Reply To: SARS cov2 and Covid 19

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“But if we simply say everyone hit by a bus would still be alive if buses were removed then clearly our only option is to remove buses.”
“Does it still make sense to simply ban all buses and lose their many advantages?”

Not really, there is consideration to the benefits of a public transport system in the balance and instead they try to mitigate the risks of people running or stumbling out infront of a bus rather than banning buses outright. All the railings at busy crossover points, those little bumps in the pavement to alert blind/visually impaired people thay are at the threshold of a crossover, audible traffic light alerts, traffic calming measures, speed bumps, reduced school zone speed limits, speed limits in general, reduced pedestrian access to motorways and busy A roads, closing off rat runs etc

In response to your second paragraph relating to death certificates and causes of death.

“I think you will agree that, using those guidelines, covid-19 would rarely, if ever, be given as an underlying cause of death where co-morbidities are listed.”

Not quite sure what you mean here but I think you mean covid 19 would rarely be listed as a significant co-morbidity in box II and more likely to be listed in the sequence in box I as part of the sequence leading directly to death. If so, that isn’t true. Prof Carl Heneghan looked at this with the trend increasing over time from 7.8% in the beginning to 29% (worryingly) in the last 8 weeks of reporting up to August:

Death certificate data: COVID-19 as the underlying cause of death

For example, someone with significant chronic obsructive pulmonary disease (COPD) gets an exacerbation because of covid 19 and dies. It might be felt that COPD was the true underlying cause leading to cardiorespiratory collapse with covid 19 being a signficant contributory factor.

You quoted

” ‘If the certificate has been completed properly, the condition on the lowest completed line of part I will have caused all of the conditions on the lines above it.’

This needs to be understood more in terms of the sequence of events/conditions.

“You are asked to start with the immediate, direct cause of death on line Ia, then to go back through the sequence of events or conditions that led to death on subsequent lines, until you reach the one that started the fatal sequence.”

“WHO defines the underlying cause of death as “a) the disease or injury which initiated the train of morbid events leading directly to death, or b) the circumstances of the accident or violence which produced the fatal injury”. From a public health point of view, preventing this first disease or injury will result in the greatest health gain.”

You gave an example of someone with cancer who also has covid. The first example they cite in that guidance document has interstitial pneumonitis as direct cause of death caused by covid then they list primary adenocarcinoma of ascending colon directly leading to Covid. I find that strange even without access to that particular patient’s records. The stage of cancer and presence (or absence) of metastatic lung disease should have been mentioned.

“It is not at all unrealistic to suppose that on many of those certificates, it was actually pneumonia that was listed at the top, and thus the ‘direct cause’ of death which terminated life.”

It is very often exactly that Steph. But if a secondary pneumonia is caused by primary covid 19 then covid 19 is the underlying cause of death. Similarly, a cachectic, immunocompromised patient with lung mets dies from a pneumonia the underlying cause will be the cancer which leads to the sequence of events which ended with pneumonia.

I think we are all, including me getting a bit bogged down wth the death cert stuff. It is good to be sceptical folks. Equally, at some point you have to work with the data we have and not what we’d like to have.

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