At the heart of the controversy surrounding Kerala’s “missing” COVID deaths is the argument that the definition of COVID deaths, as set forth by the World Health Organisation (WHO), gives much room for misinterpretation and that clinicians cannot be blamed for the confusion it creates.
However, public health experts point out that the State’s issue is not about misinterpretation, but about deaths certified by treating physicians being thrown out from the official list.
A COVID-19 death is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed case. Cases where there is a clear, unrelated alternative cause of death (e.g. trauma) are not COVID deaths.
The State claims to follow the ICMR and WHO guidelines for classifying COVID-19 as cause of death. It faithfully quotes the example cited by the WHO that deaths due to “unrelated causes such as acute myocardial infarction (MI)” are not COVID deaths.
The ICMR’s guidance document is very lucid, which states that even if a COVID-positive person has co morbidities, “that should not be listed as the underlying cause of death; the cause of death remains COVID-19”. However, the State seems to have taken refuge behind the one statement in the WHO’s guidelines, that to be defined as a COVID death, “there should be no period of complete recovery from COVID-19 between illness and death.”
“Till the time of the second wave, Kerala used to discharge all COVID patients only after they tested negative. In most persons, other than the immuno compromised, viral clearance takes place after 10-12 days. Hence a chunk of the patients who die following COVID will have tested negative. This does not mean that they had recovered from COVID before they died and their deaths unrelated to COVID,” points out Arun N.M., consultant in internal medicine, Palakkad.
WHO’s definition does leave room for misinterpretation. But these guidelines were framed in April 2020, when pretty little was known about COVID-19.
Doctors, since May last year, are well aware of the fact that COVID is a bi-phasic illness and that most complications wrought by the virus starts manifesting only after the first phase of 5-7 days, when the patient shows signs of recovery.
Later documents (May 27, 2020) by WHO speaks of how thromboembolism is common in COVID patients, which could lead to stroke or acute MI. These events can occur while the patient is recuperating at home and are indeed COVID-related deaths.
Medical professionals in the State, who have been managing COVID patients since the beginning of the pandemic are well-versed with these facts.
“If they choose to hide behind WHO’s earlier definition and interpret deaths in the COVID continuum to be unrelated to COVID, it could be that they are forced to hold up the political narrative that the State has the lowest case fatality rate,” says Dr. Arun
Epidemiologists point out that including only audited, lab-confirmed cases in the official COVID list, while excluding all suspected or probable cases of COVID 19 (cases wherein clinical or epidemiological diagnosis of COVID-19 is not backed by laboratory confirmation) is totally unscientific. This would give a skewed picture of the pandemic’s impact on State.
Kerala’s case fatality rate would still be lowest, below 1%, even if the State adopted a more inclusive definition of COVID deaths. Even at the risk of over-counting deaths, most European nations included deaths which took place in care homes or sudden deaths at home to be probable COVID deaths. While there is no internationally accepted cut-off date, Public Health England, UK, collects the data of all those with a confirmed lab diagnosis and who died within 28 days and 60 days separately.
“Old COVID death definitions will need to be updated to avoid excluding those who died due to COVID after an initial recovery,” says Rajeev Jayadevan, scientific advisor, Indian Medical Association, on Twitter.
