When most Cubans hear about a death today, they don’t think about heart disease, cancer, cerebrovascular disease – the top three causes of death in the country, but about COVID-19. Plus, we are living in a time when many people doubt just how accurate daily death counts, announced by the Ministry of Public Health (MINSAP), are. They are right to have doubts.

The official number of COVID-19 deaths in Cuba does not match the real number; which prevents us from having a more realistic idea about the pandemic’s impact on the country. The minister of Public Health himself, Jose Angel Portal Miranda, admitted that his data is biased. Authorities from several provinces have called these numbers into question – maybe by accident -, which are reported every morning by the national director of Hygiene and Epidemiology at MINSAP, Francisco Duran.

Technicalities when declaring a COVID-19 death may be watering down the real death count due to the pandemic, and are instead being recorded as the result of other ailments.

A health official in Guantanamo – whose position was not identified – admitted that there are many deaths caused by bacterial pneumonia, with more serious clinical pictures, “but if they didn’t have a positive PCR test, they can’t be classified as COVID-19 deaths, even though their bodies are then mixed with positive bodies for burial.”

ALARM BELLS RINGING

Ihosvany Fernandez, director of Communal Services in Guantanamo, told local press that on August 1, 3 and 4, there had been 80, 61 and 67 burials respectively. These figures are six times the average of daily deaths in 2020 (11) and they aren’t justified by any mass-casualty accident or natural disaster.

In addition to explaining that over 20-something of these burials had followed protocol for the handling of COVID-19 corpses, Fernandez’s statements were the first sign of an official undercounting deaths caused by SARS-CoV-2. On these very same days – August 1st, 3rd and 4th – MINSAP’s reports for Guantanamo were 10, 8 and 9 respectively.

Days later, an article in Ciego de Avila’s Invasor newspaper revealed that the minister of Health had admitted that his ministry wasn’t accurately reporting the real number of deaths.

“The daily death count issued by MINSAP only includes the deceased who had a positive PCR test at their time of death, which the Health minister admitted exclusively to Invasor; also aware of the bias in this data, because not every dead person was able to do a PCR test or get a PCR test result back,” the weekly paper from Ciego de Avila confirmed.

Several local news reports from Cienfuegos reported that daily burials ranged between 45-50, which is unusual compared to previous years – when there were only 10 fatalities on average, according to the Health Statistical Yearbook.

The urgency in increasing burial capacity at cemeteries in Las Tunas, Pinar del Rio, Ciego de Avila, Cienfuegos, Guantanamo, Santa Clara, among other provinces, proves that there has been a spike in deaths in recent months. However, you have official statistics on the one hand, and corpses on the other.

NOT A COVID-19 DEATH IF THERE’S NO POSITIVE PCR TEST

SARS-CoV-2 diagnosis tests are in shortage in Cuba. MINSAP has admitted this. The update of health protocols in late July is, partly, due to the spike in infections and not enough tests. According to the document, only symptomatic patients with a positive antigen test are given a PCR test and, in asymptomatic cases, contacts of confirmed cases “are to be on alert.”

MINSAP official, Aldo de Jesus Muñoz, told Perlavision, “we’ve stopped buying medicines in Cuba to buy PCR and antigen tests.”

Many people have complained on social media about long lines to get a COVID-19 test done, or having “allegedly” had the disease – with symptoms of the virus – without getting lab confirmation because of shortages of these diagnosis tests. If these shortages are affecting the living, there are even less resources to confirm whether a COVID-19 was the cause for a death.

Amidst this crisis of diagnosis tests – which the provincial health director in Pinar del Rio has recognized-, many COVID-19 deaths haven’t been identified as such. It doesn’t matter whether a person was in direct contact with an infected person, if there are signs of the disease in their X-ray or if they had specific symptoms like a loss of smell and taste: COVID-19 isn’t the cause of death if there isn’t a positive PCR test to back it up.

In Las Tunas, doctor Viviana Gutierres, the provincial health director, recognized that the population’s questions about official statistics of daily deaths in the province were valid.

Gutierrez explained to 26 weekly paper: “looking at the numbers, we have had some 160 patients with a clinical history that correlates with SARS-CoV-2, but not all of these cases have been confirmed with a PCR test, and so we haven’t been able to report them as such.”

The doctor added that “even though evidence points to this, there isn’t a test to support it and, as a result, the doctor following the case, in a GP clinic or assistance center, can’t sign off the death with a likely cause, if they don’t have a lab result. It’s really difficult to do this, off of just what the doctor sees at that time.”

Herein lies the reason for the government’s undercounting of COVID-19 deaths: it’s impossible to attribute a death to COVID-19, without a PCR result to prove this.

A health official in Guantanamo explained to local TV that deaths are categorized depending on their test result: confirmed (with a positive PCR test), post COVID-19 (with a negative PCR test) or suspected cases with symptoms (those who lack a PCR test result).

The National Action Protocol for COVID-19, which was updated in July, states that only patients with moderate or severe symptoms will have a PCR test administered. Those with mild symptoms will be given an antigen test and, if the result is positive, a specimen will be taken for a PCR test. Many people have died without being given their test result back or, even, without having done a test.

According to a statement from doctor Francisco Duran, “there are cases where people die and the diagnosis is still unclear, and this can take 24 – 48 hours.”

In Las Tunas, for example, a committee evaluates the clinical and epidemiological history, evolution and likely cause of every death. They can change the death certificate, in some cases.

“Up until now (August 18th), 49 people have died from COVID-19, even though the technical committee that evaluates these cases checked a total of 155,” the provincial deputy director of Health, Gregory Perez Hector, said in a TV appearance. “When a patient is suspected of having COVID-19 and passes away, this disease can’t be recorded on the death certificate without a PCR test having been done.”

WHAT DOES THE WHO/PAHO PROTOCOL OUTLINE?

Issued by the World Health Organization (WHO), the International guidelines for certification and classification (coding) of COVID-19 as cause of death considers a “death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). There should be no period of complete recovery from COVID-19 between illness and death. A death due to COVID-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.”

According to codes established by the WHO, COVID-19 should be noted or recorded on the death certificate of “every death caused by the disease, or suspected of causing or contributing to the death.”

According to every country’s availability of resources, and in order to ensure a uniform and standardized record of deaths, the WHO suggested classifying COVID-19 deaths when the virus is identified, or when it hasn’t been identified but there is a clinical/epidemiological diagnosis, or suspicion or likelihood of infection that suggests this.

It also advises that the specification of the causal sequence leading to death is important and should be noted.

For example, Cienfuegos’ provincial Public Health board told the press that they included closed death certificates of patients and reported the intermediate and basic causes of death. After checking similar records published in different provinces, we were able to verify that none of them replicated Cienfuegos’ practice of contemplating these details, as suggested by the WHO/PAHO.

Every country uses its own method to declare COVID-19 deaths; as a result, comparisons of mortality rates worldwide are inaccurate.

For example, countries such as Belgium and the US include cases confirmed by a lab, or with an X-ray or clinical symptoms that suggest this disease as a likely or presumible cause of death. In spite of this, it is estimated that death counts could be inaccurate by quite a wide margin.

This margin of inaccuracy would be greater in countries such as Cuba, which amidst a deficit of resources to diagnose the disease, still adheres to the method of including deaths with a positive PCR test and, in some cases, patients who are still in hospital even when their last result came back negative.

However, according to virologist Amilcar Perez Riverol, “hospitalized COVID-19 patients typically tested negative with their PCR test between days 11-14 after they begin to show symptoms. However, symptoms and complications derived mainly from viral replication and a deregulated immune response persist and are related to the disease, by genesis or indirectly.

“A significant percentage of patients who have died from COVID-19 around the world, were already testing negative with PCR tests.”

Inaccuracies in the number of COVID-19 infections and deaths has been a problem in many countries. This is why the WHO has urged the majority to use the same methodology.

Colombian economist Esteban Ortiz-Ospina, co-founder of the Our World in Data website, explained that “countries regularly face technical restrictions and political incentives that also affect the process.

The obsession with rankings among countries is a real problem today, which isn’t anything more than political noise and a perception. Plus, it’s wrong because the data isn’t exact enough and many different methodologies are being used to collect data,” Ortiz-Ospina added.

Scientist Amilcar Perez Riverol agrees that comparisons should be only be made if there is a standardized approach.

“Cuba and its health authorities have adopted an approach they understood. However, this approach automatically voids any comparison with deaths in any region or the world,” he wrote.

BURIAL PROTOCOL IF CONSIDERED A COVID DEATH

Yoandra Pileta received the negative PCR test result, several days after her mother had passed. However, her mother was buried as a suspected case of COVID-19 and, even though the laboratory ruled out the disease, Pileta hasn’t been able to remove her mother’s remains from the Manuel Tames cemetery in Guantanamo to put them in a family vault.

Cuban protocol for declaring COVID-19 deaths doesn’t line up with international guidelines, but it does for burials.

“Once a person has died of suspected or confirmed COVID-19, any body fluids leaking from orifices, such as the mouth or nose, should be contained, these can be covered with gauze or cotton. The body should be introduced into the body bag within the same room the death took place. This body bag should be sprayed or atomized inside and outside with disinfectant for hospital use or with sodium hypochlorite solution, before introducing the body,” national protocol states.

According to Ihosvany Fernandez, director of Communal Services in Guantanamo, these body bags are impermeabel and special, but if there aren’t enough, black trash bags are authorized to be use: one on the head and the other on the legs so they can be tied at the torso.

“Every body bag must have the deceased’s details, doctor’s name and the name of the institution where they died,” he explains. Then, it should be cremated or placed in a coffin for burial.

“Bodies should be handled by health and necrological services wearing PPE at all times, which must also be burnt after use. These measures are to be applied regardless of whether the death took place in a home, medical center or anywhere else,” the document concludes.

Every suspected case of COVID-19 – whether there is confirmation from the lab or not – must follow this protocol, which includes a ban on wakes and family members being in contact with the body.

The reality is that most deaths in Cuba today don’t have to be COVID-19 related. According to the 2020 Statistical Yearbook of Health, there was a high average of daily deaths linked to heart disease (82) cerebrovascular disease (29), malignant tumors (71), and even respiratory disease (19) – such as flu and pneumonia -, which have been the main causes of death in recent years.

Nevertheless, if the number of COVID-19 deaths doesn’t drop, this virus could become the fifth cause of death for Cubans in 2021. Even the fourth, if these reports weren’t inaccurate.

Death certificates stating COVID-19 as the cause of death with a lab result might have been an effective methodology in 2020 and the first few months of 2021; however, with the recent spike in cases and deaths and shortages of diagnosis tests, this method isn’t in keeping with the new circumstances. The method needs to be updated because the undercounting of Cuban deaths could be greater than that of other countries with a different protocol or greater diagnosis capacity, or both.

“It is becoming clearer and clearer here in Cuba, just like it has in other countries at the time, that numbers need to be checked and standardized according to approaches used by the PAHO and other countries,” virologist Perez Riverol suggested.

This article was translated into English from the original in Spanish.