It was reported that there were 293 or about 10% of the 2,796 Covid-19 deaths recorded as of May 31 were brought-in-dead (BID) cases. This figure has raised some concerns as there are cases where Covid-19 patients do not have symptoms and can deteriorate rapidly. There are also possibilities that many BID patients did not realise they were positive for Covid-19 until it was too late.
We asked experts to explain this scenario:
- What is brought-in-dead (BID) and why is this a concern?
- What can be done to reduce the number of BIDs?
Dato Dr Zainal Ariffin Omar, Malaysian Public Health Physicians’ Association (PPPKAM) President, said:
There is no detailed study on BID. But the problem is worrying with 15-20% of current Covid-19 deaths. May indicate a failure of patients to be recognized by patient and family or treat early enough or some problem with the system. Based on the KKM statistics and some observation, the majority of BIDS were people with comorbid conditions. Hypertension, diabetes, obesity, elderly and asthma amongst others. Most of them had symptoms, but not that serious and later turned into stage 3 and 4 quite fast. Therefore, Covid-19 patients with high risk and comorbidities should be properly assessed and monitored either in centres or hospitals.
Dato’ Dr Amar-Singh HSS, Senior Consultant Paediatrician, on behalf of the Malaysian Health Coalition said:
Brought-in-dead (BID) are persons who died before being admitted to the hospital and tested positive for Covid-19. It is an indicator of how well our health services are functioning and able to cope (safety net for the people) but also a gauge of the size of the outbreak locally. Of concern is the rising rate of BID (see image); currently at 9.2% for the first 11 days June 2021 (89 out of 972 deaths) i.e almost 1 in 10 Covid-19 deaths is an adult brought-in-dead.
As the data shared about BID is limited, it is uncertain if these individuals died of some other illness and were also coincidentally infected with Covid-19 or if the cause of death was directly related to Covid-19. This can be resolved by doing routine post mortems for all these persons (or a routine chest CT scan). On the other hand we are not sure if all deaths in the country are tested for Covid-19 and it is also possible that some Covid-19 deaths are missed. Currently we have to assume that all these BID deaths were due to Covid-19.
A quick analysis of BID cases from the last 3 days (33 deaths) showed that 13 (39.4%) were younger individuals under 60 years of age, 15 (45.5%) had no known comorbidities (chronic illnesses), the majority (78.8%) were Malaysian; 21 (63.6%) occurred in West Malaysia and 12 (36.4%) in East Malaysia.
Vital data required to understand the problem of BID includes:
1. Were these individuals already tested for Covid-19 but pending the results (the PCR testing delay can be 3-5 days)?
2. If tested positive, were they asked to stay at home and what were the instructions given and daily monitoring conducted by the health system? How efficient was the communication between the health services and these patients?
3. Did any of them die while waiting for a hospital bed (our ICU beds are choked).
We are beginning to hear of a number of instances where patients with Covid-19, who was managed at home, had difficulty contacting or getting support from the health services when they deteriorated. This should not be allowed to happen.
It should be noted that some individuals with Covid-19 who are deteriorating may not be aware of it; what is called ‘happy hypoxia’ or better known as ‘silent hypoxemia’. These individuals may appear asymptomatic or mildly symptomatic (appear clinically well) with no significant respiratory distress but have oxygen low saturations (SpO2 < 90%). They should be in hospital and are at risk of dying suddenly. Hence anyone on home quarantine should have a finger pulse oxymeter available to monitor their SpO2 and alert the health services if it goes below 95%.
The Malaysian Health Coalition statement on 9 June 2021 outlined key measures to be taken to reduce BID events. Granular data and analysis to understand why they happen is critical; sharing this with the public will improve understanding of the problem. There must be good access to healthcare facilities, improved monitoring of home quarantine patients, better education of the public on warning signs and increased testing capacity to identify the infected early. Enlarging our genomic testing is vital to understand if more virulent variants are spreading and contributing to rapid deterioration resulting in BID.
The high rate of BID may reflect underlying systemic failures and a system that is overrun. This can only be resolved by strong measures that involve the participation of the whole health services (government and private) with the public.
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**All previous posts about COVID-19 here: https://sciencemediacentremalaysia.com/tag/covid-19/
Bionotes of expert
Dato Dr Zainal Ariffin Omar is President of the Malaysian Public Health Physicians’ Association (PPPKAM). He is also the former Pahang health director and currently a member of the Malaysian Health Coalition (MHC).
Dato’ Dr Amar-Singh HSS is a Senior Consultant Paediatrician and former Head of Paediatric Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak. He also formerly served as a Head of Clinical Research Center in Perak and a member of the Malaysian Health Coalition (MHC).