COVID-19: The question mark over cause of death

'COVID-19 as Underlying Cause of Death (UCOD)' as per the Indian Council of Medical Research/National Centre for Disease Informatics and Research, ‘Guidance for appropriate recording of COVID-19 related deaths in India.’
'COVID-19 as Underlying Cause of Death (UCOD)' as per the Indian Council of Medical Research/National Centre for Disease Informatics and Research, ‘Guidance for appropriate recording of COVID-19 related deaths in India.’

Atono Tsükrü Kense
Kohima | August 2

Nagaland’s COVID-19 graph has been on a rapid upward trend the past week with as many as 4 deaths reported officially, till date. One perplexing question however has been attributing ‘cause of death’ with no conclusive medical consensus. 

The Department of Health & Family Welfare has classified one of the 4 deaths as “as COVID-19 positive but not due to COVID-19” and described another as having had “co-morbidities & tested COVID-19 positive.” While these remarks are far from clear, it is a blank as far as the other two recorded deaths are concerned. 

The Indian Council of Medical Research (ICMR) has come out with‘Guidance for appropriate recording of COVID-19 related deaths in India.” However, to the lay person, the explanation would be quite complicated to comprehend. 

It states, “It is likely that COVID-19 is the underlying cause of death (UCOD) that lead to ARDS or Pneumonia in most of the deaths due to COVID-19 (test positive and symptoms positive). In these cases COVID-19 must be captured…”

Further, it says, “Patients may present with other pre-existing co-morbid conditions such as chronic obstructive pulmonary disease (COPD) or asthma, chronic bronchitis, ischemic heart disease, cancer and diabetes mellitus. These conditions increase the risk of developing respiratory infections, and may lead to complications and severe disease in a COVID-19 positive individual. These conditions are not considered as UCOD as they have directly not caused death due to COVID-19. Also a patient may have many co-morbid conditions, but only those that have contributed to death should be recorded...”

As per the WHO, “a death due to COVID-19 may not be attributed to another disease and should be counted independently for pre-existing conditions that are suspected of triggering a severe course of COVID-19.”

The Morung Express posed the questions in this regard to medical professionals in the state. 

Two classification 
A doctor, on condition of anonymity, classified it this way- “COVID death and non-COVID death with COVID-19 positive.”

“A COVID death is where there is a link between cause of death and the infection. A correlation should be established by the state committee, while COVID death with COVID-19 positive is when there is no correlation between cause of death and the person being COVID positive,” the doctor further explained.

He added that there are and maybe many conditions where COVID-19 is not linked to the death and an expert committee will have to review all the probable causes and come up with a conclusion. It came with a caveat however.

According to him, the decision is ‘complex’ and will be based on ICMR classification along with instructions from the Ministry.

Another doctor maintained, “Even for us, it is really difficult and has to go case by case by the treating doctor and group discussion (consultation).”

When asked if SARS-COV2 could have aggravated the pre-existing ailments of the four deceased elderly persons, Director of Christian Institute of Health Sciences and Research (CIHSR), Dr Sedevi Angami, responded, “Maybe. But nobody will be able to give a straightforward answer.”

He added, “People die due to pneumonia, stroke, heart attack or cancer. Elderly people have multi-system problems and death of an old person is not always a straightforward case as there are always multiple issues which might contribute to their death.”

Terming COVID-19 as much more virulent than other viruses, he said that it could have attributed to their deaths, while adding that any virus causing an infection in the chest can be fatal. 

An official from the Directorate of Health and Family Welfare said the preliminary reports of all the deaths indicated “multiple co-morbidities” and that it is under investigation by the COVID-19 Death Review Committee.

Death Review Committee constituted
He informed that the ‘COVID-19 Death Review Committee’ is set up to review and ascertain the causes and circumstances leading to the death, and appropriate reporting of such deaths as per ICMR and ICD-10 protocols.

The Death Review Committee, constituted on July 28, comprises of a 9-member team of doctors with subject experts including forensics, pathologist, physician, microbiologist and others.

CMO and MS of all districts were also directed to constitute District COVID-19 Death Review Committee comprising of officers from district health authority and subject experts from district hospital/health centre. The district committee will review all COVID-19 positive deaths and submit the report.

“All concerned are directed to refrain from reporting such deaths as due to COVID-19 before review by the State Committee,” stated the order issued by the H&FW Principal Director.