The second volume of COVID-19 death audit report released by the Kerala Health Department has once again re-opened the controversy over the State’s death reporting process, which many senior health officials themselves believe, has left out many legitimate “probable COVID-19 deaths” out of the official list.
The death audit report (vol. 2) released by the Health Department pertains to 63 deaths in July (including two in June) which were all lab-confirmed cases of the pandemic.
Of these 63, only 51 cases wherein the death audit committee assessed the underlying cause of death to be COVID-19 has been included in the official tally for analysis. Seven cases — three cases of acute myocardial infarction (MI), three cases of cancers and one suicide — have been assessed as non-COVID-19 deaths and excluded from analysis. One death was left out as the deceased was a native of Tamil Nadu. Four cases are pending for post-mortem results.
A COVID-19 death is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case. Cases where there is a clear, unrelated alternative cause of death (e.g. trauma) are not deaths owing to the pandemic. There should be no period of complete recovery from COVID-19 between illness and death.
The State claims that it is following the international guidelines of the World Health Organisation (WHO) for certification and classification of the COVID-19 as cause of death. It faithfully quotes the WHO to claim that deaths due to “unrelated causes like acute MI” are not novel coronavirus deaths.
“However, it is now quite well known that Acute MI is a relevant complication of COVID‐19 and that due to thrombo inflammation, even those patients without any cardiac history can have diffuse coronary thrombosis. Even Acute MI deaths which occur after a COVID patient has been tested negative and discharged should be seen as a continuum of the disease and not as an unrelated incident,” a senior clinician said.
Public health experts point out that for some inexplicable reason, for death classification, the State has chosen the WHO document over the ICMR’s guidance document, which is a very lucid piece of writing.
The ICMR is very clear that even if a positive person has co-morbidities, “that should not be listed as the underlying cause of death; the cause of death remains COVID-19” .
They also pointed out that while the WHO document technically says the same thing as the ICMR , it leaves some room for misinterpretation, behind which the State has taken cover.
Kerala’s exclusion of one death from analysis because the deceased is not a Keralite is totally irrational because all COVID-19 deaths that occurred in the State is part of the State’s pandemic picture.
The death audit report analyses only lab-confirmed cases. Leaving behind all “suspect or probable cases of COVID-19” or cases wherein clinical or epidemiological diagnosis of the viral infection is not backed by laboratory confirmation is not a scientific practice and would leave a huge gap in the State’s assessment of pandemic impact, experts said.
Also, the ICMR has never told States to institute death audit committees to sit in judgment over the Medical Certification of Cause of Death (MCCD) , which has been prepared by clinicians who have actually treated the patient, it is pointed out.
During a pandemic, it is only wise that all pandemic-related deaths, including suspected or unconfirmed cases, are considered COVID-19 deaths, not just to avoid confusions but also to ensure data transparency.
“New information on COVID-19 also points to neurological manifestations and vascular complications, which can trigger anything from altered mental status to an MI or stroke. During the pandemic, if more people are dying of complications due to their co-morbidities, these deaths, including some suicides, should ideally be listed as COVID-19 deaths.
“What is most interesting is that Kerala has one of the best case fatality rates of 0.37, which still would not go beyond 0.6 even if we were to include all unconfirmed deaths. Unfortunately, Kerala’s attempts to keep out some deaths from the official list has sullied the State’s image and put a question mark on the integrity of the medical fraternity here,” a public health official said.
He pointed to the example of Belgium, which has one of the highest COVID-19 death rates in Europe because they have chosen to include all suspected deaths too in their figures. Belgium’s top virologist was quoted as saying, “it might be an overestimation but it is the only honest way to do it .”
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