Covid-19 mortality has been decreasing because of better understanding of transmission of infection, spread of infection and pathophysiology of disease; availability of better diagnostic tools etc
Globally, as of September 9, 2020, the Covid-19 is affecting 213 countries and territories around the world and two international conveyances. More than 28 million new cases were reported, more than 0.90 million deaths occurred and more than 20 million people recovered and were discharged. The cumulative calculated death percentage was 3.05 percent by August 31; and the trend has been decreasing since April (Table 1).
As on 11.00 am IST September 10, 2020, eight South Asian Association of Regional Cooperation (SAARC) countries (Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka) reported more than five million new cases, more than 87,000 deaths and more than four million patients recovered. (Table 2) The cumulative calculated death percentage and recovery percentage were around 1.68 percent and 78.2 percent respectively. (Table 2). The cumulative death percentage in South Asia is half of the global.
In fact, we need to identify not merely the reported cases but actual number of cases at the given point of time. We don't have actual and accurate statistics of asymptomatic cases as quite a number of cases are asymptomatic, sufficient number of mild cases may not be reported to healthcare facilities, and the number of tests performed by countries varied.
Also, the sensitivity of the RT-PCR is around 70 percent (the false negative cases around 30 percent) and the testing has not been performed on the entire population, so, the actual number of cases is estimated to be at several times higher than the reported cases. Hence, the actual percentage of deaths may likely be less than reported.
Knowing the number of reported deaths during a period of the pandemic is not enough but knowing the number of excess deaths in a given population over the time may carry weight, which is yet to be known/reported. Also, the Covid-19 pandemic may lead to increased deaths from some other diseases such as TB, dengue, and fewer deaths from some other causes such as road accidents. Hence, both reported mortality figures and excess mortality figures are required to understand the death toll of the pandemic Covid-19.
As per the Center for Disease Control and Prevention (CDC), up to one third of the patients infected with Covid-19 may never develop any symptoms but they can transmit the disease. Among symptomatic patients, 80 percent will have only very mild to moderate disease and can be managed as outpatients and kept in home isolation; 15 percent will develop lower respiratory tract infection and may require hospitalisation and will recover; 3-5 percent will require intensive care and may need ventilator support and 0.5-1 percent of patients will die. The data may vary a little bit between continent to continent, country to country, and within country between state to state and within state between district to district.
John Ioannidis, physician and epidemiologist with a fellowship training in infectious diseases from USA believes that infection fatality rate values as different as 0.05 percent and 1 percent is clearly still possible.
We are of the opinion that in case of Covid-19, soon recovery will likely be the rule and death will be an exception. Our opinion is based on the facts that mortality has been decreasing because of better understanding of transmission of infection, spread of infection and pathophysiology of disease; availability of better diagnostic tools; better understanding of natural history of infection and disease; better management of severe and critically ill patients; better understanding of healthcare professionals about the infection and its prevention and diseases and its management, use of personal protective equipment (PPE) and importance of isolation and quarantine; better understanding of public health professionals about contact tracing mechanism, risk communication and risk reduction strategy; better understanding of public about the infection and disease, its prevention and management; better coordination among the World Health Organization and other international, national and local organisations, collaborators, academician and scientists.
Conditions however apply. The condition is that we have continue to follow the basics i.e. follow and implement infection prevention and control measures (handwashing/hand-hygiene, droplet precautions, contact precautions, aerosol precautions, respiratory etiquette, environmental hygiene, masking) and physical distancing until effective and efficacious vaccine/s with no major adverse effects for mass vaccination are available (herd immunity develops) and/or effective and efficacious drugs without major side effects for prophylaxis are available, accessible and affordable and specific drug/s for treatment are available. And we have to sustain our efforts in containing and mitigating the pandemic with the strategy of contact tracing, testing, isolation of cases and quarantine the contacts with active community participation.
Furthermore, we agree that the death is a great loss for a person and family but truth is that the death is a reality and mortality is associated with every disease, be it communicable disease or non-communicable disease, unless the infection/disease has reached the stage of eradication. In case of exponentially growing, highly contagious communicable infection/disease like Covid-19, the urgent need and immediate target is to contain the infection and reduce mortality. The world knows it and has a capacity to contain the infection, reduce the mortality and drive the fear out of the mind of public.
Rano Mal Piryani is Professor of Internal Medicine, Head Department of Internal Medicine and Chief Coordinator- Health Professions Training Committee, Coordinator Covid-19 Task Committee, Universal College of Medical Sciences, Bhairahawa, Nepal
Suneel Piryani is Public Health Consultant, Karachi, Pakistan.
Muzaherul Huq is former Regional Advisor, World Health Organization, South East Regional Office, Bangladesh