Yojna and other interrelated activities in the area of research / Public Health / other sectors like insurance. COVID-19 mortality age-sex distribution pattern in India are important indicators for evidence-based monitoring of COVID-19 in the population. The Conference on Vital Statistics in 1961 had recommended the scheme of MCCD which evolved in three phases with first phase in the teaching hospitals of the State including field areas attached to them, missionary hospitals etc., second phase extended to District & Sub-division hospitals, specialized hospitals, private hospitals and third phase added private and other public hospitals & Primary Health Units, private physicians practicing modern medicine [5]. Legally RBD is statutory backed under sections 10(2), 10(3), 17(1) (b) and 23(3) of the Registration of Births &Deaths (RBD) Act, 1969. World Health Organization (WHO) at regular intervals reviews the arrangement of International Classification of Diseases (ICD); tenth amendment of the ICD (ICD-10) was certified by the 43rd World Health Assembly (WHA) in May 1990 and adopted in the ORGI (Office of the Registrar General & Census Commissioner, India) for categorization of causes of deaths since 1999 report on MCCD. The latest ICD-11 was adopted by the 72nd WHA in 2019 effective from 1st January 2022 [10, 9]. In the year 2020, as per recommendation of WHO the Indian Council of Medical Research (ICMR), recommended codes for covering Covid 19 related mortality (U07.1 and U07.2) as a separate major cause group. Covid 19 related mortality contributed for 8.9 per cent in total medically certified deaths with shares of 9.8 % and 7.1 % of males and females respectively [5, 11].

Objectives

The States & UTs of India has been harshly affected by the COVID-19 pandemic which has not resolved till date; although the new cases and new mortality is greatly reduced in India as well as on global basis. The certified mortality and mortality associated with COVID-19 is still under controversy as mentioned above in the background. This research study aimed to assess percentage of (including COVID-19) mortality medically certified among total registered deaths in 36 States & UTs of India for the period 2018-2020 as well as trends of COVID-19 mortality age-sex distribution pattern in India during 2020 which are medically certified due to COVID-19 pandemic in India with available data resources.

Study Design

The mortality figures for this novel cross sectional retrospective observational research study were obtained through CRS (Civil Registration System) of India established under the RBD Act, 1969. The data available were obtained on medically certified cause of deaths from States/UTs has been collected, tabulated, analysed in compliance with the ICD - Tenth Revision (1993). Deaths due to Covid-19 (U07.1 and U07.2) were added as mentioned above. The statistics on percentage of mortality medically certified among total registered mortality in 36 States & UTs of India during 2018- 2020 and COVID-19 mortality age-sex distribution pattern in India were derived with the use of Microsoft office and stata software and presented, cross tabulating them by indicators of the deceased. The time series data analysis of MCCD by major cause groups for different years will be added in next version.

Setting

The necessary data for the title mentioned research question were collected from CRS (civil registration system) for different states and UTs (union territories) for the title mentioned period and analyzed for specificity, measurability, credibility, reproducibility, and timeliness -see Table-1, 2, 3,

Participants

Participants were all states and union territories of India reporting as per above mentioned guidelines. The selections of participants were purely on the basis of available data of MCCD.

Variables

All the variables are mentioned in tables 1-5. Data sources/measurement Source: CRS Report 2018-2019-2020 available at - https:// crsorgi.gov.in/mccd-reports.html Statistical analysis of COVID-19 mortality With more data in next version we will discuss statistical analysis and inferences.

Deaths Reported under Covid 19

COVID-19 associated mortality were leading cause group accounting for 8.9 per cent of total medically certified deaths at national level. Gender analysis revealed that 9.8 per cent of male and 7.1 per cent of female were medically certified as COVID-19 mortality at national level. The age distribution and statistical analysis of medically certified deaths due to Covid 19 for the cases of virus identified and not identified i.e. U07.1 & U07.2 were presented in Table 2, 3, 4 and figure 3, 4 and 5. More description and analysis will be discussed in next version with more data. In MCCD, as discussed earlier an urgent situation ICD-10 code of ‘U07.1 COVID 19, virus identified’ is imparted to diagnosis of COVID-19 which was definite by laboratory testing whereas ICD-10 code of ‘U07.2 COVID-19, virus not identified’ is imparted to a clinical or epidemiological diagnosis of COVID-19 in the circumstances where laboratory verification is unconvincing or not available. Both these codes U07.1 and U07.2 were used by the States/UTs for COVID-19 mortality coding as the cause of mortality. Table-2 shows that out of total 1,60, 618 COVID-19 associated mortality the virus was acknowledged in 1, 38,713

deceased whereas it was not confirmed in 21,905 cases.

Table 3 and Figure 5 shows that, the maximum percentage of death of 29.4 % was in the age group of 70 years or above followed by 55-64 years age group accounting for 23.9 % while the age group of 65-69, with class interval of only 5 years accounted for significant 14.5 per cent of COVID-19 mortality. This observational research study revealed that the majority of COVID-19 mortality was found in the age group of 45 years and above accounting for 82.7 per cent of total deaths in the group. The percentage of female mortality aged 34 years and below as well as for 55-64 years age group and 65-69 years age group, to total female deaths are greater in comparison to corresponding age groups mortality for male while in other groups male mortality were more than females. Out of the total 1, 60,618 MCCD as COVID-19 deaths; 1, 14,217 male and 46,401 female died due to COVID-19, which indicates that COVID-19 is more detrimental for males. The age and sex wise allocation of COVID-19 mortality is shown in table-2, 3, 4 and figures 3, 4, 5.

Strength and Limitations

This is a novel cross sectional research study with peculiar research question in the context of India. The key limitation is availability of data.