The COVID-19 mortality effects of underlying health conditions in India: a modelling study
Authors: Novosad Paul , Jain Radhika , Campion Alison , Asher Sam 
Published: July 2020

ABSTRACTObjectiveTo model how known COVID-19 comorbidities will affect mortality rates and the age distribution of mortality in a large lower middle income country (India), as compared with a high income country (England), and to identify which health conditions drive any differences.DesignModelling study.SettingEngland and India.Participants1,375,548 respondents aged 18 to 99 to the District Level Household Survey-4 and Annual Health Survey in India. Additional information on health condition prevalence on individuals aged 18 to 99 was obtained from the Health Survey for England and the Global Burden of Diseases, Risk Factors, and Injuries Studies (GBD).Main outcome measuresThe primary outcome was the proportional increase in age-specific mortality in each country due to the prevalence of each COVID-19 mortality risk factor (diabetes, hypertension, obesity, chronic heart disease, respiratory illness, kidney disease, liver disease, and cancer, among others). The combined change in overall mortality and the share of deaths under 60 from the combination of risk factors was estimated in each country.ResultsRelative to England, Indians have higher rates of diabetes (10.6% vs. 8.5%), chronic respiratory disease (4.8% vs. 2.5%), and kidney disease (9.7% vs. 5.6%), and lower rates of obesity (4.4% vs. 27.9%), chronic heart disease (4.4% vs. 5.9%), and cancer (0.3% vs. 2.8%). Population COVID-19 mortality in India relative to England is most increased by diabetes (+5.4%) and chronic respiratory disease (+2.3%), and most reduced by obesity (−9.7%), cancer (−3.2%), and chronic heart disease (−1.9%). Overall, comorbidities lower mortality in India relative to England by 9.7%. Accounting for demographics and population health explains a third of the difference in share of deaths under age 60 between the two countries.ConclusionsKnown COVID-19 health risk factors are not expected to have a large effect on aggregate mortality or its age distribution in India relative to England. The high share of COVID-19 deaths from people under 60 in low- and middle-income countries (LMICs) remains unexplained. Understanding mortality risk associated with health conditions prevalent in LMICs, such as malnutrition and HIV/AIDS, is essential for understanding differential mortality.SUMMARY BOXWhat is already known on this topicCOVID-19 infections in low- and middle-income countries (LMICs) are rising rapidly, with the burden of mortality concentrated at much younger ages than in rich countries.A range of pre-existing health conditions can increase the severity of COVID-19 infections.It is feared that poor population health may worsen the severity of the pandemic in LMICs.What this study addsThe COVID-19 comorbidities that have been studied to date may have only a very small effect on aggregate mortality in India relative to England and do not shift the mortality burden toward lower ages at all.India’s younger demographics can explain only a third of the substantial difference in the share of deaths under age 60 between India and England.However, mortality risk associated with health conditions prevalent in LMICs, such as malnutrition and HIV/AIDS, is unknown and research on this topic is urgently needed.