A rise in backlog in Covid deaths in Kerala is a function of comparably higher level of testing, including targeted testing when only those with major symptoms and close contacts of the infected are tested, and prompt reporting following Supreme Court guidelines. 

These guidelines say that any death being reported within a month of virus infection, irrespective of the most proximate cause (except suicide), has to be considered as Covid death, says Dr TS Anish, Associate Professor, Community Medicine, Government Medical College, Thiruvananthapuram. 

Not actual Covid deaths

A member of the State Covid Task Force, Anish said that all deaths being classified as such may not therefore be actual Covid deaths. “If we take Kerala’s case, six out of 1,000 people die every year of natural causes. Most of these deaths are of elderly people who are vulnerable to Covid, too.” 

Some of them could also get infected in a State marked out for rampant virus transmission and have entered the official list. But excess mortality data suggest that additional deaths being reported compare well with the number of Covid deaths published so far by the State. 

The SC guidelines have a salutary effect in that not a single Covid death would go unreported. “But epidemiologically speaking, not all cases may in reality get classified as such. The upshot is that kin of the deceased become eligible to claim a compensation under the SC guidelines,” said Anish. 

Kerala at a disadvantage 

There are a few issues that seem to work to Kerala’s disadvantage here, he added. One, the high level of awareness that makes it possible for kin of the deceased to push the case for being included under the list eligible for compensation, which, in turn, gets added to the State’s official Covid death list.

“Now, we have a situation where the State government encourages the kin of a person dying within one month after contracting the virus to go to the nearest health centre and report it as a Covid death. This is unlike many other States, where Covid deaths and compensation cases are listed separately.” 

Almost mirroring these views, Dr Rajeev Jayadevan, Vice-Chairman, IMA Kerala Research Cell, says that documenting and declaring a Covid death has always been a contentious matter. 

30-day positivity rule 

The WHO and ICMR guidelines were followed initially where the treating doctor would decide whether the cause of death was directly the result of Covid, Jayadevan told BusinessLine.

However, the definition that is currently followed is based on the 30-day Covid positivity rule, where any individual who has had a positive Covid test (or clinical diagnosis of Covid) within 30 days prior to the date of death, is considered a Covid case. 

The problem with the original definition was that some Covid deaths might have been missed because of lack of documentation. This may have led to undercounting, he said. The problem with the latter definition is that of overcounting, Jayadevan explained.

Sure in asymptomatic cases

In other words, all individuals who die within 30 days of a Covid positive test, would not have died directly of Covid. For instance, in the current Omicron surge, hospitals are seeing a situation, where even asymptomatic persons without contact history turn Covid-positive. 

Obviously, they are unaffected by the SARS-CoV-2 virus, which is well-known to cause completely asymptomatic and silent infections in large numbers of people, Jayadevan added.

Doctors have lately reported several instances where people have died from unrelated illnesses, and yet come under the classification of Covid death because of the technicality of the new rule.

Looking at the Kerala scenario, Jayadevan said that the overall death rate before the pandemic was about 680 deaths per day, from a crude death rate of 6.9 per 1,000 per year. During the third wave, a large number of people have been testing positive. The test positivity rate is close to 50 per cent. 

This means that among an average number of 680 deaths that occur every day, at least a few people would have had a Covid test that is positive, without the actual disease being the cause of death. To an extent, this factor explains the recent increase in Covid deaths, said Jayadevan.

 

Exaggerated mortality rate

While these individuals are eligible for compensation by the existing order of the Supreme Court of India, it would be scientifically inaccurate to classify them as Covid deaths. 

“This is because doing so will not only exaggerate the true Covid mortality rate, but also affect interpretations of future scientific studies, including that of vaccine effectiveness.” 

It would be prudent to decouple these two entities, and only those individuals whose health deteriorated as a direct result of Covid, be officially classified as Covid deaths for scientific and research purposes, Jayadevan suggested.

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