It is now common knowledge that the elderly & those with co-morbid conditions are more vulnerable to COVID-19 related complications. The USA & the UK have been releasing comprehensive data on COVID-19 deaths in their countries along with the causes for these deaths, including details on other co-morbid conditions. India needs to follow suit and release such detailed data at the earliest.
Since the first death due to COVID-19 was reported in Wuhan, China during January’2020, there have been more than 9.08 lakh deaths reported across the world as caused due to COVID-19. However, all these recorded deaths are not exclusively due to COVID-19.
Death often is the result of a combined effect of two or more related or independent conditions. One condition may lead to other conditions that prove to be fatal. There could be a new condition that might aggravate an existing condition, resulting in death.
COVID-19, which is currently spread across 215 countries in the world is an infectious disease which is caused by a newly discovered coronavirus. As per World Health Organization (WHO), the infection causes mild to moderate respiratory illness in most of the affected people. However, it could be more serious in the elderly or those already suffering from medical conditions like – respiratory diseases, diabetes, cardiovascular disease, cancer etc.
Hence, while COVID-19 by itself might not be fatal, it might aggravate a pre-existing condition which would ultimately result in the death of the infected person. COVID-19, being a new disease, it is important to understand the impact of the disease on the infected population to be able to ascertain and develop strategies to control the infection as well as mitigate fatalities.
Therefore, recording the relevant information about causes of death in patients infected with COVID-19 i.e. co-morbidities, would offer insights in understanding COVID-19. This information can help in identifying infection patterns at both micro and macro level and plan interventions accordingly.
Codes for standardized recording of COVID-19 related deaths introduced by WHO
The observed cases of COVID-19 present a wide range – from mild to severe to fatal depending on the severity of the infection and co-morbid conditions. COVID-19 is reported to cause pneumonia, cardiac and intra vascular related complications, ARDS (Acute Respiratory Distress Syndrome) etc. which may lead to death.
Further, patients with pre-exiting conditions like Asthma, cancer, heart diseases etc. have higher risk of developing respiratory infections and complications in a COVID-19 positive individual. But they might not have directly contributed to the death due to COVID-19 or only a few of many co-morbid conditions might have caused the death.
Hence it is important to identify and clinically record the exact reason for a death. Identifying the patterns of the infection and death is possible only through a standardized recording of the disease and the death.
Therefore, WHO has introduced standard codes to record COVID-19 related cases & deaths. There are two codes introduced as part of ICD-10 (10th version of International Code of Diseases)
The two Codes represent two broad categorizations.
- U07.1 – Confirmed cases i.e. where the virus is identified
- U07.2 – Suspect cases i.e. probable infected cases wherein the virus is yet to be identified.
Based on the symptoms and presence of Co-morbidities, the confirmed cases that are coded under U07.1 are further classified into three different groups.
- Positive test result by the patient not showing any symptoms.
- Positive test result with COVID-19 documented as cause of death. Here additional details of interventions and procedures needs to be specified along with the code.
- Positive test result with other symptoms and existing conditions. In this case, apart from U07.1, the other codes related to the existing diseases/conditions along with symptoms needs to be provided.
For any suspect and probable cases, code U07.2 is used. These cases are those where there is a probability of infection, but which is not yet confirmed i.e. coming in contact with an infected person, history of travel etc. In these cases, apart from the code for COVID-19, codes which are related to the symptoms needs to be recorded.
As per WHO, both these categories (i.e. U07.1 & U07.2) can be used for cause of death coding.
This information would help in determining if COVID-19 as an underlying Cause of Death. The rules which are applied in determining the single underlying cause of death is same as the one currently followed for influenza.
In USA, Influenza & Pneumonia followed by Respiratory failure are the top co-contributing causes for COVID-19 related deaths.
Apart from being the country with the highest number of recorded COVID-19 cases, USA also has the highest number of COVID-19 related deaths with around 1.95 lakh deaths, a fatality rate of nearly 3%.
USA’s Centres for Disease Controls & Prevention (CDC) furnishes a weekly update with the details of the causes of COVID-19 related deaths along with other information such as age, geographical location etc. , which provides useful insights on the spread of COVID-19 infection.
As per the latest update on 05 September 2020, out of the total COVID-19 related deaths, only 6% of the deaths have COVID-19 mentioned as the only cause of death. The rest of the deaths have other health conditions as a contributing cause. As per CDC, each death has on an average 2.6 additional conditions listed as causes of death.
Therefore, a single death can have multiple causes of death. Hence, in the data provided, CDC cautions against aggregation of the causes of death figures as there is scope of multiple count of the same death. However, as per the information provided, the greatest number of deaths list ‘Influenza & Pneumonia’ as one of the top contributing causes of death with more than 74 thousand cases mentioning it as a cause.
From a broad categorization, health conditions that are related to respiratory diseases are the top contributing causes for COVID-19 related deaths, followed by causes that are related to circulatory diseases. There are multiple causes listed under these both diseases.
Respiratory Failure, another respiratory related cause is the second major cause followed by Hypertensive Diseases (Part of Circulatory related conditions). Diabetes, Cardiac arrest, ARDS (Adult Respiratory Distress Syndrome) etc. are among the other major health conditions that are listed as co-morbidities for COVID-19 related deaths in USA.
Information on Contributing Co-morbidities for COVID-19 deaths not available in India
In accordance with the guidelines for COVID-19 related codes issued by WHO, Government of India’s Ministry of Health & Family Welfare (MOHFW) has also issued guidelines about recording of COVID-19 related deaths. These guidelines provide the required information for identifying and recording the cause of death in COVID-19 cases.
As highlighted in the guidelines issued by WHO, COVID-19 as the underlying cause of death needs to be ascertained, as well as any symptoms and co-morbidities accompanying COVID-19 infection and deaths ought to be clearly coded and apt description provided.
The guidelines, prescribe the usage of E-Mortality (e-Mor) portal to record COVID-19 related deaths. Based on these directions from MOHFW, it can be presumed that WHO’s codes and guidelines are being followed or supposed to be followed in India to record COVID-19 related deaths.
However, no such information is available in the public domain even though the MOHFW provides daily updates on COVID-19 situation in the country.
We tried accessing the data of COVID-19 deaths in other countries, in line with USA and found that U.K also publishes the data, albeit not as detailed as USA. We could not find similar information for other countries, at least on their official portals.
While, respiratory related diseases are considered to be major contributing factors (as seen in case of USA), it cannot be ascertained if the same trend prevails in India as well in the absence of detailed data. With India currently leading the daily numbers for COVID-19 positive cases as well as deaths, India specific information on the health conditions/comorbidities for COVID-19 related deaths on the lines of the USA & UK could provide useful insights and help governments plan necessary interventions.
Featured Image: COVID-19 deaths