Underlying Cause Of Death (part 1)
Investigation of the hike in care home non-COVID deaths in England & Wales during 2020 (rev 1.2)
In my previous newsletter I added a final section called Fly In The Ointment and reproduce it again here because substack mailout is a one shot system and subscribers don’t get to see revisions unless they actively browse my newsletters online.
A Fly In The Ointment
All this analysis assumes that care homes across England & Wales in early 2020 had access to PCR testing as and when required. Anecdotal evidence coming to me from those in the care sector suggests this was not the case. We must note that physicians could code COVID death merely by scribbling U07.2 COVID-19, virus unidentified on the death certificate. No test necessary! I trust physicians far more than I do the diagnostic test so we may ask why they opted to code these care home deaths as they did given they’d presumably be guided by symptom and clinical course. In this regard we must also note the buzzing in the ointment generated by WHO’s recommendations on death certification:
"With reference to section 4.2.3 of volume 2 of ICD-10, the purpose of mortality classification (coding) is to produce the most useful cause of death statistics possible. Thus, whether a sequence is listed as ‘rejected’ or ‘accepted’ may reflect interests of importance for public health rather than what is acceptable from a purely medical point of view. Therefore, always apply these instructions, whether they can be considered medically correct or not."
Bold is mine.
We are thus left with a hike in care home mortality that is being called COVID but may not be, and a hike that is being called Non-COVID but may not be! Unless we get our hands on the medical notes accompanying each certificate we shall never know what happened in care homes back in early 2020.
Where Next?
There’s nothing more depressing to an analyst than undertaking a cunning analysis to sit back glowing with pleasure only find the data are well-dodgy. We have care home COVID deaths that may not be COVID and care home Non-COVID deaths that may be COVID. I thus rummaged once more in the larder of the Office for National Statistics to find this handy spreadsheet and it wasn’t long before these tray bakes were coming out of the oven…
Before we get stuck in we must note the definition: Number of deaths to care home residents involving Influenza and/or Pneumonia by week of registration 2017-2021. Bold is mine.
We’ve all heard that the flu magically disappeared for the 2020/21 season and here is a green line suggesting this was the case, though I doubt that tests were run on care home residents to confirm matters. Back in 1966 England won the world cup and Abraham Maslow wrote "If the only tool you have is a hammer, it is tempting to treat everything as if it were a nail". I suspect this extends to physicians with death certificates who are following WHO guidelines, though some bods favour fancy hypothesis pertaining to viral dominance. It may be just me getting cranky in my retirement but I consider it a bizarre fact of medico-politics that the UKHSA manage to detect several viral strains each season1 yet somehow seem to ignore the theory of dominance when it comes to tabulating the data arising from these. SARS-COV-2 must be very special!
Given the games that are being played the purple pneumonia plot is the one that interests me the most because of that dirty great spike during early 2020. We may note that the seasonal spike for the 2020/21 winter season looks pretty much like the pre-pandemic seasonal spikes for 2016/17 and 2017/18, with 2019/20 being a lean year for death. I am reluctant to go all political and call 2020/21 a ‘third wave’ since deaths involving pneumonia look pretty much par for the course to me!
Let’s take a closer look at that dirty great spike…
I’ve slapped down a pre-pandemic mean with 3 sigma control boundaries and these alert us to something untoward happening 2020/w14 - 2020/w20, which is pretty much the period I’ve been ranting on about. This tells us one important thing - that the hike in COVID and non-COVID death was coincident with a hike in pneumonia. Obviously we have no way of knowing whether SARS-COV-2 or something else was making all the running since the PCR test wasn’t used in care homes then; all physicians had to go on was symptom, clinical course and the usual battery of bloods.
So far so good but tomorrow I shall present another dirty great fly buzzing in the ointment. We shall get to see what that word involving means…
A(H1N1)pdm09, A(H3N2), A(unsubtyped), Influenza B, RSV, Rhinovirus, Parainfluenza, hMPV, Adenovirus.