Vietnam has passed the milestone of 15,000 deaths related to covid (the exact number is 16186). I kept wondering how to interpret this number, and wondering how health officials would define a covid death. This sentence is simple but very important. I think it’s important to distinguish ‘died from covid’ and ‘died with covid’.

Many people compare mortality rates between Vietnam and Thailand. Thailand has twice the number of infections than Vietnam, but the number of deaths is 8% lower than Vietnam. In fact, the mortality rate in Vietnam (2.5%) is even higher than in Cambodia (2.0%) (See Figure 1).

Why is there such a big difference between countries in the region? Any one of us can think of a reason to explain, and the reason may be that Vietnam’s health system is still weak in overloaded conditions, maybe lack of machinery and medicine, there are could be a prolonged blockade, etc. All of those reasons may be true, but other countries like Laos or Cambodia are just like us, also lacking in all aspects (perhaps Thailand is a bit more ). I’m afraid the ‘mechanical reason‘ That’s hard to explain why Vietnam has so many deaths in this epidemic.

I thought about the technical reason: how to count and determine the cause of death.

In order for you to understand the problem, I would like to summarize a case in Australia as follows. Last year, a young man named Nathan Turner, aged 30, died at home after showing flu-like symptoms. When the hospital did an autopsy, they declared him positive for covid. So his death was considered a ‘covid death.’ But later, the cause of death was thoroughly investigated, it was discovered that he had many complicated diseases, and tested again, but this time the result was negative! Therefore, counting him in the covid death statistic is wrong. The story speaks to the complexity of determining the cause of death.

1. Determine cause of death and covid

In Australia, statistical officials have specific guidelines for determining causes of death. The Australian guide roughly states that If the deceased person is infected with nCov, the death certificate should state that COVID-19 is the cause of death, regardless of whether Covid-19 was the direct cause, or is presumed to be, to cause or contribute to the death [1]. In other words, if the patient has a stroke and covid, the cause of death must be listed as covid.

In the US, at a time when the number of deaths is soaring, there is a debate about the cause of death related to covid. The CDC has a whole document that lists causes of death, and reading that document shows how complicated it is [2].

But if you read it carefully, you will see that Anyone who has been infected with nCov and later died must list Covid-19 as the cause of death. This regulation is very similar to Australia. Many people in medicine disagree with this classification, but the rules are rules and doctors who write death certificates must follow!

The problem is that the cause of death often depends on the individual doctor. On cdc.gov [3] there is an interesting dialogue about writing causes of death, and I can summarize as follows:

Ask: For those cases where people die from diseases like cancer or late-stage Alzheimer’s, and before they die they are infected with covid, how do doctors judge the cause of death?

Answer (summary): It is not easy to determine the cause of an individual’s death, especially if they have a terminal illness. For example, if a patient has terminal cancer and the doctor thinks he has 6 months to live, but because he has covid and died before 6 months, the doctor will probably write the cause of death as covid. . But in the end it depends on who writes the death certificate.

The sentence that depends on the person writing the death certificate is very important. This fact suggests that the cause of death is not objectively determined. If 2 people get covid and die, doctor A can go through the history and say the cause of death is kidney failure, but doctor B can write the cause as covid.

That is one reason why the number of deaths related to Covoid-19 is so high.

2. ‘Die with the virus’ or ‘died with the virus’?

The vast majority or absolute majority of covid-related deaths are over 60 years old. Well, people of that age often have comorbidities (called ‘comorbidities’). In Australia, according to one analysis, 73% of covid deaths had comorbidities [4]. Common diseases are dementia, chronic heart disease, diabetes, high blood pressure, respiratory disease, cancer, and bone and joint diseases (see Figure 2).

Two weeks ago, the New South Wales State Government changed the way it talks about covid deaths. They stated that from now on, health officials will write/said that “death with virus” (die with the virus) instead of “death from virus ” (died from the virus). The expression ‘die with the virus’ is less defined and modest than the phrase ‘died with the virus’. In fact, I personally have been using that expression since last year: covid-associated deaths.

3. Is the cause of death covid in Vietnam accurate?

Back to the question of why Vietnam has recorded more covid deaths than other countries (such as Thailand) even though the number of infections is lower. I think it is most likely due to technical reasons in determining the cause of death.

As mentioned above, in Australia and the US, there are regulations on how to write the cause of death on the death certificate. I don’t know if there is such a regulation in Vietnam. Looking at the website of the Ministry of Health, there is no regulation on recording the cause of death. If not, I think it is better to prepare a regulation on death certificate so that the doctor can base on that to determine the exact cause.

Which, with or without regulation, the cause of death is still an unbiased information, because it depends on the doctor’s judgment. As seen in the above dialogue at the CDC (USA), determining the cause of covid deaths is often just a personal judgment. Therefore, the hypothesis is that the number of covid deaths in Vietnam is certainly not a true reflection of the situation, and the comparisons between countries are only meant for information rather than for reference.

Those of you who directly record the death certificate can share your experience with other friends.

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[1] https://www.abs.gov.au/ausstats/abs@.nsf/mf/1205.0.55.001

[2] https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf

[3] https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210319/TRANSCRIPT_STATCAST_031921.pdf

[4] https://www.abs.gov.au/articles/covid-19-mortality-0