Topic: Deaths’ analysis: Why are we still losing patients?

Speaker: Dr Rahul Pandit, Director Intensive Care, Prof Emeritus Critical care Fortis Hospital Mulund Mumbai; visiting consultant Wagga Base Hospital, Australia, Maharashtra Task Force Member 

12th February, 2021, Saturday

9.30am-11am

• Analysis of data up to 30^th January, 2022 shows that cases that spurted up in the months of December and January have started coming down. UK, USA, Brazil and Russia are still in the upsurge, while India, Canada, South Africa have showing a declining trend.
• Evaluation of deaths shows that nearly 25,000 deaths are occurring in the US in a day; India has still not flattened and there is a slight upsurge. Deaths are increasing in Brazil, but coming down in South Africa. In Russia, though the number of cases are going up, the deaths have lagged by 2-3 weeks. In the UK, deaths have flattened off and hopefully will start coming down.
• Deaths during the first wave in a tertiary care center with dedicated COVID-19 ICU were analysed based on age, gender and comorbidities. Data was based on 514 ICU patients. Patients >50 years had a high chance of dying. Almost 80% of patients who died were male and almost 85% of those who succumbed had comorbidities, mainly five – HT, DM, IHD, obesity (BMI >30), malignancy and autoimmune disease (Indian J Crit Care Med. Sept. 2021).
• Prospective mortality data of 9 ICUs across the western part of Maharashtra compared the first and second wave. Five predictors of mortality were identified: Age (>50), gender (male > female), wave (second wave > first wave), HRCT score (higher the score, higher the mortality) and comorbidities.
• The third wave in Maharashtra is predominantly Omicron with 10% delta. Analysis of one month data of this year (Jan 1- Jan 31) showed that as the cases started to trend down, the deaths also went down and they have remained low.
• Comparison of the three waves show that CFR increased from 3.99% to 33% in the 51-100 age group. This trend remained the same during the second wave. Despite the large number of cases, the CFR remained less. Two inferences can be drawn from this: one that there were a large number of people who were infected, but not all of them were sick. Secondly, our understanding of the disease was very poor in the first wave but now we understood the disease a little better and so were able to save more lives. The health infrastructure also improve significantly.
• In the third wave, the chances of mortality are much higher if age ≥60 years.
• In 2020, the higher the age, higher the chances of mortality. However, deaths were also occurring in the 41-50 age group indicating that younger lives were being lost. Again in Jan-Dec. 2021, more younger people (31-40 and 41-50 age groups) were dying. In Jan. 2022, 41-50 age group continue to have lot of problems. So, the trend did not change. We were losing younger people during the second wave, which was a concern.
• American Academy of Pediatrics (AAP) data shows that 18% children were affected, but mortality remained low (0.00%-0.24% of all Covid-19 deaths) and 0.00%-0.01% of all child Covid-19 cases resulted in death.
• Data from University of Queensland and Flinders University showed that those who got a booster dose, the chances of dying are less than 0.1%. This increases to more than 7 in the ≥60 age group. This shows that primary vaccination  + booster has helped.
• Data from UK showed that the vaccine effectiveness against omicron reaches >90% for deaths and ~60% for infection.
• In the US, as per data on Dec. 4, 2021, the unvaccinated population outnumbers the vaccinated population by a huge margin with 9.74% chances of dying if unvaccinated and 0.71% if vaccinated but no booster and 0.1% or less if vaccinated and boosted.
• There is a large population of unvaccinated population including in the developed countries. 
• Most current vaccines have an immune escape phenomenon seen.
• Omicron is less severe but no mild especially in the unvaccinated and elderly. This vulnerable population should have been reverse isolated, but it was not done anywhere in the world because of the very large number of cases. It is mostly this group which developed severe disease and succumbed.
• People have dropped their guard with covid-appropriate behavior taking a back seat, especially in people who perceived to have hybrid immunity.
• People brought infection to homes and infected the elderly and vulnerable population.
• Many countries, where vaccination was large and almost covering the entire population, discussed becoming mask-free. Unfortunately, this thought process translated in countries where vaccination was nowhere near some of the fully vaccinated people.
• A narrative that this is the end of the pandemic is worrying.
• A peculiar aspect of the third wave is “incidental Covid”. Patients were hospitalized due to other reasons such as head injury/MI/stroke/GI bleed etc and were found to be positive when tested on admission as per hospital policy. All these conditions per se have higher mortality than Covid but they were all labelled as Covid deaths. But Covid was not the primary cause of death in them. Incidental Covid is one of the possible reasons why we are still losing lives.
• Another reason speculated for mortality is the conundrum of high numbers. We do not have the exact number of people who were actually infected. Many were asymptomatic and were not getting tested.
• Some countries approved booster doses much earlier to the high-risk population.
• Inequitable distribution of vaccines across the world where some countries have 3-4 doses, while there are other countries which have none. So, resolving this inequity in vaccines could have helped.
• Vaccination is the only to ensure that no new variant emerges, which is more severe than the currently circulating ones. If this happens, the major population of the world would be definitely protected from death; whether it would protect from hospitalization also is difficult to say.
• Doctors were exposed to high viral loads during the first and second wave. Also many doctors have multiple comorbidities and how well-controlled they are is a big question.
• People are in denial about Omicron, which has led them stop being careful.
• Even if it’s a mild symptom like a scratch in the throat, one must see a doctor and get tested. This message should be imparted to the public.
• We have to learn to live with the virus in a safe way, which means make sure that the comorbidities are well-controlled and truly within the range. Take the booster dose as per the country’s vaccination program.
• Children should be allowed to go to school despite the vaccination status. But there should be 
• a good public/parent education program to try to convince them to get their children vaccinated.
• Infection among the healthcare workers has led to a staff shortage

Participants

Member National Medical Associations

Dr Yeh Woei Chong, Singapore, Chair CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO

Dr Marthanda Pillai, India Member World Medical Council, Advisor CMAAO

Dr Wasiq Qazi, Pakistan, President-elect CMAAO

Dr Ravi Naidu, Malaysia

Dr Angelique Coetzee, South Africa

Dr Akhtar Hussain, South Africa

Dr Qaiser Sajjad, Pakistan 

Dr Marie Uzawa Urabe, Japan

Dr Muh-Yong Yen, Taiwan

Dr Prakash Budhathoki, Nepal

Invitees

Dr Rahul Pandit, India

Dr Mulazim Hussain Bukhari, Pakistan

Dr Patricia La’Brooyi

Dr Chong Tsung Wen

Dr Aarthy Kanan

Dr Diane Campbell

Dr Nidhi Dhawan

Dr Manisha Kukreja

Dr Anita Dhar

Dr Kiran Chopra

Dr Kiran Vinayak

Dr S Sharma, Editor IJCP Group

Moderator

Mr Saurabh Aggarwal