Furore over deaths tied to causes other than COVID-19
In recent times there have been reports that most deaths associated with COVID-19 pandemic in Nigeria and indeed all over the world may be due to other causes.A new study found that 35 per cent of excess deaths in pandemic’s early months are tied to cause other than COVID-19.
The United States (U.S.) study, “Excess Deaths from COVID-19 and Other Causes, March-April 2020,” showed that only 65 per cent of the excess deaths that occurred in March and April were attributed to COVID-19, meaning more than one-third were linked to other causes.
According to the study published Wednesday in the Journal of the American Medical Association, further investigation is needed to determine just how many deaths were from COVID-19 and how many were indirect deaths “caused by disruptions in society that diminished or delayed access to health care and the social determinants of health (example, jobs, income, food security).”
The researchers said this paper’s results underscore the need for health systems and public officials to make sure services are available not only for COVID-19 but for other health problems. The study showed what happened in the states that were overwhelmed by cases in March and April. The researchers are worried that the same spikes in excess deaths may now be occurring in other states that are being overwhelmed.
The researchers at Virginia Commonwealth University (VCU) and Yale University found that some of these were indirect deaths from the pandemic that occurred among people with acute emergencies, such as a heart attack or stroke, who may have been afraid to go to a hospital for fear of getting the virus. Those who did seek emergency care, particularly in the areas hardest hit by the virus, may not have been able to get the treatment they needed, such as ventilator support if the hospital was overwhelmed by the surge.
Lead author and director emeritus of VCU’s Center on Society and Health, Dr. Steven Woolf, said others might have died from a chronic health condition, such as diabetes or cancer that was exacerbated by the effects of the pandemic. “Still others may have struggled to deal with the consequences of job loss or social isolation.”
Woolf, a professor in the Department of Family Medicine and Population Health at VCU School of Medicine, explained: “There are several potential reasons for this under-count. Some of it may reflect under-reporting; it takes awhile for some of these data to come in. Some cases might involve patients with COVID-19 who died from related complications, such as heart disease, and those complications may have been listed as the cause of death rather than COVID-19.
“But a third possibility, the one we’re quite concerned about, is indirect mortality — deaths caused by the response to the pandemic. People who never had the virus may have died from other causes because of the spillover effects of the pandemic, such as delayed medical care, economic hardship or emotional distress.”
Woolf added: “We can’t forget about mental health. A number of people struggling with depression, addiction and very difficult economic conditions caused by lockdowns may have become increasingly desperate, and some may have died by suicide. People addicted to opioids and other drugs may have overdosed. All told, what we’re seeing is a death count well beyond what we would normally expect for this time of year, and it’s only partially explained by COVID-19.”
The researchers said resources should be available for those facing unemployment, loss of income and food and housing insecurity, including help with the mental health challenges, such as depression, anxiety or addiction that these hardships could present.
MEANWHILE, medical experts have made recommendations on how to reduce the rising number of deaths caused by inability of hospitals to manage other chronic diseases due to the Coronavirus disease (COVID-19) pandemic that has overstretched their capacities and capabilities.
The medical experts include: a consultant Ocular Oncologist and Executive Director of Mass Medical Mission (MMM), Dr. Abia Nzelu; a public health physician and founding partner Health Systems Consult, Dr. Nkata Nwani Chuku; a consultant epidemiologist and Executive Director of National Primary Health Care Development Agency (NPHCDA), Dr. Faisal Shuaib; a consultant in Geriatric, Regenerative, Cosmetic and Aesthetic Medicine and Medical Director of Glory Wellness & Regenerative Centre, Lagos, Dr. David Ikudayisi; a consultant public health physician and Executive Secretary Enugu State Agency for the Control of AIDS (ENSACA), Dr. Arthur Chinedu Idoko; and a consultant policy strategist, healthcare management expert and Director General, Delta State Contributory Health Commission (DSCHC), Dr. Ben Nkechika.
Ikudayisi said it is important during this novel pandemic to ask for the COVID-19 status of patients upon arrival at the clinics, medical centres, and hospitals.
On the greater implications of this situation beyond increasing number of deaths erroneously linked to COVID-19, Ikudayisi said patients that could have been taken care of at early stage of their medical conditions end up deteriorating at home due lack of treatment and end up to dying from conditions that are easily manageable.
To address the issue, the physician recommended that the NCDC should allow more private reputable laboratory centres to also test for COVID-19. Ikudayisi said the government cannot do it all alone and there are more private laboratory centres that are up to standard, modern and will meet NCDC criteria. Otherwise, he said, the NCDC should rapidly open more testing centres to meet the testing demands as the current centres are overwhelmed and do not respond in appropriate time to testing and releasing the test reports.
Ikudayisi said all hospitals should have comprehensive hospital preparedness checklist for Coronavirus Disease 2019 and this checklist has to be adapted to meet the unique needs and circumstances of each hospital.
Idoko said hospitals should inquire and look into patient’s COVID-19 status or presence of certain risk factors but “not demand” COVID-19 certificate/ report.
Idoko said it is only essential that patients are triaged on arrival for care especially in these seasons; it is actually safe for the patient, the health care worker, other hospital staff, in fact, everyone. Triaged is the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors.
The public health physician said the greater implication if hospitals “demand a COVID-19 status certificate/ report” is that a lot of sick people would not only be discouraged from visiting hospitals because of the attendant difficulties but would resort to self help with all the associated dangers. “Many people with other chronic illnesses and underlying medical conditions who have previously been on treatment even before the pandemic would not be able to access care, and what will happen? More deaths,” he said.
Nkechika said hospitals should not demand COVID-19 status certificate/report before treating patients. “It is discriminatory, against the code of medical practice and ethically improper,” he said.
Nkechika, however, said looking at it specifically from the current COVID-19 situation in the country where availability/cost of PPE and specific training on how to use them for the management of COVID-19 virus infection spread is a major challenge, healthcare providers especially those in the private sector who have not received adequate support for the management of COVID-19 compared to the public sector providers, have been left with no choice but to operate within their capacity to provide service and self-protect. Nkechika said with adequate support ranging from provision of PPE and palliative financing support to purchase the now very scarce and expensive PPE, the private providers are capable, willing and ready to provide service to all patients and identify those with COVID-19 for referral to special treatment centres.
He said financial palliative/support should be extended to the private healthcare providers because they see the bulk of the patient load in Nigeria and command more “Patient Care Trust” in the Nigeria healthcare system.
Nkechika said more qualified private healthcare facilities should be accredited and capacitated to as COVID-19 management centres. He said with their efficiency of service capability, pressure on the government established COVID-19 centres will reduce and the “well to do” COVID-19 patients will have the option of going to these facilities, creating more capacity and resources at the government COVID-19 facilities for other cases. Nkechika said some COVID-19 cases are now managing themselves at home due to mistrust with government healthcare facilities despite its obvious consequences.
Shuaib told The Guardian: “As you know, COVID-19 pandemic has placed enormous burdens on the health system. Typically, before treating patients, clinicians may need to carry out investigations to get the status of patients with regards to various ailments. So, knowing the COVID-19 status is really not out of place before commencing treatment. However, the absence of a status result should not stop clinicians from providing care.”
Shuaib said apart from deaths linked to COVID-19, there is often delays in treatment of COVID-19 infected patients as well. He said the longer such persons stay in their homes and communities, the more the chance of transmission and escalation of cases.
Nzelu said Non-Communicable Diseases (NCDs) – including cancer and cardiovascular diseases are responsible for over 70 per cent of global deaths (killing 41 million people).
Nzelu said the current COVID-19 pandemic has further compounded the situation for NCD patients, who are at higher risk of severe COVID-19-related illness and death. She said apart from the increased susceptibility of NCD patients to COVID-19; COVID-19 has also exposed and overstretched the dearth of health care infrastructure in Nigeria.
The physician said insisting on COVID-19 certificate before admitting patients is not an ideal situation, given the rate of community transmission of COVID-19 and the plethora of symptoms that cut across every system of the body, every patient that presents at any hospital should be accepted and treated as a potential COVID-19 patient by taking universal precaution against COVID-19. This, she said, is especially important, since a good proportion of COVID-19 cases are asymptomatic.
Chuku told The Guardian: “Patients should not be denied care without a COVID certificate because there is no such policy from government. COVID has not chased away other illnesses we have in our country. Besides to get a COVID certificate you have tested right? Do we have the capacity to test every Nigerian? The answer is no!
“Turning away patients without a COVID certificate will mean we are sentencing people with ailments to die!”
Meanwhile, an update to the Scientific Brief by the World Health Organisation (WHO) entitled ‘Smoking and COVID-19,’ published yesterday concluded: “At the time of this review, the available evidence suggests that smoking is associated with increased severity of disease and death in hospitalised COVID-19 patients. Although likely related to severity, there is no evidence to quantify the risk to smokers of hospitalization with COVID-19 or of infection by Severe Acute Respiratory Syndrome Coronavirus type 2 (SARS-CoV-2) was found in the peer-reviewed literature. Population-based studies are needed to address these questions.”
According to the WHO, given the well-established harms associated with tobacco use and second-hand smoke exposure; it recommends that tobacco users stop using tobacco. Proven interventions to help users quit include toll-free quit lines, mobile text-messaging cessation programmes, nicotine replacement therapies and other approved medications.
Since its publication, a study entitled ‘Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19’ by Mehra et al. has been retracted by the New England Journal of Medicine. This version of the Scientific Brief has removed the study from the review. The removal of this study from the review does not change the conclusions of the analysis.
What is the risk of severe COVID-19 disease and death amongst smokers? Zhao et al. analysed data from seven studies (1726 patients) and found a statistically significant association between smoking and severity of COVID-19 outcomes amongst patients. The statistical significance disappeared when the largest study by Guan et al. was removed from the analysis (a sensitivity test to see the impact of a single study on the findings of the meta-analysis).
An updated version of this meta-analysis, which included an additional study, remained significant when this same sensitivity test was applied however. Vardavas et al. analysed data from five studies totalling 1549 patients and calculated a relative risk that indicated a non-significant relationship between smoking and severity of COVID-19. However, the same authors found a statistically significant association between smoking status and primary endpoints of admission to Intensive Care Unit (ICU), ventilator use or death.
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