Abstract
OBJECTIVE: India had an estimated three to five million excess deaths from causes attributable to SARS-CoV-2 during 2020-2021, far exceeding official government statistics. Most deaths in India occur in rural areas, where medical certification of deaths is limited. Yet, the effects of the pandemic in rural settings remain largely undocumented. We estimated the cause-specific excess mortality in rural areas of selected states of India. DESIGN: Longitudinal analyses of hospital mortality data. SETTINGS: India's Health Management Information System (HMIS) reports the number of deaths by cause for adolescents or adults aged 10 years or more. We examined eight states with high coverage of the expected number of deaths in rural areas. PARTICIPANTS: We analysed monthly death reports from the HMIS, which covered approximately 0.2 million health facilities during 2018-2023. We compared excess deaths during the peak COVID-19 months in rural health facilities to pre-COVID-19 and non-peak periods of 2021, and categorised reported causes by their probable association with COVID-19. PRIMARY OUTCOME MEASURE: Excesses of cause-specific and total mortality. RESULTS: During the April-June 2021 SARS-CoV-2 wave, predominantly driven by the Delta variant, monthly deaths in rural health facilities across India surged from approximately 200 000 to 500 000. In eight states with high-quality reporting, rural facility deaths increased by 270% (95% CI 267% to 272%) compared with the same months in 2018-2019, prior to the COVID-19 pandemic. Notably, this surge occurred despite a sharp decline in hospital admissions following the national lockdown in March 2020. The largest relative increase was for fever-related and respiratory diseases, and these deaths were markedly elevated even when compared to non-peak months of 2021. Generalising these findings from eight states to all of rural India yields an estimate of approximately 2.6 million excess rural deaths in April-June 2021. In contrast, there were few excess deaths during the Omicron viral waves in 2022-2023. CONCLUSION: COVID-19 substantially increased deaths in rural India during April-June 2021, but reassuringly, no significant excess mortality was observed in subsequent years. The HMIS provides an important opportunity to strengthen routine mortality surveillance in rural India.