COVID-19 mortality effects of underlying health conditions in India: a modelling study

Objective To model how known COVID-19 comorbidities affect mortality rates and the age distribution of mortality in a large lower-middle-income country (India), and to identify which health conditions drive differences with high-income countries. Design Modelling study. Setting England and India. Participants Individual data were obtained from the fourth round of the District Level Household Survey and Annual Health Survey in India, and aggregate data were obtained from the Health Survey for England and the Global Burden of Disease, Risk Factors and Injuries Studies. Main outcome measures The primary outcome was the modelled age-specific mortality in each country due to each COVID-19 mortality risk factor (diabetes, hypertension, obesity and respiratory illness, among others). The change in overall mortality and in the share of deaths under age 60 from the combination of risk factors was estimated in each country. Results Relative to England, Indians have higher rates of diabetes (10.6% vs 8.5%) and chronic respiratory disease (4.8% vs 2.5%), 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 uncontrolled diabetes (+5.67%) and chronic respiratory disease (+1.88%), and most reduced by obesity (-5.47%), cancer (-3.65%) and chronic heart disease (-1.20%). Comorbidities were associated with a 6.26% lower risk of mortality in India compared with England. Demographics and population health explain a third of the difference in share of deaths under age 60 between the two countries. Conclusions Known COVID-19 health risk factors are not expected to have a large effect on mortality or its age distribution in India relative to England. The high share of COVID-19 deaths from people under age 60 in low- and middle-income countries (LMICs) remains unexplained. Understanding the mortality risk associated with health conditions prevalent in LMICs, such as malnutrition and HIV/AIDS, is essential for understanding differential mortality.