Bhutan goes for a stricter definition than WHO for its first COVID-19 death

If the Ministry of Health went by the World Health Organization (WHO) definition of a COVID-19 death, then Bhutan would still be having zero COVID-19 deaths.

However, the Health Minister Dasho Dechen Wangmo said that the MoH decided to go with the Center for Diseases Control (CDC) USA and the Regional WHO definitions which are tighter and wider encompassing definition of COVID-19 deaths.

As per WHO’s ‘International Guidelines for Certification and Classification of COVID-19 as Cause of Death’ it says that in the death certificate there are two parts with Part 1 being the ‘Cause of death’ and part 2 being ‘Other significant conditions contributing to death’. 

It says that only if COVID-19 is listed in Part one, can it be classified as a COVID-19 death and not in part 2 where a person having COVID-19 may have died due to other reasons.

Giving an example of a COVID-19 death the WHO guideline lists Acute Respiratory Distress and Pneumonia along with being COVID-19 positive, as death due to COVID-19 in part 1 with part 2 being coronary artery diseases, type 2 diabetes etc.

In the case of the Bhutanese death under this general WHO definition Bhutan would still have zero deaths because according to the Thursday evening press release on the MoH Facebook page the 34-year-old man with COVID-19 died due to hepato-renal failure.

The press release talked about the the man’s ‘severe acute hepatitis’ and ‘acute kidney failure’ and said ‘the prognosis of such cases with hepato-renal failure is grave’.

In simple language the MoH was essentially saying what caused his death was his liver and kidney failure both of which are conditions which he had before COVID-19.

As per WHO’s certification part 1 or cause of death is hepato-renal failure and part 2 or ‘Other significant conditions contributing to death’ would be COVID-19. So under WHO’s definition Bhutan would still have no COVID-19 death.

However, the stricter CDC accepts it as a COVID-19 death even if COVID is mentioned in part 2 as a contributing factor.

The MoH stance did not come about easily as there was much debate into late night between various experts including in the Technical Advisory Group.

 Even the Thursday 7 pm announcement of the 34-year-old’s death did not list it as a COVID-19 death and the health COVID-19 statistics dashboard around the same time reflected zero deaths.

It was decided around late night that the death would be reflected as Bhutan’s first COVID-19 death.

The Health minister reflecting the above clarified that while it will be Bhutan’s first death with COVID-19 the death technically is not purely due to COVID-19 but due to his co-morbidities.

She said a COVID-19 death would involve pneumonia and other symptoms which the patient did not have. Lyonpo said that the WHO has a very broad definition of COVID-19 death and so they went with the CDC and Regional WHO one.

WHO’s definition says ‘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). There should be no period of complete recovery from COVID-19 between illness and death. A death due to COVID-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.”

The Health Minister said that 30 to 40 percent of COVID-19 deaths have co-morbidity and under the above definitions they come under the COVID-19 death even though the death is due to the man’s hepato-renal failure.

She said that the man has died ‘with COVID-19’ which is dying with the disease but not specifically due to COVID-19.

The issue of definition of the death with or by COVID-19 came up when a 50-year-old lady with auto immune diseases passed away on 25th December days after she had recoverd from COVID-19 and tested negative for COVID-19.

At the time, Lyonchhen Dasho (Dr) Lotay Tshering said that ‘death due to COVID’ is a death caused by COVID and ‘death with COVID’ is a patient who dies due to some terminal illness and who would have anyhow died, but just happened to have COVID.

The PM had said that only people who die due to COVID are counted as COVID- deaths under the WHO classification.

The Prime minister had said that the lady did not even fit in either of the above categories as she had already tested negative on the RT-PCR a while ago.

It is now clear that the MoH faced with the death of the 34-year-old man had a strong internal debate on the issue and had decided to follow the stricter CDC model of reporting COVID-19 deaths.

One wisdom behind this is that the virus is still relatively unknown but it has shown itself to impact a variety of organs and even cause blood clots and is particularly severe on on people with co-morbidities.

Given these facts and the unknowns Bhutan had decided to take stronger position then even the broad WHO classification.

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