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Saturday, August 15, 2020

Not every patient who died ‘with’ COVID-19, died ‘from’ COVID-19

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By Dr Kebba S Bojang

Majority of people who contracted COVID-19, do not die from it. And not every patient who died with it, died from it. Most people (about 80%),according to WHO, recover from the disease without needing special treatment, and for the majority – especially for children and young adults – illness due to COVID-19 is generally minor. However, for some people it can cause serious illness, requiring hospitalization, which can lead to death.

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Even though the case fatality rate for COVID-19 infection (i.e., the total number of deaths in patients positive for COVID-19 divided by the total number of people with a positive test) is not high, given the huge scale of the pandemic, the actual numbers of deaths are considerable. In The Gambia, of the COVID-19 cases, three people, so far, have been reported to have died. These three were diagnosed of having had the virus after their demise.

Diagnosing death is usually fairly easy; assigning cause of death, not so much. Death certificates all over the world, even from academic institutions, are rife with errors as reported in a study published in the journal, The Archives of Pathology & Laboratory Medicine. Death certificate is a legal document with diverse and far-reaching applications. In terms of disease surveillance, it contains epidemiologic data that are essential for formulating vital statistics and allocating public health resources. As such, it is important its completion is thorough and accurate. At times, aside the untoward errors that occur in completing the certificate, the cause of death can be deliberately falsified in order to serve specific purposes.

In this pandemic, determination of which deaths constitute that of COVID-19 will be a matter of interpretation; depending on the guidelines being followed in any given place. However, WHO guideline states that it should be made sure that deaths that are certified as Covid-19 were actually DUE TO COVID-19. This will follow that not every person who had had or was a probable case of COVID-19 and died could have only died from the virus.

The individual could have had other conditions that are as well lethal. In fact, the high likelihood, in some places, of counting as COVID-19 all deaths that occur in people who contracted the disease has led to some asserting that COVID-19 mortality numbers are being overstated. George D. Lundberg, a professor of pathologist, writing on Medscape ( a website providing access to medical information for clinicians) in Junemade an analogy of such a scenario with that of the annual death rate from Influenza from 2010 to 2019 reported by CDC, by stating that the huge numbers given were not a true representation of actual deaths from Influenza. He posited that the huge numbers resulted from lumping influenza and bacterial pneumonia. And that a large number of patients did not die from Influenza but rather with influenza that is comorbid with something else lethal.

Professor Karol Sikora, an ex-WHO Director, speaking on Planet Normal podcast of The Telegraph Network in June reiterated the assertion above by stating that the real coronavirus death toll in the UK could be much lower than the official toll as doctors may have marked the virus as the cause of death on certificates if there was “any hint” COVID-19 played a part, when in reality the virus may not have been the actual cause of those mortalities. On July 17, UK Health Secretary Matt Hancock asked Public Health England (PHE) to pause issuing daily coronavirus death toll figures and urgently review estimation of their daily death statistic after being accused of issuing dodgy stats. PHE stands accused of including in their death figures anyone who ever tested positive for COVID-19 and dies even if they have died from something else.

However, there are those who contend that deaths due COVID-19 were being understated with the new evidence that patients can die from its other complications beside those of respiratory system (acute respiratory distress syndrome). According to a report in Scientific American, some young people who have died of stroke and heart attack and tested positive for COVID-19 could have been assigned COVID-19 as cause of death; now that we know the virus can cause blood clotting problems leading to stroke and complications in organs throughout the body.

Mortality due to COVID-19 had been understood to be mainly due to the respiratory complication of the disease(acute respiratory distress syndrome). A Study published in The International Journal of Infectious Diseases in May, looking at the clinical characteristic of all mortality cases with COVID-19, found all the mortality cases to be due to respiratory failure. It was the anticipation of this complication leading to death in COVID-19 patients that had led to the increase demand for ventilators all over the world at the initial stage of the pandemic. However, as knowledge and understanding of the virus increased, it wasrealized that COVID-19 is more than a respiratory disease. It is now understood to have multi-organ effects; causing multiple organ dysfunction, beside the lungs, commonly in heart, kidney and liver.

Accurately determining if COVID-19 was the last straw, or is part of causal sequence of events leading to the immediate cause of death will depend on the situation. Determination of death as that of COVID-19 in a clinically compatible illness, in a probable or confirmed case, where there is no alternative cause of death that is not related to COVID disease (e.g. trauma) may be straight forward. However, in some cases particularly those who died at home or die just on arrival at emergency room; or in the case of the first three mortalities reported in The Gambia who were diagnosed of having had the disease after death, determination can be little fuzzy. It can be challenging to know if these patients died of COVID-19, or with COVID-19. Autopsy could help answer this question, but autopsy rates, even pre-pandemic, were very low. And most importantly, there are special biosafety concerns associated with patients who have died having COVID-19.

People who are over 60 years, and people who have underlying chronic medical conditions such as diabetes, hypertension, chronic respiratory diseases, coronary artery disease are reported to be predisposed to developing severe form of COVID-19 and death. However, this does not mean that people with these comorbidities would not die from them while they have COVID-19. People with hypertension who contracted Covid-19 can still die from conditions which can be attributed to the preexisting hypertension. So is in the cases of those with diabetes, chronic respiratory disease, cancer, etc. As per WHO guideline to certify as due to Covid-19, the death may not be attributed to another disease and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19. And that, Covid-19 should be part of a sequence ending with a terminal condition (Example acute respiratory distress syndrome due to COVID-19) resulting to death.

In certifying death, an immediate cause of death, as well as the chain of events that led to that final disease or incident are listed. Other conditions contributing to death but not directly are listed too in a separate space. For COVID-19, the immediate cause of death might be listed as respiratory distress, “due to pneumonia”, which was “due to COVID-19.” As in ‘death ? respiratory distress ? pneumonia ? COVID-19’. Other factors such as heart disease, diabetes or high blood pressure would then be listed as contributory factors.
However, in situations where COVID-19 is believed to be an epiphenomenon, it should be listed as contributory factory. In such situations, mortalities should be described as ‘COVID-19 associated’ and not ‘COVID-19 mortality’; as association is not the same as causality.

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