Estimating COVID-19– Related Mortality in India: An Epidemiological ChallengeWith Insufficient Data

As of May 16, 2021, India, a country with a population of 1.38 billion, was second only to the United States in the total number of reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases (nearly 25 million) and third following the United States and Brazil in total reported deaths (> 270 000).1 Data from seroprevalence studies and limited excess mortality calculations offer evidence that the actual numbers of infections and deaths are likely much larger than the ones reported. We recognize that multiple challenges lead to underreporting of COVID-19 fatalities including (1) deaths that occur outside of hospitals that either are not captured or incur a lag, (2) deaths that are classified under comorbid illnesses, (3) deaths that are attributable to low access to quality health care or a shortage of health care resources, and (4) deaths that are undetected as a result of an inadequate COVID-19 testing program. Our review of the existing evidence suggests that the problem is particularly acute for India, where a large number of deaths (especially ones happening outside a health care facility or in rural areas) routinely remain medically unreported.