Why Maharashtra has India’s highest Covid-19 mortality numbers

At 72, Maharashtra death toll is significantly higher than other states with high number of cases, such as Tamil Nadu & Delhi that have reported 8 and 9 deaths, respectively.

An aerial view of Mumbai during nation-wide lockdown in wake of coronavirus pandemic (Representational Image)| PTI

New Delhi: As India’s coronavirus case load went past the 5,000-mark, Maharashtra stood as the country’s worst hit state with nearly a fifth of the national burden.

As of Thursday, Chief Minister Uddhav Thackeray’s state had 1,135 coronavirus cases and 72 deaths, including eight new reported casualties. The nationwide death toll stood at 166.

This means Maharashtra that has 20 per cent of the country’s cases accounts for 43 per cent of the deaths in India.

Maharashtra’s Covid-19 mortality rate of 6.3 per cent is also over twice the country’s rate of 2.8 per cent.

While 22 out of the state’s 36 districts have seen coronavirus patients, Mumbai is the worst affected with 714 (62 per cent) total cases and 45 (62 per cent) deaths.

Because of more tests

Merely having a higher number of cases, however, doesn’t mean Maharashtra has India’s highest coronavirus infection rate.

“The logical explanation is that the more the state tests, the more cases it will find,” said Tarun Bhatnagar, scientist, National Institute of Epidemiology, Chennai. The states that have been testing more number of suspected cases even with the current guidelines will find more cases, he said.

Maharashtra had conducted 20,877 tests as of Tuesday, which is 16.8 per cent of India’s total samples tested.

An analysis by Giridhar R. Babu, professor and head, lifecourse epidemiology, Public Health Foundation of India, shows Maharashtra has conducted 92.4 tests per million people.

Published in global health journal BMJ Blog, the analysis of Covid-19 testing rates, confirmed cases and mortality figures in 30 Indian states showed Maharashtra and Karnataka that reported higher number of deaths also tested more on a per million basis.

Elderly with comorbidities among the dead

The death toll in Maharashtra is significantly higher than other states that have a high number of cases, such as Tamil Nadu (738) and Delhi (669). The casualty figure in these states is at 8 and 9, respectively.

“The absolute number of deaths in the country is too low to make a conclusion that the number of deaths is high in Maharashtra,” Raman Gangakhedkar, head of infectious diseases, Indian Council of Medical Research (ICMR), said at a press meet Wednesday.

The higher toll can be attributed to comorbidities, age, severity of disease, late admission and poor hospital outcomes, said Babu.

While about half the patients were from the 21-50 age bracket, they accounted for only 17 per cent of the deaths. Those in the 61-90 age group accounted for 31 per cent of cases and 82 per cent of all deaths, showed an analysis of 868 cases and 52 deaths in an 8 April report by Maharashtra’s medical education and drugs department.

The mortality rate in the 61-80 age bracket was over 23 per cent, while it was less than 2 per cent in 21-40, the report said.

Further, 63 per cent of the cases are among men. They also account for 73 per cent of the deaths. This is consistent with national and international data.

Majority of the deaths (78 per cent) as on 6 April were among those with pre-existing chronic illness like diabetes, hypertension and other serious diseases, according to the Maharashtra state bulletin.

“Those who have comorbidities have higher risk of complications and deaths,” said Bhatnagar. He added that even though many states argue that the deaths were due to comorbidities than due coronavirus, deaths in those positive for the virus have to be counted as coronavirus deaths.

‘Strictly following the criteria’

T. Sunderraman, former dean of School of Health Systems Studies, Tata Institute
of Social Sciences, said, “I would not be too worried about the higher death rate.”

The death rate Maharashtra is reporting can be expected if the state is strictly following the criteria and testing those with severe cases and not the mild or moderate cases, he said.

He added more rigorous contact tracing is needed for each positive case, like the states have done for Delhi’s Tablighi Jamaat event, where even asymptomatic patients were tested in order to find more cases and isolate them.

Maharashtra had reportedly traced 1,500 members of Tablighi Jamaat and quarantined 1,350 of them.

The Maharashtra education and drugs department has been releasing a detailed analysis of the cases every evening, and also started a live dashboard.

Late detection

Many of the cases in Mumbai are hospital-related infections, with patients who were admitted for other ailments later testing positive and spreading it among healthcare staff.

This could either be due to no clear travel or contact history, pointing to the fact that the state needs to increase its testing in milder cases and do a stricter quarantine of the contacts of the positive cases especially in case of deaths, said Sunderraman.

If cases are detected late, that can also play a role in high numbers of deaths, said Lav Agarwal, Joint Secretary, Union Ministry of Health, at Wednesday’s press briefing. “This is why early identification of cases is important.”

The lockdown situation

Earlier this week, Maharashtra Health Minister Rajesh Tope said the withdrawal of lockdown in the state would depend on the situation between 10 and 15 April. He suggested that affected places like Mumbai may see an extension of the lockdown.

As of 8 April, the Brihanmumbai Municipal Corporation has reportedly declared 241 containment zones in the city — areas with a high number of Covid-19 cases sealed off with no outdoor or indoor movement permitted and people asked to stay inside their homes.