Recently, the Annual Report on the Medical Certification of Cause of Death (MCCD), 2020 was released by the Office of the Registrar General & Census Commissioner, India (ORGI). According to the report, there were around 18.12 lakh medically certified deaths in 2020, which is about 22% of the estimated 81.16 lakhs deaths in 2020. Large Variation between states in the share of ‘Medically Certified Deaths’ due to various causes.
Recently, the Annual Report on the Medical Certification of Cause of Death (MCCD), 2020 was released by the Office of the Registrar General & Census Commissioner, India (ORGI). The report contains vital statistics on causes of death obtained through the Civil Registration System under the Registration of Births and Deaths Act, 1969. Data on medically certified causes of deaths received from each state/UT is compiled in the report. In the 2020 report, new codes to capture deaths due to COVID-19 have been introduced following ICMR’s recommendation.
State-wise data on medically certified deaths by age, sex, and cause of death in the calendar year are some of the important statistics in the report. Such data is important to monitor the health trends in the population. Further, periodic cause-specific mortality statistics are useful for administrators, policy planners, researchers, etc. for evidence-based decision-making in the domain of public health such as resource allocation, monitoring of indicators, and identifying the priorities for programs and other related activities while undertaking appropriate curative and preventive measures for various health problems. Moreover, the data helps in the furtherance of medical research and identify areas for improving the methods of diagnosis and analysis.
Cause of death of only 22.5% out of 81.16 lakhs has been medically certified
According to the report, there were around 18.12 lakh deaths in 2020, including 11.6 lakh males and 6.52 lakh females, that were medically certified. The annual report on Vital Statistics of India based on the Civil Registration System (2020) reported that the total number of registered deaths at the national level was estimated at 81.16 lakhs in 2020. Excluding the figures of registered deaths from Jammu & Kashmir and Ladakh, the total deaths registered was nearly 80.63 lakhs. However, out of these 80+ lakh deaths registered, only about 18.12 lakh deaths have been medically certified. In other words, the cause of death is medically certified in only 22.5% of deaths in 2020. This percentage varies from 3.4% in Bihar to 100% in Goa and Manipur.
However, the percentage of medically certified deaths as compared to the total number of registered deaths is the highest in 2020 in the last three decades. Over the years, there has only been a marginal improvement in the share of medically certified deaths- from 20% in 2011 to 22.5% in 2020.
9 leading causes of death, including COVID-19, accounted for nearly 90% of the medically certified deaths
In 2020, the nine leading cause groups of death together accounted for about 88.9% of all the medically certified deaths. These are- Diseases of the Circulatory System; Diseases of the Respiratory System; Codes for Special Purposes (COVID-19 deaths); Certain Infectious and Parasitic Diseases; Endocrine, Nutritional and Metabolic Diseases; Injury, Poisoning and Certain Other Consequences of External Causes; Neoplasms; Certain Conditions Originating in the Perinatal Period; and Symptoms, Sign and Abnormal Clinical & Laboratory Findings Not Elsewhere Classified.
The trend in the share of deaths due to leading causes seen above indicates that diseases of the circulatory system such as diseases of the pulmonary circulation and other forms of Heart Diseases, Hypertensive diseases, etc. are the cause of death in the majority of the certified deaths since 2000. It accounted for more than 30% of the medically certified deaths in each of the years since 2014.
Respiratory diseases such as pneumonia, bronchitis, asthma, etc. were the second leading cause in 2020. The share of deaths due to lung diseases has been on a rise since 2014. This is for the first time since 2000 that the share of deaths due to lung diseases has touched 10%. Prior to 2020, the share of deaths due to certain infectious and parasitic diseases was the second leading cause. However, in 2020, its share was the lowest in the last two decades with 7.1%, 2.7 percentage points lower than in 2019. Though it has been on a decline for decades, such a steep decline was not reported earlier.
Deaths due to COVID-19 accounted for 8.9% of the medically certified deaths in 2020. In 2020, the deaths due to circulatory diseases, respiratory diseases, and COVID-19 together accounted for 51%. That is, out of 100 medically certified deaths, 51 were caused by one of the three in the pandemic year of 2020.
Share of deaths due to certain conditions originating in the ‘Perinatal Period’ dropped by 1.3 percentage points in 2020 as compared to 2019, while that due to Neoplasms and Symptoms, Signs & Abnormal Clinical & Laboratory Findings N.E.C. dropped by 0.9 and 2.7 percentage points respectively in 2020.
The large variance between States in Medically certified deaths due to certain causes
In the following chart, data of the 10 states/UTs with the largest share of the medically certified cause of death is depicted. There are a few outliers in these trends in the last five years (2016 to 2020).
- The share of deaths due to respiratory illnesses in Gujarat has more than doubled- from 8.2% in 2019 to 19.1% in 2020, an increase of nearly 11 percentage points. Similarly, the share of deaths due to respiratory illnesses has increased by 6.9 percentage points to cross 22% in Rajasthan and increased by 4.2 percentage points in Odisha. Even Madhya Pradesh witnessed an increase of 2.7 percentage points to touch 7.2%, up from 4.5% in 2019. In contrast to the past trends, in Jharkhand and Bihar, the share of deaths due to respiratory illnesses dropped by 11.5 and 8.2 percentage points in 2020, to reach the lowest in the last five years.
- The share of deaths medically certified due to circulatory system diseases has gone up by more than 51 percentage points in Jharkhand (from 9.8% in 2019 to 61.3% in 2020) while the same in Assam, and Andhra Pradesh has gone up by 30 and 28.2 percentage points respectively. At the same time, the share has dropped by 11 to 19 percentage points in Madhya Pradesh, Haryana, and Telangana.
- The share of deaths due to infectious diseases has dropped across almost all the states in 2020. However, this decline was by 12 to 17 percentage points in Jharkhand, Bihar, Arunachal Pradesh, and Assam.
- In Andhra Pradesh, where the share of deaths due to certain conditions of the perinatal period was 6.2% in 8.2% in 2018 and 2019, dropped to 2.2% in 2020.
- Share of neoplasms or cancer-related medically certified deaths was below 4% in Telangana between 2016 and 2018. In 2020, this touched 19.1%. On the other hand, in Assam, the share has dropped by 9.2 percentage points.
- Share of medically certified deaths due to Symptoms Signs & Abnormal Clinical Findings “Not Elsewhere Classified” dropped from 16.2% in 2019 to 1.7% in 2020 in Andhra Pradesh. In Gujarat where this share was always above 30%, dropped to 16.4% in 2020 while Madhya Pradesh has registered an increase from 7% in 2017 to 30.6% in 2020.
Deaths due to pneumonia increased in 2020
Apart from these, the share of deaths due to tuberculosis dropped from 28.5% to 23% between 2018 and 2020 while that due to septicaemia increased from 38% in 2016 to 49% in 2020, among deaths due to certain infectious diseases and parasites. The diagnosis and treatment of tuberculosis was a cause of concern amidst the pandemic since unprecedented lockdowns and movement restrictions limited people’s access to healthcare. Moreover, higher vulnerability to infection in older people and those with comorbidities also made people hesitant to visit hospitals and clinics.
Under deaths due to respiratory diseases, the share of deaths due to pneumonia increased from 14.3% in 2019 to 22.5% in 2020 while that due to Asthma dropped from 8% in 2019 to 5.6% in 2020. COVID-19 is associated with lung damage, breathing problems and pneumonia.
While going through this data, one must keep in mind that this represents less than one-quarter of the estimated deaths in the country in 2020. These numbers are still not adequate to understand the underlying causes of death and for the government to take any corrective action. The large variation across states further reduces the reliability of the data. Efforts should be made to ensure that the share of MCCD reaches at least 50% in the near future.