COVID death tally: Confusion over parameters keeps count fluid

How to ascertain a death as COVID death is still a point of debate as far as experts as concerned. There are many who argue that the death of a person tested positive, irrespective of the gravity of comorbidities, is a COVID death unless it is a suicide, accident or murder.

Doctors and experts took sides in the grooming controversy around whether the government is underplaying the death count. The official COVID dashboard of Kerala has given how certain deaths are eschewed from the list of COVID deaths in the state.

As per the dashboard, as on August 18, 52 deaths out of the total confirmed cases had been excluded from the COVID-19 death list of Kerala. The death toll till date is 169. In some of the cases –  excluded from the list – the cause of death was ascertained as cancer and heart attack. The Kerala Government claims that it has been following the WHO guidelines on defining Covid death and there is no deliberate effort to conceal the actual death toll.

As per guidelines issued by WHO, the definition goes as follows: ‘A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma)’.

“It is not necessary that in all cases the presence of the virus is the cause of death, especially for asymptomatic cases,” says Dr K P Aravindan, who is a member of the expert committee that advises the state government on COVID-related matters. “There were some discrepancies in the data earlier only because of the confusion among health workers with regard to the guidelines and there was no conspiracy behind it,” he said. “Even otherwise the death toll is very low in Kerala, a change in a few numbers does not make any difference,” Dr Aravindan said, dismissing the conspiracy theories.

The list of cases excluded as shown in the dashboard cites deaths due to heart attack and cancer. “COVID might not be the sole reason for all cases in which there were fatal comorbidities. There is a detailed medical examination for each case and the final decision is taken by the medical board. Hence the everyday figures being released by the Government need not be final,” says Dr Mohammed Asheel, the Director of Social Security Mission of Kerala.

However, those who speak for the Government are not able to explain why a few deaths of cancer also were excluded from the list if the Government is strictly following the WHO guidelines. The guideline issued on April 20 unambiguously stated: ‘A death due to COVID-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of pre-existing conditions that are suspected of triggering a severe course of COVID-19’.

“This happens only in some specific cases of which the cause of death is ascertained to be the existing cancer condition and not the presence of the virus. On the other hand, there are cases of cancer included in the list of COVID death,” says Dr Mohammed Asheel.

A section of doctors and experts are strong critics of this policy. “We cannot say that COVID has nothing to do with the death of a person whose immediate cause of death ascertained to be something else – heart attack or any other comorbidities,” says Dr Arun N M, who has had an independent research on the discrepancies in the data provided by the State. According to Dr Arun, the presence of the virus accelerates the fatality, for example, the chances of a blood clot in a COVID positive person is high which could lead to a heart attack.

”Thromboembolism and bleeding is well known in COVID. So COVID should be mentioned in the medical certificate. How can you be sure that COVID did not play a part in accelerating the death? All over the world, an inclusive policy is followed mainly because in a pandemic like that of SARS Cov 2 which can cause myocardial ischemia, arterial and venous thrombosis and DIC it’s highly unlikely that SARS Cov 2 infection did not play any role in accelerating death,” says Dr Arun. Under these guidelines, Dr Arun claims that 35 to 40 per cent of COVID deaths are recorded as non COVID deaths in the state.

Though the cause of death is ascertained as a non-COVID one, the protocol with regard to cremation has been strictly followed in all cases. Whether a case of COVID death or not is being taken into consideration only for the purpose of including in the data bank. This practice also causes confusion among people. “If the cause of death is not COVID, then why do we have to follow the cremation protocol is the question being asked by many. “The presence of virus is there in the COVID positive patient whatever the medically diagnosed cause of death is. Hence we have to follow the protocol,” says Dr Asheel.

A person being tested negative prior to his death does not give a reason to list the death as a non-COVID one, according to Dr Arun. The damage being done by the virus is done which leads to death. It is immaterial whether the presence of virus does persist at the time of death if he dies in a reasonable period of time. However, many, including Dr Arun think that the government is listening to criticism which is being reflected in the data.

“Over a period of three weeks from July 22, it is noted that 36 per cent of the total deaths of COVID positive cases are recorded as non-COVID deaths. But a change is visible from August 14 onwards. From 14 to 17 of this month, only 9 per cent of cases are recorded as non-Covid deaths,” says Dr Arun.