18 May 2022

Dying 'from' or dying 'with' COVID? It's more complicated than you think

| Lottie Twyford
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ICU beds at hospital

Yesterday, 80 people were in the Territory’s hospitals with the virus. Five were in the ICU (pictured) and two required ventilation. Photo: ACT Government.

Since the beginning of the year, 47 Canberrans have died ‘with’ COVID-19. To yesterday (17 May), there have been 59 deaths related to the virus since the beginning of the pandemic.

They are sobering facts.

And every time a death is reported, a question is raised: why do we report deaths ‘with’ COVID-19 and not deaths ‘from’ COVID-19?

What’s the quick answer?

Unfortunately, there really isn’t one.

Using ‘with’ makes things easier for health authorities as there’s an agreed-upon set of reporting guidelines.

In the future, it will also make it easier for researchers to learn more about the pandemic.

But it’s also partly because understanding a cause of death can be quite complicated. This is particularly true if the person who died was elderly and/or had underlying health conditions.

What do we know about COVID-19 deaths already?

Of the 2639 Australian COVID-19 deaths reported to the Australian Bureau of Statistics before 31 January 2022, nearly all of them (2556; 97%) have been directly linked to the virus.

But 91 per cent of these deaths occurred in people who had at least one other health condition and the median age for a COVID death was 83.7 years old.

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What’s the current definition of a COVID death?

At this point in the pandemic, all states and territories are following national guidelines for defining and reporting COVID deaths.

The Federal Department of Health defines a COVID-19 death as a death of a person who is either a confirmed or probable COVID-19 case.

But they do not attribute death to COVID-19 if there is a clear alternative – such as if a person tested positive for the virus but then was involved in a major car accident.

In cases where a person has had a ‘distinct period of recovery’ between illness and death, that shouldn’t be counted as a COVID death either.

Who determines cause of death?

It’s up to the medical practitioner, or in some cases the coroner, to determine the primary cause of death, as well as any contributing factors.

All of these are listed on that individual’s death certificate. ACT Health says if COVID-19 is written as either the primary cause of death or a contributing factor, that death is noted and reported as a COVID death.

Australian National University.

In years to come, experts will look back on the pandemic and see what more can be learned. Photo: Michelle Kroll.

What do the experts say?

For elderly people, one infectious diseases expert said COVID-19 is often the “straw that breaks the camel’s back”.

“When you’re in your 80s or 90s you might have heart disease, lung disease or cancer, as well as COVID-19 – so which do you attribute the cause of death to?” asks ANU Medical School Professor Peter Collignon.

“That’s when things get complex because, at some point, you have to attribute the death to these things proportionately. So it’s easier to say ‘with’ rather than ‘from’ because you can’t look at every death individually yet.”

So, if COVID-19 isn’t the ‘smoking gun’, why is it important we know about the deaths?

Well, Professor Collignon says it’s not okay to simply stop reporting deaths – complicated and complex as the data may be – as it may downplay the role of COVID-19 in the person’s death.

In the future, it’s likely we will be able to put a number on the number, or percentage of deaths, which were caused by COVID-19 or were hastened by it.

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Will we learn more in the future?

In all likelihood, the answer is yes, as experts just like Professor Collignon will undertake research into the pandemic.

If that data isn’t collected now, this will never be able to happen.

It’s also not the first (and probably won’t be the last) time studies like this will be conducted.

By way of an example, two decades ago, Professor Collignon was involved in a study which looked at people who died with Staphylococcus aureus (often referred to as ‘staph’ or ‘golden staph’) in the bloodstream. Like COVID-19, lots of the people who died had underlying health conditions.

To work out how a person died, researchers had to assess whether or not they believed a person would still have been alive in 12 months had they not contracted staph. Similar questions may be asked about COVID-19 deaths.

Row of AFP officers and traffic

Remember the days of checkpoints at the Territory’s borders? Photo: Michelle Kroll.

Is this just about public health?

No. This is also complicated (but if you’ve followed the ‘with’ and ‘from’ argument closely, you knew that already). After all, it’s now been more than two years of lockdowns, border closures, emergency declarations, mandates, masks, checking in, working from home, learning from home (and much more). The pandemic has impacted much more than health.

As Professor Collignon puts it: “it’s controversial, it’s political and it’s emotional … so we need to know more.”

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“death of a person who is either a confirmed or probable COVID-19 case”

Yeh mate he’s “probably” got Covid…

We were all held hostage for two years, and as we are now slowly catching Covid (vaccinated) it turns out that it’s just another flu. This “highly contagious” virus hasn’t travelled like wild fire as promised.

The media lies and politicians who were indecisive and incompetent are squarely to blame.

We had AstraZeneca in stock yet we were scared off this by the media, instead we remained at home and continued to believe this virus was going to kill us all.

Lies.

I can not see society behaving as well and being as compliant when the next pandemic comes our way.

Covid is not “just a flu”.

And it has spread extremely fast through the community as was predicted.

Despite whether you think our restrictions were over the top (I do), it’s clear that we prevented tens of thousands of deaths and the vaccines have prevented even more.

Whilst I also agree that the scare campaign against the AZ Vaccine was very dumb, overall Australia has done very well in our response.

Covid spread fast and far. Extremely contagious. The restrictions saved a lot of lives. Compare the % of deaths here to the USA. You can deny the facts as much as you want, but doesn’t change the facts.
It was over the top with AZ, but I had it anyway. Earlier than I was normally entitled to; being allowed to, as I was a carer.

Seem to remember some decades ago there was news about high prostrate cancer death figures.

Some medico type whiz kids went over the figures, and came up with the announcement that most ole boys were dying ‘with’ prostrate cancer, rather than ‘from’ the cancer.

Brilliant…ly irrelevant. The question is the proximate cause of death. It is now well understood that prostate cancer was “over-medicalised” which is why AIHW then advised against PSA testing over-70s. Prostate cancer may be a comorbity when you die of cardiac arrest, the proximate cause. Angina may be a comorbidity when you die of respiratory failure, engendered by Covid-19.

Thank you phydeaux for your brilliant…ly replied note.
I wonder if NZ authorities have changed their records.
https://www.1news.co.nz/2021/11/11/new-lynn-shooting-victim-was-positive-for-covid-19/

Merc, it literally says in your article that they will report them listed as “under investigation” until finalised by clinicians or the coroner.

Merc, additional to the reading advised by chewy (it helps not to jump on the first headline) see my response to Acton, below (2:18 PM 18 May 2022) where I provide definition formally used, and link an ABS explanation (with examples) of process.

phydeaux thanks for your note.
In my original posting i did say ”I wonder if NZ authorities have changed their records”.

So Merc, do you regularly post articles where they answer the question you raise?

Not sure of your point, do you have evidence that they haven’t updated their figures?

I’d love to see it, would really make this thread more interesting than a useless news article from months ago.

Either way your dead

Your dead what? Your budgie?
Besides, at time of writing, I’m not.
Cheers

“ACT Health says if COVID-19 is written as either the primary cause of death or a contributing factor, that death is noted and reported as a COVID death.”
The statistics are exagerating deaths from Covid if there is even a possibility that the real cause of death was not Covid but something else, like pneumonia, heart disease or a car accident. A death from Covid must be a death caused by Covid, not a death where Covid is simply detectable (died with Covid) or a contributing factor to some minor degree.
Recording Covid deaths as being both from Covid and with Covid undermines the veracity of Covid death data now and in the future. Faulty or dubious Covid statistics complicates national and state health policy, misallocates medical resources and reduces public confidence in lockdowns, school closures, mandates and directives based on those statistics.
I’m sure Prof. Collignon would agree that differing national and international standards of Covid recording and data collection also makes it difficult to compare Covid death rates between countries.

This is completely illogical because under your definition you would almost never attribute a death to any cause except the ending of brain function.

You can make the same argument you have above about any disease.

The scientists still work through the exact impact of COVID overall which is exactly what professor Collignon has said.

The only people arguing against this are those who want to downplay the seriousness of COVID because of their preconceived notions of the government response to it

So true Chewy14,
It is just too easy to “discount” Covid when there are other health conditions.
My mother is in her 90s and with that, she has a few age-related health conditions. Her existing condition, in themselves, is manageable, however, I’d expect if she contracted Covid, she wouldn’t survive.
I would be livered if a bureaucrat used the downgraded the significance of her passing by using words like “with”, when the truth

is more likely to be “of”.
Every person who is lost is/was someone’s loved one.

Adding: Acton states that a person who has COVID-19 and dies of trauma (medically defined) in a vehicle accident

… will be defined as a Covid death. This is fatuous, not to mention false. ABS states the definitions clearly and in accord with WHO guides, as used by most similar countries.
“A death directly due to COVID-19 is defined by the WHO as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). There should be no period of complete recovery from COVID-19 between illness and death.”
You can find it, with examples of death coding, here: https://www.abs.gov.au/about/legislation-and-policy/freedom-information/disclosure-log/FOI_19%20July%202021.pdf

Respiratory diseases have always been among the most common cause of death among the elderly. Mostly because they already have a long list of existing problems, and even the common cold can be too much for their bodies to handle. Viral induced pneumonia was often referred to as the “old man’s friend” for this reason. Given the massive age disparity in deaths, it’s really a question of whether anything has changed. It seems likely that many of the elderly who sadly died would have died anyway from influenza or another existing virus. In which case, it’s about the framing, not the death.

Dying anyway is not unusual. The question is identifying causes, for interventions.

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