Kerala was among the six states in India where Covid-19 was the leading cause of death in 2021, as per the latest Medical Certification of Cause of Death (MCCD) 2021 released by the Office of the Registrar General of India. Karnataka, Manipur, Meghalaya, Uttarakhand and Uttar Pradesh were the other states where Covid killed more people than any other disease.

Nationwide, deaths reported due to Covid-19 accounted for 17.3 per cent of total medically certified deaths and has been recorded as the second leading cause for group of deaths in 2021. Diseases of circulatory system, Covid-19 and diseases of respiratory system remained the top three leading causes of death in the country in 2021.

In Kerala, Covid caused 35 per cent of total medically certified deaths, marking a shift from the usual trend where cardiovascular disease has always been the top cause of death. In 2021, as Covid peaked, circulatory system diseases contributed to 20.7 per cent of medically certified deaths while cancer accounted for 9.6 per cent mortality in Kerala.

In 2020, cancer was the cause of death in 15 per cent of total medically certified deaths, while cardiovascular diseases' share was 28.6 per cent in Kerala. According to the health officials and infectious disease experts, Kerala's high rate of Covid deaths reflected increased community testing, diagnosis and reporting. "There was a major change in the way Covid deaths were recorded in Kerala following the reconciliation of deaths following the Supreme Court order and distribution of ex-gratia for the kin of Covid victims. Kerala was one among the very few states which recorded better Covid testing and reporting capacity. The latest figures are a reflection of this practice," a health official said. 

In September 2021, the Kerala government issued guidelines for Covid-19 death declaration document as per the directions of the Ministry of Health and Family Welfare. The state formed a Covid-19 death ascertaining committee (CDAC) to issue the official document of Covid-19 death. In June 2021, the Supreme Court directed the government to issue simplified guidelines for issuance of death certified/official document stating the exact cause of death.

"Following the directions issued by the Supreme Court, if a person who had been tested positive for Covid-19 died within one month due to heart disease or any other major causes, that was recorded as Covid death. Kerala's high percentage of Covid deaths is a result of following the guideline and massive community testing. If testing is done in a low-risk group, deaths happening in that group get added under other causes," said Dr Anish TS, nodal officer, Kerala One Health, Centre for Nipah Research and Resilience, and Professor of Community Medicine.

The percentage of medically certified deaths to total registered deaths in Kerala in 2021 was 10.6. During 2021, as per recommendation of Indian Council of Medical Research, codes for covering deaths due to Covid-19 (U07.1 and U07.2) were recorded as a separate major cause group. Kerala's all-cause mortality showed an increase of 88,665 between 2020 and 2021 according to the total registered deaths in Kerala.