Chikungunya is a virus spread by the bite of the Aedes mosquito, which recently reemerged as a massive epidemic in the Indian Ocean islands and India. Chikungunya is generally considered self-limiting and has been reported as non-fatal but, since March 2005, one-third of the 770,000 people in the Indian Ocean Island of R�union (a French territory) have been affected by Chikungunya with 237 deaths. India reported 1.3 million cases of Chikungunya however the Government of India has not reported any deaths. However there is evidence that deaths due to Chikungunya did occur. The lack of official reports of deaths is mainly due to the poor recording of ‘Causes of Death’ in India. The London Bills of Mortality from the 17th provides a very good example of the importance of proper reporting of deaths especially during an epidemic period. This paper reflects on the London bills of mortality and modern day lessons to be drawn from it as well as the reasons behind the apparent lack of death reporting in 2006’s Chikungunya epidemic.

Mavalankar, Dileep

Ramani, K. V.

Shastri Priya

English

Research Papers in Economics

  INDIAN INSTITUTE OF MANAGEMENT 
AHMEDABAD y  INDIA 
Research and Publications 
 
 
 
 
 
 
 
 
Chikungunya Epidemic Mortality in India: 
Lessons from “17
th Century Bills of Mortality” still relevant 
 
Dileep Mavalankar 
Priya Shastri 
K.V. Ramani 
 
W.P. No.2007-07-12 
July 2007 
 
 
 
 
 
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INDIAN INSTITUTE OF MANAGEMENT 
AHMEDABAD-380 015 
INDIA   IIMA  y  INDIA 
Research and Publications 
Chikungunya Epidemic Mortality in India: 
Lessons from “17
th Century Bills of Mortality” still relevant 
 
 
Dileep Mavalankar 
Priya Shastri 
K.V. Ramani 
 
 
Abstract 
 
Chikungunya is a virus spread by the bite of the Aedes mosquito, which recently 
reemerged as a massive epidemic in the Indian Ocean islands and India. 
Chikungunya is generally considered self-limiting and has been reported as non-fatal 
but, since March 2005, one-third of the 770,000 people in the Indian Ocean Island of 
Réunion (a French territory) have been affected by Chikungunya with 237 deaths.   
India reported 1.3 million cases of Chikungunya however the Government of India 
has not reported any deaths.  However there is evidence that deaths due to 
Chikungunya did occur. The lack of official reports of deaths is mainly due to the 
poor recording of ‘Causes of Death’ in India. The London Bills of Mortality from the 
17th provides a very good example of the importance of proper reporting of deaths 
especially during an epidemic period. This paper reflects on the London bills of 
mortality and modern day lessons to be drawn from it as well as the reasons behind 
the apparent lack of death reporting in 2006’s Chikungunya epidemic. 
   
 
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Chikungunya Epidemic Mortality in India: 
Lessons from “17
th Century Bills of Mortality” still relevant 
 
 
Introduction 
 
Chikungunya is a virus spread by the bite of the Aedes mosquito, which recently reemerged 
as a massive epidemic in the Indian Ocean islands and India. Severe morbidity and a rise in 
mortality have also been reported. This disease was discovered in Africa in 1953.
1 The 
clinical picture of Chikungunya is similar to Dengue (high fever and body ache); but it is also 
characterized by symptoms of severe joint pain. Chikungunya is generally considered self-
limiting and has been reported as non-fatal in the past. However, severe forms of the disease 
affecting the Central Nervous System and fulminant hepatitis have been reported recently 
along with several deaths. Since March 2005, one-third of the 770,000 people in the Indian 
Ocean Island of Réunion (a French territory) have been affected by Chikungunya with 237 
deaths.
1 Researchers have also reported an overall increase in mortality on this island during 
the epidemic.
2 The Chikungunya strain found on the Réunion Island has also undergone 
some mutation and microevolution and therefore better adapted to the mosquito vector.
3 This 
could help explain the high virulence of Chikungunya virus, increased morbidity and 
mortality seen in the recent epidemic.  
 
In spite of the 1.3 million reported cases of Chikungunya, the Government of India has not 
reported any deaths.
4   Poor reporting of deaths and ‘cause of death’ recording in India could 
have contributed to no records of Chikungunya deaths. In contrast, the detailed ‘London Bills 
of Mortality’ initiated  400 years ago did a much better job of documenting deaths due to the 
plague in England. These bills also started the ‘Cause of death’ recording for public health 
use.
5 In this paper evidence of the presence of Chikungunya deaths in India is discussed. 
Learning from the “Bills of Mortality”; the Government of India, World Health Organization 
(WHO) and other international agencies, must ensure proper recording of deaths and detailed 
investigation of the cause of death during epidemics in developing countries like India. 
   
 
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The Chikungunya Epidemic in India 
 
Chikungunya re-emerged in India in December 2005 after a gap of 32 years. Official figures 
from the government of India indicate 1.39 million suspected Chikungunya cases from 152 
districts across 10 states in India.
4, 6 The epidemic spread rapidly and affected many 
communities with an attack rate as high as 40-60% .
7 The most likely explanation of this 
rapid penetration of the virus could be the lack of herd immunity in the population, 
unplanned development, poor public health systems- specifically the vector control systems 
and perhaps mutation in the virus.  
 
Recently, the first reported Chikungunya deaths on the Réunion Island took the French 
authorities and the world by surprise as Chikungunya was previously considered non-fatal. 
French scientists reported a mortality rate of about 1 per 1000 cases on this Island.
2 The 
strain of virus in this Indian Ocean Island’s outbreak and the Indian subcontinent were found 
to be of the same African Sub-type.
8  Surprisingly, the Government of India has not reported 
any deaths in spite of 1.39 million officially reported cases.  
 
Ahmedabad city and other parts of Gujarat State (population ~ 50 million) were in the grip of 
a massive epidemic of Chikungunya during July- October 2006 with more than 70,000 
officially reported cases. Our observations in the city of Ahmedabad and reports from other 
parts of the country during the epidemic months (August-October 2006) indicate the strong 
evidence of many deaths due to Chikungunya. The evidence for deaths is as follows:  
 
1.  One Non Governmental Organization (NGO) hospital and two private hospitals in 
Ahmedabad have issued several death certificated or case summaries showing 
Chikungunya as one of the causes of death. 
2.  Two crematoria in Ahmedabad have recorded substantial increase in the total number 
of bodies cremated during the epidemic months, with several deaths indicating 
Chikungunya as cause of death as entered in the crematorium register.  
   
 
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3.  Some newspaper and news magazine reported serious complications and deaths 
following Chikungunya.
9  
4.  Data from Registrar of Births and Deaths (RBD) of Ahmedabad city shows gross 
excess number of deaths during the epidemic months as compared to the same 
months in the previous two years.  
5.  A surgeon, Dr. Astha Trivedi has presented a paper “Surgical Complications due to 
Chikungunya” at the annual conference of  the ‘Association of Surgeons’ in Gujarat 
(15-17 Dec 2006)  which showed 33% mortality in 60 selected cases of surgical 
complications of Chikungunya. 
6.  Members of Parliament (MPs) from several states have raised questions in the 
national parliament on cases and deaths due to Chikungunya. 
10 
 
 
I. 
a. Death and Chikungunya Data from the crematorium located next to the V.S. hospital 
Month  Total Deaths  Chiukungunya death out of total death 
reported 
May’06 216  0 
June ‘06  152  0 
July ‘06  171  1 (as fever) 80 years old  
August’06  263  2 (as fever) 70 & 80 yrs. old 
Sept. ‘06  383  20 deaths: 
(15 as CKG + 5 as fever) 
Oct. ‘06  315  8 deaths: 
(6 as CKG + 2 as fever) 
(Source: A.M.C. crematoriums register at crematorium located next to V.S.Hospital) 
 
b. Death and Chikungunya Data from Dhudheshwar and Wadej Crematorium 
 
Name of the 
Crematorium     May  June  July   August  Sep.  October
Total Deaths  144 139 137 226  233  189
Chikungunya cases  0 0 0 0  12  16
Dudheshwar 
  
   Fever cases  4 4 2 11  36  11
Total Deaths  279 279 243 344  445  334
Chikungunya 0 0 0 1  22  8
Wadej  
  
   Fever Cases  5 3 2 8  15  11
 
 
 
   
 
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Why are there no reported Chikungunya deaths in India?  
 
No deaths due to Chikungunya have been reported by the government of India even though 
there have been 1.3 million reported cases. On 22
nd November 2006, our national health 
minister stated in the parliament that “There are no reported deaths directly attributable to 
Chikungunya from any of the affected state in the country” in response to a Loksabha 
question on “the number of persons died during last one year of Chikungunya”.
10 The key 
reasons for not finding any Chikungunya deaths, in our opinion are:  
1. Poor reporting of death, and causes of death. 
2.  Lack of availability of blood testing facilities for the virus (with only two 
government institutes in the whole county). Only 13000 samples have been sent 
for testing out of 1.3 million suspected cases. Many hospital authorities are afraid 
to stamp a death case as Chikungunya without a positive blood test. Instead such 
deaths are attributed to fever, viral fever, multi-organ failure or Cardio Respiratory 
Failure (CRF). 
3. The clinical case definition of Chikungunya death has not been developed or 
disseminated widely by any national/state health authority or any research institute.  
4. No systematic efforts have been made to screen all the deaths during the epidemic 
to identify which of them were due to Chikungunya.  
5. No system was developed to follow up the 1.3 million reported cases of 
Chikungunya to see if any of them had resulted in death.  
 
When we discussed the issue of Chikungunya deaths with various government authorities, 
they dismissed it as a “non-fatal disease” or due to “poor clinical management by the 
doctors”. They also stated that deaths occurred only in old people suffering from other 
chronic diseases and hence not attributable to Chikungunya. The government’s casual 
attitude towards the epidemic and its deaths is very shocking. The lack of reporting of 
Chikungunya deaths could also be due to the fear of adverse reaction from political, social 
and economic fronts.  Under reporting of death is very common for all deaths in India and 
not restricted to Chikungunya deaths, as seen in the table below. 
   
 
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II . Death reported by government, estimated by Global Burden of Diseases (GBD) and 
% under reporting   
 
Disease Reported  deaths 
in India ,2000
11
Estimated deaths 
in India, 2000
12
 
Estimated % of 
underreporting by 
the Government. 
Malaria                      932    14000     93.3 
Dengue                          7      6000     99.8 
Japanese Encephalitis         556      1000     44.4 
Diarrhea       2918   553000     99.4 
 
 
During the epidemic a national expert team investigated the epidemic in Ahmedabad during 
12
th-16
th September.
13 The National Institute of Virology experts also collected blood 
samples from seriously ill patients in Ahmedabad city during the epidemic, but neither team 
systematically investigate any deaths. Instead they relied on the poorly developed routine 
death reporting system for data. After our insistence, the Gujarat Government and the 
Ahmedabad Municipal Corporation have recently begun some investigation of death records. 
 
Estimates of Deaths Due to Chikungunya: 
 
Applying the mortality rate of Réunion which was 237 deaths from the 258,000 cases 
reported we have estimated that India could have 1194 deaths from the 1.3 million cases 
reported.  A more realistic estimate would be at least 6000 or as high as 18000 deaths during 
the epidemic period (Mavlankar D, Shastri P, Raman P. Chikungunya epidemic in India: A 
major Public Health disaster. (Unpublished Observations)
 
The Role of International Agencies: 
 
It is surprising that the WHO and the Center for Disease Control (CDC) of USA have not 
played a proactive role in studying and documenting the epidemic including mortality or 
warning the countries about its possible spread. Even after recent papers published by 
   
 
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scientists of  the French Government Public Health Institute which show mortality from  the 
Chikungunya on Reunion island, the WHO website mentions that “Chikungunya  is rarely a 
life threatening infection” 
14
 
What India can learn from “Bills of Mortality?” 
 
The ‘Bills of Mortality’ were the first systematic collection and compilation of death 
statistics started in London and parts of England during the late 17
th century as a way to 
record the total number of deaths, especially deaths due to the Plague epidemics. The 
recording of ‘cause of death’ began in 1629.
5 These causes were entered in the records by the 
parish clerks and were sent to the city office every Tuesday. This process was so systematic, 
regular, and transparent that these records were printed and distributed on every Thursday to 
the general public.
1 Apart from the weekly records - “a general account of the whole year 
was given before Christmas day”. 
15 The “Bills of Mortality” were replaced by the creation of 
the General Register Office for England and Wales in 1837.
5 These statistics were vital in 
analyzing the number of deaths, disease outbreaks and epidemics and formed the basis of 
public health actions in England. They were an important tool which citizens and politicians 
used to pressurize civic authorities to implement various sanitary reforms and health 
measures in England. Are these bills of mortality from the 17
th century relevant to the 21
st 
century India?  The controversy on Chikungunya deaths shows that India must take action 
urgently to improve the system of death registration and should also publish and make public 
mortality data on a weekly basis with a proper cause of death analysis. This will be useful in 
predicting and understanding such epidemics better. This calls for a political and 
administrative commitment to strengthen the state, district and city/town offices of ‘registrar 
of births and deaths’ and epidemiological units. It also calls for more training of doctors, 
nurses and medical record clerks to accurately report cause of death. Strict monitoring and 
follow up for causes of death reporting is needed. Non-reporting or misreporting has to be 
reprimanded to improve the situation.  
 
   
 
W.P.  No.  2007-07-12  Page No. 8 
                                                 
1 Even today the city of Ahmedabad takes 3-4 weeks at the end of the month to come up with a total number of 
registered  deaths, and there is no cause of death analysis. 
   IIMA  y  INDIA 
Research and Publications 
The situation in India may not be unique. Many developing countries are in the same 
situation and can also learn a lot from ‘Bills of Mortality’. Suppressing data or not recording 
the cause of death in epidemics may lead to a more expansive spread of the epidemic.  Hence 
the Government of India, WHO, CDC, the Gates foundation and other global health leaders 
must invest in improving death reporting and epidemic analysis response mechanism which 
are the basics of any public health system. If we do not improve the cause of death reporting 
then in the future more dangerous diseases like SARS and the Bird flu may spread wildly and 
kill many more before epidemics are even detected. 
   
 
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References 
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543. 
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Disease Outbreak, Reunion island. Emerging Infectious Diseases, 2006; 12(12): 1994. 
3.  Schuffenecker I, Iteman I.  Genome Microevolution of the Chikungunya viruses causing 
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13. National Institute of Communicable Diseases, Government of India. Epidemiological 
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Chikungunya Epidemic Mortality in India: Lessons from 17th Century Bills of Mortality Still Relevant

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Chikungunya Epidemic Mortality in India: Lessons from 17th Century Bills of Mortality Still Relevant

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