The second wave of the Kovid epidemic has placed a heavy burden on our health system. There have been reports of reduced tests in several Indian states and cities. Some states have accused private labs of imposing restrictions on positivity rates, which are not allowed to be violated. Collecting home samples can be very difficult. In Delhi, on May 3, only 61,045 tests were conducted. Of these, 16% were rapid antigen tests (RATs). At some free testing sites, RAT and reverse transcription-polymerase chain reaction (RT-PCR) tests are performed on each patient. Therefore, there may also be some double counting. Delhi on the other hand conducted 100,000 exams in mid-April. With the new wave, test numbers have declined and positivity rates are the work of testing.
Today, it takes 3-4 days to report test results. Timely inspections and release of reports are required for a number of reasons. 1) Test results are pending, most people do not take prescription drugs. If they receive their reports within four days, this window will be lost when people are most likely infected. 2) It increases the chances of hospitalization. 3) Infected patients are at risk of spreading the infection to others. 4) Strong and reliable health statistics and epidemiological data help in allocating financial and technical resources effectively and in targeted health interventions.
The evolution of new variants of Kovid warrants gives not only an increase in testing, but also a subsequent genetic sequence. According to Johns Hopkins University, India ranks less than a tenth of the genetically reported cases, and ranks 102nd in India in the coronavirus genome. While India has the capacity to handle a large number of scenes every day, our problem is the availability of metadata. In general, metadata describes a sequence of DNA / RNA sequences. Note that the new variant increases the chance of a false negative result from the RT-PCR test.
India formed the SARS-COV-2 Genomics Consortium last December to study the evolution of the virus. Viral genome sequencing data is generated and analyzed by eight regional sequencing laboratories and then sent to the National Center for Disease Control (NCDC) in Col for collection and integration. The NCDC also regularly collects data from the states. Unfortunately, without proper metadata for genetic sequences, malignant variants cannot be detected. This data should be collected by overcrowded frontline healthcare workers, who have no incentive. Genome sequencing requires more investment in infrastructure and encourages states and health workers to collect metadata appropriately.
Another perennial problem is the quality of our mortality statistics. There are reports of under-report deaths. Registration of births and deaths is regulated by the Births and Deaths Registration (RBD) Act, 1969. However, the implementation of this ordinance is up to the state governments. Prior to the pandemic, deaths were reported less frequently, but the pandemic exacerbated the problem. In the global assessment of Civil Registration Systems (CRS) across the country, India’s CRS is rated the lowest on a significant statistical performance index (<0.25). Due to the Kovid epidemic, accurate data collection on deaths and mortality is currently the most important. This will enable us to vaccinate targets in clusters with high mortality rates. However, Kovid or not, India needs strong and reliable death statistics.
The latest CRS data (legal requirement) indicates that only 50-80% of deaths were reported in 21 days in Chhattisgarh, Meghalaya, Tripura, Jammu & Kashmir, Assam, Telangana, West Bengal, Rajasthan, Karnataka and Kerala. In Manipur, Arunachal Pradesh and Nagaland, less than half of the deaths were recorded within the stipulated time frame.
If a death is reported, there is no cause of death. Of the deaths recorded under CRS, only 21.2% nationally were the cause of clinically confirmed death. Jharkhand (4.6%), Uttar Pradesh (5.1%), Uttarakhand (11.1%), Odisha (11.1%), Kerala (11.9%), Assam (12%), Rajasthan (13.1%), Bihar (13.6%), Himachal Pradesh (15%), Haryana (20.4) and Gujarat (23.4) have the lowest medically confirmed mortality rates.
According to CRS data, in 2018, 86% of all deaths were recorded, of which only 21.2% were clinically confirmed. Only 18.5% of all deaths in the country are medically attributed to cause of death. Furthermore, 13.1% of clinically certified deaths are classified in the category of ‘Symptoms, Signs & Extraordinary Clinical and Laboratory Research Nowhere’ (ICD R-99) with ‘Medical Certificate of Death’. According to statistics, it is the eighth leading cause of death in India. This is due to the large number of cases classified as ICD R-99: 1) lack of awareness among health professionals about the relevant ICD signals; Or 2) lack of skill and equipment to determine the cause of death. If a death is classified as R-99, technically, it should raise the agenda, as it may be due to a new malignant infection.
A robust health care system that can respond to a health crisis must rely on reliable death statistics as well as mortality information. Under-reporting is of no use; This makes the situation worse. Proper death statistics do not bring back the dead, but save lives.
These are the personal opinions of the authors
Bibek Debray & Aditya Sinha are the Chairman and Assistant Consultant on the Prime Minister’s Economic Advisory Council respectively.