Participants
Anyone admitted to emergency ward and died at any health facility ED in India across 36 states and union territories whose information data is registered with HMIS, MoHFW, and Government of India.
Descriptive data
This research study included all residents of India, of all ages, of any sex, religion, caste etc. The cause of death is not specific but place of death is specific i.e. ED of any health facility in India. Anyone died of any cause and not only COVID-19 was included in the study. Of course the deaths due to SARS-CoV-2 infection are also included.
Outcome data
The outcome data were presented as table 1, 2, and 3, 4, 5, 6 and figures 1, 2, 3, 4 and 5.
Table-1- Month wise comparison of Mortality at all public-private-urban-rural health facilities of India in 2019 (pre-pandemic era)
Month-Year
|
Item code
HMIS
|
Number of deaths occurring at Emergency Department
|
Total
|
All India
|
Month-Year
|
Item code
HMIS
|
Number of deaths occurring at Emergency Department
|
Total
|
Total [(A+B) or (C+D)]
|
Public [A]
|
Private [B]
|
Urban [C]
|
Rural [D]
|
Jan-19
|
14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
15011
|
14709
|
302
|
1619
|
13392
|
Feb-19
|
14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
9740
|
9442
|
298
|
1513
|
8227
|
Mar-19
|
14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
14280
|
13824
|
456
|
1663
|
12617
|
Apr-19
|
14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
11833
|
11511
|
322
|
1516
|
10317
|
May-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
12077
|
11691
|
386
|
1710
|
10367
|
Jun-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
12308
|
11834
|
474
|
1763
|
10545
|
Jul-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
12501
|
12063
|
438
|
1700
|
10801
|
Aug-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
13085
|
12619
|
466
|
2012
|
11073
|
Sep-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
11914
|
11488
|
426
|
1649
|
10265
|
Oct-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
13972
|
13421
|
551
|
2400
|
11572
|
Nov-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
12069
|
11614
|
455
|
1637
|
10432
|
Dec-19
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
11716
|
11320
|
396
|
1631
|
10085
|
Total
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
Total
|
150506
|
145536
|
4970
|
20813
|
129693
|
Mean/month
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
Total
|
12542.1
|
12128
|
414.166
|
1734.4
|
10807.7
|
Table-2 - Month wise comparison of Mortality at all public-private-urban-rural health facilities of India in 2020 (first year of pandemic era)
Month-Year
|
Item code
HMIS
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
All India
|
Month-Year
|
Item code
HMIS
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
Total [(A+B) or (C+D)]
|
Public [A]
|
Private [B]
|
Urban [C]
|
Rural [D]
|
Jan-20
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
14136
|
13696
|
440
|
2330
|
11806
|
Feb-20
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
12689
|
12225
|
464
|
2616
|
10073
|
Mar-20
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
10887
|
10471
|
416
|
1463
|
9424
|
Apr-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
14185
|
13831
|
354
|
4821
|
9364
|
May-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
14201
|
13707
|
494
|
6026
|
8175
|
Jun-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
14782
|
13967
|
815
|
5853
|
8929
|
Jul-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
12354
|
11423
|
931
|
5976
|
6378
|
Aug-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
17005
|
16494
|
511
|
7165
|
9840
|
Sep-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
18056
|
17546
|
510
|
10142
|
7914
|
Oct-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
25014
|
22275
|
2739
|
13444
|
11570
|
Nov-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
22384
|
19679
|
2705
|
8567
|
13817
|
Dec-20
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
17111
|
16486
|
625
|
7303
|
9808
|
Total
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
192804
|
181800
|
11004
|
75706
|
117098
|
Mean/month
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
16067
|
15150
|
917
|
6308.83
|
9758.16
|
Other analyses
Statistical analysis: The data for mortality occurring at the Emergency Department of health facilities in India from 1st January 2019 to 31st May 2021 is analyzed with stata and presented below in table 4, 5 and 6. The lockdown and unlock down periods are mentioned to show a little scenario of impacts of both, hence included the timeline. ED mortality increased sharply from August 2020 following the Unlock 2.0: 1 July 2020 – 31 July 2020 (31 days). From March 2021 the ED mortality have seen a tremendous rise following Unlock 10.0: 1 March 2021 - 31 March 2021 (31 days) see figure-1. The Government of India had declared a nationwide lockdown on 24th march 2020 as listed below and this lockdown has also disrupted many other essential services [3]
Table-3- Month wise comparison of Mortality at public-private-urban-rural health facilities of India in 2021 (second year of pandemic era)
Month-Year
|
Item code
HMIS
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
All India
|
Month-Year
|
Item code
HMIS
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
Total [(A+B) or C+D)]
|
Public [A]
|
Private [B]
|
Urban [C]
|
Rural [D]
|
Jan-21
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
18089
|
15013
|
3076
|
8302
|
9787
|
Feb-21
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
18261
|
16905
|
1356
|
10683
|
7578
|
Mar-21
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
14219
|
13277
|
942
|
6838
|
7381
|
Apr-21
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
21846
|
18957
|
2889
|
10480
|
11366
|
May-21
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
36377
|
32613
|
3764
|
21881
|
14496
|
Total
|
'14.7
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
108792
|
96765
|
12027
|
58184
|
50608
|
Mean/month
|
'14.7'
|
Number of deaths occurring at Emergency Department
|
TOTAL
|
21758.4
|
19353
|
2405.4
|
11636.8
|
10121.6
|
Table-4- Statistical analysis of Pre-pandemic era
Pre-pandemic era summary statistics
|
No. of Obs
|
Deaths occurring at Emergency Department
|
Variable
|
Obs
|
Mean
|
Std. Dev.
|
Min
|
Max
|
Total
|
12
|
12542.17
|
1394.251
|
9740
|
15011
|
Public health facility
|
12
|
12128
|
1370.285
|
9442
|
14709
|
Private health facility
|
12
|
414.1667
|
76.75798
|
298
|
551
|
Urban health facility
|
12
|
1734.417
|
245.9277
|
1513
|
2400
|
Rural health facility
|
12
|
10807.75
|
1304.842
|
8227
|
13392
|
Confidence Interval- means Deaths occurring at Emergency Department
|
Variable
|
No. of Obs
|
Mean
|
Std. Err.
|
[95% Conf. Interval]
|
Total
|
12
|
12542.17
|
402.4856
|
11656.3
|
13428.03
|
Public health facility
|
12
|
12128
|
395.5671
|
11257.36
|
12998.64
|
Private health facility
|
12
|
414.1667
|
22.15812
|
365.397
|
462.9364
|
Urban health facility
|
12
|
1734.417
|
70.99322
|
1578.162
|
1890.672
|
Rural health facility
|
12
|
10807.75
|
376.6756
|
9978.693
|
11636.81
|
{(Lockdown Phase 1: 25 March 2020 – 14 April 2020 (21 days)-Lockdown Phase 2: 15 April 2020 – 3 May 2020 (19 days)-Lockdown Phase 3: 4 May 2020 – 17 May 2020 (14 days)-Lockdown Phase 4: 18 May 2020 – 31 May 2020 (14 days)}. The lockdown strategy is found effective to control the COVID-19 outbreak but there are several limitations to impose lockdown for longtime [10]. Hence the government of India started unlock as follow [11]:{Unlock down 1.0: 1 June 2020 – 30 June 2020 (30 days)-Unlock down 2.0: 1 July 2020 – 31 July 2020 (31 days)-Unlock down 3.0: 1 August 2020 – 31 August 2020 (31 days)-Unlock down 4.0: 1 September 2020 - 30 September 2020 (30 days)-Unlock down 5.0: 1 October 2020 - 31 October 2020 (31 days)-Unlock down 6.0: 1 November 2020 - 30 November 2020 (30 days)-Unlock 7.0: 1 December 2020 - 31 December 2020 (31 days)-Unlock down 8.0: 1 January 2021 - 31 January 2021 (31 days)-Unlock down 9.0: 1 February 2021 - 28 February 2021 (28 days)-Unlock down 10.0: 1 March 2021 - 31 March 2021 (31 days)-Unlock down 11.0: 1 April 2021 - 30 April 2021 (30 days)-Unlock down 12.0: 1 May 2021 - 31 May 2021 (31 days)-Unlock down 13.0: 1 June 2021 - 30 June 2021 (30 days)-Unlock down 14.0: 1 July 2021 - 31 July 2021 (31 days)-Unlock down 15.0: 1 August 2021 - 31 August 2021 (31 days)-Unlock down 16.0 : 1 September 2021 - 30 September 2021 (30 days)-Unlock down 17.0 : 1 October 2021 - 31 October 2021 (31 days)-Unlock down 18.0: 1 November 2021-30 November 2021 (30 days)-Unlock down 19.0: 1 December 2021-31 December 2021 (31 days)-Unlock down 20.0: 1 January 2022-31 January 2022 (9 days)
Table-5- Statistical analysis of first-pandemic era-2020
pandemic era summary statistics
|
No. of Obs
|
Deaths occurring at Emergency Department
|
Variable Obs
|
No. of Obs
|
Mean
|
Std. Dev.
|
Min
|
Max
|
Total
|
12
|
16067
|
4159.466
|
10887
|
25014
|
Public health facility
|
12
|
15150
|
3467.83
|
10471
|
22275
|
Private health facility
|
12
|
917
|
859.3134
|
354
|
2739
|
Urban health facility
|
12
|
6308.833
|
3411.037
|
1463
|
13444
|
Rural health facility
|
12
|
9758.167
|
1962.054
|
6378
|
13817
|
Confidence Interval- means Deaths occurring at Emergency Department
|
Variable
|
No. of Obs
|
Mean
|
Std. Err.
|
[95% Conf. Interval]
|
Total
|
12
|
16067
|
1200.734
|
13424.2
|
18709.8
|
Public health facility
|
12
|
15150
|
1001.076
|
12946.65
|
17353.35
|
Private health facility
|
12
|
917
|
248.0624
|
371.0183
|
1462.982
|
Urban health facility
|
12
|
6308.833
|
984.6816
|
4141.564
|
8476.103
|
Rural health facility
|
12
|
9758.167
|
566.3963
|
8511.537
|
11004.8
|
|
|
|
|
|
|
|
|
|
|
|
Table-6- Statistical analysis of second-pandemic era-2021
pandemic era summary statistics
|
No. of Obs
|
Deaths occurring at Emergency Department
|
Variable Obs
|
No. of Obs
|
Mean
|
Std. Dev.
|
Min
|
Max
|
Total
|
5
|
21758.4
|
8605.957
|
14219
|
36377
|
Public health facility
|
5
|
19353
|
7709.256
|
13277
|
32613
|
Private health facility
|
5
|
2405.4
|
1201.265
|
942
|
3764
|
Urban health facility
|
5
|
11636.8
|
5944.345
|
6838
|
21881
|
Rural health facility
|
5
|
10121.6
|
2948.587
|
7381
|
14496
|
Confidence Interval- means Deaths occurring at Emergency Department
|
Variable
|
No. of Obs
|
Mean
|
Std. Err.
|
[95% Conf. Interval]
|
Total
|
5
|
21758.4
|
3848.701
|
11072.69
|
32444.11
|
Public health facility
|
5
|
19353
|
3447.684
|
9780.695
|
28925.31
|
Private health facility
|
5
|
2405.4
|
537.2219
|
913.8329
|
3896.967
|
Urban health facility
|
5
|
11636.8
|
2658.392
|
4255.921
|
19017.68
|
Rural health facility
|
5
|
10121.6
|
1318.648
|
6460.446
|
13782.75
|
Main results
A. Impact of COVID-19 pandemic on number of death occurring at the Emergency Department of all health facilities cumulative
The study results found that largest total number of death occurred in the ED during may 2021 whereas the least number of deaths occurred in February 2019 (linear regression is not done for forecasting adjustments due to two factors, first the COVID-19 situation and mortality is changing as well as largely associated with virulence of strain [9] and to keep data from accredited source intact on real grounds). During the first year of the pandemic, average cumulative mortality per month (Jan2020-Dec2020) in the emergency department (ED) of rural, urban, public and private hospitals in India was 16067per month whereas before the pandemic it was 12542 per month while during second year of pandemic i.e. 2021 the average mortality increased to 21758 per month (up to May 2021) see table1, 2, and 3, 4, 5, 6 and figures 1, 2, 3, 4 and 5.
Compared to the pre-pandemic era, in the 1st year of pandemic era the total number of deaths occurring at Emergency Department of rural, urban, public and private hospitals increased 1.28 times or 3525 per month average increase is seen see figure 1, Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department increased 1.73 times or 9216 per month average increase is seen see figure 1, Table 1 and 3.
B. Impact of COVID-19 pandemic on number of death occurring at the Emergency Department of public health facilities
The study results found that largest total number of death occurred in the ED of public health facility during may 2021 whereas the least number of deaths occurred in February 2019 (limitation is data availability up to May 2021 from accredited sources). During the first year of the pandemic, average mortality per month (Jan2020-Dec2020) in the emergency department (ED) of public hospitals in India was 15150 per month whereas before the pandemic it was 12128 per month while during second year of pandemic i.e. 2021 the average mortality increased to 19353 per month (up to May 2021).
Compared to pre-pandemic era in the first year of pandemic era the total number of deaths occurring at Emergency Department of public health facility increased 1.24 times or 3022 per month average increase is seen see figure 2, Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of public health facility increased 1.59 times or 7225 per month average increase is seen see figure-2, Table 1 and 3.
C. Impact of COVID-19 pandemic on number of death occurring at the Emergency Department of private health facilities The study results found that largest total number of death occurred in the ED of private health facility during may 2021 whereas the least number of deaths occurred in February 2019 (limitation is data availability from accredited sources). During the first year of the pandemic, average mortality per month (Jan2020-Dec2020) in the emergency department (ED) of private hospitals in India was 917 per month whereas before the pandemic it was 414 per month while during second year of pandemic i.e. 2021 the average mortality increased to 2405 per month (up to May 2021).
Compared to pre-pandemic era in the first year of pandemic era the total number of deaths occurring at Emergency Department of private health facility increased 2.21 times or 503 per month average increase is seen see figure 3, Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of private health facility increased 5.80 times or 1991 per month average increase is seen see figure 3,Table 1 and 3.
D. Impact of COVID-19 pandemic on number of death occurring at the Emergency Department of urban health facilities
The study results found that largest total number of death occurred in the ED of urban health facility during may 2021 whereas the least number of deaths occurred in March 2020 (limitation is data availability up to may 2021 from accredited sources). During the first year of the pandemic, average mortality per month (Jan2020-Dec2020) in the emergency department (ED) of urban hospitals in India was 6308 per month whereas before the pandemic it was 1734 per month while during second year of pandemic i.e. 2021 the average mortality increased to 11636.8 per month (up to May 2021).Compared to pre-pandemic era in the first year of pandemic era the average total number of deaths occurring at Emergency Department of urban health facility increased 3.64 times or 4574 per month average increase is seen see figure 4, Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of urban health facility increased 6.71 times or 9902 per month average increase is seen see figure 4,Table 1 and 3.
E. Impact of COVID-19 pandemic on number of death occurring at the Emergency Department of rural health facilities The study results found that largest total number of death occurred in the ED of rural health facility during may 2021 whereas the least number of deaths occurred in July 2020 (limitation is data availability up to may 2021 from accredited sources).
During the first year of the pandemic, average mortality per month (Jan2020-Dec2020) in the emergency department (ED) of rural hospitals in India was 9758 per month whereas before the pandemic it was 10807 per month while during second year of pandemic i.e. 2021 the average mortality reduced to 10121 per month (up to May 2021).Compared to pre-pandemic era in the first year of pandemic era the average total number of deaths occurring at Emergency Department of rural health facility reduced by 1.12 times or 1049 per month average decrease is seen see figure 5, Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of rural health facility reduced by 1.07 times or 686 per month average decrease is seen see figure 5,Table 1 and 3.
Here it is remarkable to note that compared to pre-pandemic era in the first year of pandemic era the average total number of deaths occurring at Emergency Department of rural health facility reduced by 1.12 times or 1049 per month average decrease is seen as well as compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of rural health facility reduced by 1.07 times or 686 per month average decrease is seen, whereas the urban facilities of healthcare has reported an increase in mortality during COVID-19 pandemic years. This may be due to shifting or referral of critical patients to urban higher centers. Still in India it’s very unfortunate that urban population is still devoid of higher tertiary centers.
The study results found that largest total number of death occurred in the ED of public health facility during may 2021 whereas the least number of deaths occurred in February 2019 (limitation is data availability from accredited sources). During the first year of the pandemic, average mortality per month (Jan2020-Dec2020) in the emergency department (ED) of public hospitals in India was 15150 per month whereas before the pandemic it was 12128 per month while during second year of pandemic i.e. 2021 the average mortality increased to 19353 per month (up to May 2021).
Compared to pre-pandemic era in the first year of pandemic era the total number of deaths occurring at Emergency Department of public health facility increased 1.24 times or 3022 per month average increase is seen see Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of public health facility increased 1.59 times or 7225 per month average increase is seen see Table 1 and 3.