Evidence of age-related inequities in COVID mortality in the Indian state of Manipur using hospital records and death certificates

COVID-19 mortality has been widely associated with recognized risk factors, including older age and pre-existing comorbidities. However, emerging evidence from low- and middle-income settings indicates that younger adults may also experience substantial fatality due to social and structural vulnerabilities. This study examined age-related inequities in COVID-19 mortality in Manipur, India, using hospital records and Medical Certificates of Cause of Death. A retrospective analytical record-based study was conducted using hospital records and Medical Certificates of Cause of Death (MCCD) for COVID-19 deaths reported between March 2020 and June 2021. Descriptive statistics and chi-square tests were used to compare characteristics between age groups. Data from 1,000 confirmed COVID-19 deaths (≥ 18 years) in five plain districts of Manipur were included and analysed. Deaths were categorised into younger adults (18–44 years) and older adults (> 44 years). Socio-demographic characteristics, comorbidities, clinical course, and selected laboratory parameters were compared by age and sex using descriptive statistics and chi-square tests. Younger adults accounted for 12.6% of deaths. Among younger adults, mortality was strongly associated with social and economic vulnerabilities, including unmarried status, childlessness, engagement in informal or service-sector occupations, and absence of regular income( p < 0.05). Notably, a significant proportion of younger adult deaths occurred among individuals without documented chronic conditions( p < 0.05). Laboratory findings indicate elevated inflammatory and coagulation markers, including D-dimer and C-reactive protein, across age groups. COVID-19 mortality in Manipur reflected pronounced age-related inequities shaped by social determinants and health system factors rather than age or comorbidity alone. Social determinants and inflammatory biomarkers played an important role in younger adult deaths.