India has had 3· 6 million cases of COVID-19, the third most in the world after the USA and Brazil, with 65 288 officially confirmed deaths from the disease as of Sept 1, 2020. The Indian Government says that the national recovery rate has reached 77% and the case fatality rate is down to 1· 8%, due to “timely and effective clinical management of the patients in critical care” according to an official statement on Aug 30. However, experts who spoke with The Lancet have pointed to several sources of uncertainty in India’s COVID-19 mortality data. It is unclear how suspected or probable COVID-19-attributable deaths are being included in mortality estimates. Indian Council of Medical Research (ICMR) guidelines stipulate that deaths of people with suspected or probable COVID-19 should be included in mortality data, based on WHO ICD-10 codes for COVID-19-related deaths. However, the guidelines are advisory. Information about whether state data on deaths include suspected and probable cases is not in the public domain and the Indian Ministry of Health and Family Welfare did not respond to The Lancet’s requests for clarification.

“For COVID-19, we have to throw the net more widely to capture all the deaths (confirmed and suspected) in order to understand the disease better and for its management” says Prashant Mathur, director of the National Centre for Disease Informatics and Research (NCDIR), an ICMR body.“It is important to correctly record the cause of deaths. But it is up to individual states to follow these guidelines. As per the existing law, NCDIR is not required to get data about suspected or probable deaths from states so I can’t say whether deaths are being certified.”