The number of deaths with coronavirus that the Ministry of Health records, which this Tuesday reached 13,798, includes people who have tested positive for the diagnostic test, and does not count suspicious people who have not been confirmed. It is so according to protocols, but this week Minister Salvador Illa referred to it for the first time: “Anyone who is positively diagnosed and dies is counted as deceased by coronavirus.” The last update of Health on patient management, of March 31, only contemplates tests in two cases: for seriously hospitalized patients, and for health workers, socio-health workers, and other essential workers. There are exceptions for “especially vulnerable people or residents of closed institutions”, that is, mainly for users of residences.
Each community has had its own procedures apart. Two weeks ago, Madrid stopped testing patients with typical severe clinical conditions – such as bilateral pneumonia – to free laboratories. The daily balance of official data is also incomplete because deaths in residences in some communities are not included. In addition, in the case of Catalonia, the Generalitat has admitted that there is a possibility that an elderly person who lives in a residence but dies in the hospital will pass both the statistics of hospital deaths and those of residences. This Tuesday 133 deaths from coronavirus, which are the hospital deaths, were registered and reported to the Ministry in Catalonia, but the same day, the nursing homes reported 214.
How is excess death calculated?
One of the ways to assess the real impact of coronavirus on mortality beyond those officially diagnosed is through death and burial data from civil registries. The data available so far show an increase in deaths of around 50% compared to the average of the last decade.Although all the experts ask for time to know how much of the increase in mortality in Spain is attributable to the pandemic.
Ildefonso Hernández, spokesperson for the Spanish Society of Public Health (SESPAS) explains that having an under-representation of the mortality of an epidemic while it is happening is “the most frequent”. “It happens every year with seasonal flu,” he says. Hernández, who was General Director of Public Health of the Government from 2008 to 2011, lists the criteria on the basis of which, once the first phase has been completed, it can be calculated with greater accuracy: information from the so-called sentinel networks of epidemiological surveillance, mortality certificates and microbiological investigations. “With all the sources, an assessment is made. And now it is premature. More in this situation, that there are many people who work at home, on leave … there may be delays and changes that will be picked up.”
What deaths are being left out?
“A number, with perfect precision, is not going to be given even in countries with the most sophisticated systems. It is impossible,” ditches Hernández. He gives an example: “If a person had pancreatic cancer with few months of life expectancy, but COVID-19 has precipitated his death, what is the cause of death? Surely the cancer, even though the infection has overtaken it But all this will be a work of coding the death certificates, which we will be able to verify in due course. ” Details as complex as the “death defect” will have to be taken into account. Perhaps in May 2020 there will be fewer deaths than expected, precisely by people whose death has been precipitated. “We also have to calculate that mortality has been reduced this month in traffic accidents, or due to contamination, so there may be more excess even than estimated. It is very complex.”
To draw the crisis correctly with all its edges, it will be necessary to count even the “indirect deaths”; that is to say, people who, suffering other pathologies, saw their attendance diminished, for things like delays in the doctor or that did not directly and their situation was complicated. The Spanish Society of Cardiology calculated that since the State of Alarm was declared there has been a reduction of 57% in diagnostic tests in its setting, and up to 81% less intervention in coronary structural procedures. “We are concerned because the reduction does not respond to the epidemiological reality but probably to the fear of patients to get COVID-19 if they go to the hospital. The risk of increased morbidity and mortality from this is notable, especially for acute myocardial infarction “they warn.
When will we know?
Encrypting the true magnitude, with all its nuances, is “a job that requires many heads to take into account all these biases,” says Ildefonso Hernández. Pere Godoy, president of the Spanish Society of Epidemiology, also remembers the usual of this type of delay in following up on epidemics, and everything that makes it impossible to know the volume of the tragedy per day. But it does not give too long terms: “It is not as direct as making a sum of the expected and gross mortality. But we will be able to have some analyzes in a relatively short time: in May we can already observe the calculation of March and April, when the given the peak of the pandemic, and have some conclusions. “
How are deaths being recorded?
By law, the civil registry first records the death and then issues the burial license. However, as an exceptional measure in the face of the increase in deaths and the minimal services of personnel, since March 23, the registries have been allowed to only issue the burial license and leave the registration of the deaths for later.
This exception means that, regardless of the medical causes of the deaths, at the statistical level the registry data is incomplete. For example, the Barcelona registry has stopped registering deaths for two weeks – it will overcome the state of alarm – and only issues burial licenses, whose data has not been published by the Catalan High Court of Justice. Yes it has the one from Castilla la Mancha or that of Madrid: in the first two weeks of alarm, 9,007 burial licenses were issued, while deaths registered in Madrid due to coronaviruses were 3,392.
To try to define more precisely the number of deaths, the Ministry of Justice has urgently asked the civil registries in Spain to send information on all registered deaths since March 14. Specifically, a relationship is requested stating both the registered deaths and the number of burial licenses that have been granted, as well as the municipality where the death occurred and whether it was in a hospital, residence or habitual residence. The ministry does not ask, however, to distinguish the cause of death or that the records state whether they are deceased by COVID-19 or for any other reason.
Could “suspicious cases” be assessed?
Health classified, from the beginning, “suspicious” cases and, for a few weeks, “possible” but does not reflect them in the statistics it provides. It has recently been announced that in New York City, “deceased” cases who died at home without COVID-19 diagnosis will be counted.
Would it be possible in Spain? Pere Godoy (SEE) sees it as “difficult” at this stage of the crisis. It has no longer been established in a “systematic” way, but depends on medical practice: “Many doctors, knowing that someone has died in a residence where there has been an outbreak, they are certifying it even though there is no microbiological test. But this has Much clinical variability depends on the interpretation of the healthcare provider, on the circumstances of death, on clinical resources … in some cases it has been possible, in many it has not. ” Those certificates stating that the person has died with COVID-19 although it is not the main cause could also be analyzed in the future, but it is an even more complex way: “It would have to be a very specific documentation work.”
¿Why is it so important?
During this month, and at the peak of the healthcare pressure, it has been taken as a priority to correctly assist patients, beyond knowing the diagnosis, which is why it was also ordered by Health to stop diagnosing mild patients. How important is it that one day we can effectively know the magnitude of the pandemic in Spain? “Much,” replies Ildefonso Hernández. “Knowing the real impact of this infection will serve to communicate it to other countries. And above all, to improve in the face of future waves and shape health responses. To know, for example, if there has been an excess of lethality that we cannot justify with variables of age and comorbidity. Only knowing all the dimensions of the situation will we be able to know where the health service has failed and hit it and do it better next time. “