The issues behind MoH’s change in COVID-19 death definition

Since the first COVID death in 7 January 2021 till the 10th death on 27 March 2022, Bhutan followed the Center for Diseases Control (CDC) USA and the Regional WHO definitions which classifies any death with COVID-19 as a COVID death.

Exceptions are made in cases like vehicle accidents or assault where it is clear the cause of death is the accident or the assault.

However, in a release on 31 March 2022 announcing the 11th COVID-19 death the MoH said, “Henceforth, as per the WHO and National guidelines, only deaths directly resulting from respiratory symptoms (pneumonia, ARDS) and/or sepsis as determined clinically, will be declared as COVID-19 deaths.”

It said that that the National Clinical Team is tasked to carry out detailed clinical assessments of any deaths in people infected with COVID-19 to determine the root cause of the death.

The 11th death was counted as a COVID-19 death under the April 2020 WHO definition as the 52-year-old woman who was referred from Paro, was a patient of advanced cervical cancer resulting into multiple other medical conditions.

She was on palliative care and got infected with the COVID-19 virus. Despite active management, she succumbed to medical complications that are associated with COVID-19 pneumonia and respiratory failure.

BPC employee death

The issue first propped up when a newspaper pointed out that a Bhutan Power Corporation employee in his late 20s who had COVID-19 along with kidney failure and high blood pressure had died due to complications during dialysis but his death was not classified as a COVID death.

When The Bhutanese asked the MoH why this BPC employee death was not classified as a COVID-19 death the MoH said, “The death was not announced as COVID-19 death because the actual cause of death was a heart attack that was induced by extremely High Blood Pressure.”

Technical Advisory Group (TAG) member Dr Sonam Wangchuk said that a dedicated clinical team will classify COVID-19 deaths now under the WHO definition because as the community infection spreads there will be people dying of other diseases but it could have got classified as COVID deaths only because they have COVID.

He said that if COVID is not the primary cause of the death then it will not be listed as a COVID death even if the person has contracted the diseases.

The CDC position Bhutan followed till now

The CDC position on COVID-19 deaths is often misunderstood even in USA itself as an attempt to inflate the death tally.

However, the CDC position is much more nuanced and complicated.

The Association of American Medical Colleges (AAMC) website in an article says that at the core of the issue is the fact that COVID-19 kills in myriad ways, typically setting off a combination of potentially fatal afflictions. 

The article quoting Doctor Sara Auld, a critical care physician at Atlanta’s Emory University Hospital says “COVID-19 can cause an extraordinarily wide range of clinical complications. While pneumonia and respiratory failure are the most common manifestations, it can also cause blood clots, including strokes and heart attacks.”

When a COVID-19 patient dies, “it’s usually a cascade of events that lead to death — it’s not one thing,” agrees Daniel Handel, MD, MBA, MPH, chief medical officer for Indiana University Health’s South Central Region in Bloomington, says the article.

In addition, the disease’s brutal impact on people with other medical conditions — such as diabetes, hypertension, and heart ailments — can make COVID-19 one of several contributors to a death, says Sally Aiken, MD, chief medical examiner of Spokane County, Washington.

Aiken has seen cases where elderly people who were in advanced decline due to Alzheimer’s disease and atrial fibrillation contracted COVID-19 and soon died.

As per the CDC guidelines the death certificate has two parts of ‘immediate causes’ and contributors or conditions and if COVID-19 is there in either sections then it is classified as a COVID death.

The article quotes the The Alaska Department of Health and Social Services explanation on its website which why the disease is cited if it played any role at all.

“Whether COVID-19 shortened a life by 15 years or 15 minutes; whether COVID-19 is an underlying or contributing condition, the virus was in circulation, infected an Alaskan, and hastened their death,” said the site.

Bhutan’s first COVID-19 death

In the case of Bhutan, the first COVID-19 death was on 7 January 2021. The 34-year-old man with COVID-19 died due to hepato-renal failure.

At that time if Bhutan had followed the WHO guideline then that would not count as a COVID death as it was not the main cause, but after much discussion late into the evening among experts it was decided that Bhutan would follow the stricter CDC and regional WHO guidelines as opposed to the WHO guideline of April 2020.

Under the same WHO guideline many of the 11 deaths so far would not count as COVID-19 deaths.

In late 2020 there were three deaths of co-morbid people who died just after clearing COVID-19 and though they could not make it out of the ventilator they were not classified as COVID-deaths.

The first death of a comorbid patient was that of a 30-year-old lady with lung cancer on 24th December 2020.

The second well known death occurred on 25th December 2020 when a 52-year-old lady with an auto immune disease also died while on ventilation after she had tested negative for COVID-19 on 19th December.

At the time, Lyonchhen Dasho (Dr) Lotay Tshering referring to this case 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. The PM had said that only people who die due to COVID are counted as COVID- deaths under the WHO classification.

The third death took place a day later on 26th December when an 84-year-old man who had a heart condition and a pacemaker inserted into his heart also died after clearing COVID-19.

A senior doctor at JDWNRH who is also a specialist and has been involved in two rounds of personally treating COVID-19 patients had said at the time that while COVID-19 may not be the direct cause of death in the three comorbid cases, the virus would have definitely made it tougher for all of them.

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