The Kerala government’s process of classifying deaths due to COVID-19 has left the medical community in the state perplexed. According to the dashboard maintained by the Kerala government, there are 223 COVID-19 deaths in the state so far. However, according to medical professionals, including the government-constituted panel of experts, there could be more fatalities that the Health Department is not attributing to death caused by COVID-19.
According to reports, since the process of counting deaths is ambiguous, the expert panel has recommended that Kerala audit the number of deaths once again.
According to unofficial data, about 171 COVID-19 patients are estimated to be excluded from the state’s death tally, especially the deaths between July 20 and August 6. This unofficial list has recorded 394 deaths due to COVID-19, against the 223 deaths reported by the state government as on Monday.
Dr Arun NM, a Palakkad-based internal medicine expert, and Davis Tom, an IT professional based in Thiruvananthapuram, put together crowd-sourced data on all COVID-19 deaths in Kerala so far, based on multiple media reports and official data on the public domain. This unofficial list has recorded 394 deaths due to COVID-19, against the 223 deaths reported by the state government as on Monday. This means that an estimated 171 deaths have been excluded from the official list of COVID-19 fatalities.
“The notable lapse here is the exclusion of decedents with certain conditions like cancer or myocardial infarction (heart attack), which may have contributed to death by COVID-19,” said Dr Arun.
The unofficial data by Dr Arun and Davis excluded COVID-19 patients who died due to accidents, drowning, suicide, those with identifiable cause for death (in which COVID-19 might not have played any part) and those who died three or more days after being discharged from a COVID-19 hospital. The list includes patients who were suspected to have acute myocardial infarctions and acute stroke, “as COVID-19 can mimic these conditions,” said Dr Arun.
It must be noted that the Kerala government has still not included two COVID-19 deaths reported in April: A resident of Mahe (territorially in Puducherry) who died in Pariyaram Medical College Hospital in Kannur on April 10; and a 71-year-old Palakkad resident who contracted the virus in Kerala but died in Tamil Nadu’s Coimbatore district while undergoing treatment, on April 11. In both cases, in the absence of clarity over the protocols — whether the domicile of the patient, region of contraction of the disease and region of death should be considered — the two deaths have not been documented by either government.
Kerala says it follows the guidelines (issued on April 16) by the World Health Organisation (WHO) for certification and classification of COVID-19 deaths. According to WHO, 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.”
The death of COVID-19 patients due to physical trauma, such as injuries due to an external force caused by accidents and falls, are not counted as a fatality caused by the disease.
The WHO definition further reads: “A death due to COVID-19 may not be attributed to another disease (eg cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.”
However, Dr Arun argued, “SARS-CoV-2 infection is more severe in some subsets of the population, including the older people; men; and those with pre-existing diseases like cancer, chronic kidney disease, liver cirrhosis, heart disease, uncontrolled diabetes, hypertension and chronic lung disease, among others. Such pre-existing conditions can lead to severe COVID-19 infection and death.”
Incidentally, Kerala does not follow the guidelines by the Indian Council of Medical Research (ICMR) to report COVID-19 deaths. ICMR identifies cancer, cardiovascular disease and stroke among the significant conditions, which are “believed to have unfavourably influenced the course of the disease leading to death”. In cases of pneumonia, cardiac injury and blood clotting, ICMR says, COVID-19 should be treated as the underlying cause of death.
Many medical professionals pointed out that after July 20, the Kerala government allegedly stopped including decedents with cancer, who were on dialysis and ventilators, who received plasma therapy, and those who had developed changes in ECG (electrocardiogram). “Usually, COVID-19 can cause ECG changes and mimic a heart attack or a stroke,” said Dr Arun.
Dr Padmanabha Shenoy, an immunologist in Kerala, also made a similar argument. “A cancer patient’s immunity system is already weak. If that patient contracts the virus, saying it has not influenced his/her death is absurd,” he said.
There have been multiple studies to suggest that COVID-19 can cause heart injury, even among those without any underlying heart issues. “Some men in Kerala, who were in their early 30s and 40s and were diagnosed with COVID-19 when admitted to hospital, have suddenly died due to heart attack,” said Dr Padmanabha.
Incidentally, some patients, who tested negative via antigen test before their deaths, are also not being included as COVID-19 deaths. According to Dr Arun, those who died within the three days of discharge from hospitals, are counted as COVID-19 deaths, while patients who died three days after the discharge are excluded from the list.
“COVID-19 death is not only because of the virus but because the immune system overreacts. Irrespective of the negative test result, the disease has already caused damage to that patient’s body,” pointed out Dr Padmanabha, explaining why even such deaths should be counted.
Without a postmortem, COVID-19 as the cause of death cannot be ruled out. “A postmortem angiography, for example, can help identify the types of blood clots, which can be used to better understand this disease,” added Dr Arun.
In some cases, Dr Padmanabha said, the family of the deceased also are reluctant to report the death as COVID-19 as that may affect the burial process.
On August 10, an 11-member panel of medical experts, constituted by the Kerala government in March, submitted its report on the underreporting of COVID-19 deaths in the state, although it did not specify an exact figure of unaccounted fatalities.
These were some of their recommendations to the government: “The recent change in practice in recording COVID related deaths need to be reviewed in the light of WHO and ICMR guidelines and modification made. Clear guidelines on documenting COVID related deaths to be issued so that the government's position on this issue is unambiguous. An audit of all the COVID deaths so far to be made and necessary corrections made in official documents if necessary."
Four days later, on August 14, the government issued an evasive statement, a document, titled “Discussion paper, COVID 19, Ascertaining cause of deaths: Myths and Facts’.
The first ‘myth’ it tried to bust was “the state attributing the cause to the comorbidity and to refuse documenting COVID as the cause [sic].” Beyond the response of “this is wrong information,” it has not offered any substantial evidence to counter the claim. The government also denied changing the policy of reporting death when the number of deaths increased in the state by July when it started reporting community spread and clusters.
According to Kerala’s new testing strategy (released on August 15), two samples should be collected from a person brought dead. While swab one is for provisional results via CB-NAAT (which is confirmatory), the second swab is sent to the National Institute of Virology (NIV) in Alappuzha for a confirmatory test. Sending samples to NIV, all experts TNM spoke to said, will cause delay and is a waste of resources.
“It is appropriate to send the second sample to NIV Alappuzha to avoid any undue controversies regarding the testing and the results,” defended the government document.
It also claimed that Kerala is the only state to test ‘brought dead bodies with suspected COVID-19’ for the disease. However, several states like Karnataka, Tamil Nadu and Telangana have been following a similar procedure.
Dr Abraham Varghese, president of the Indian Medical Association (IMA) Kerala unit, told TNM that they had requested the Chief Minister and Health Secretary for the treatment record and history of all patients for a survey. “We have to study several reasons that cause deaths due to COVID-19. However, we are yet to receive these reports,” he said.
While experts agree that the issue of underreporting is not unique to Kerala, Dr Arun said, “This is not a race for a medal. There should be transparency for the sake of good data on this new disease.”