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\begin{document}


\def\RunningAuthor{Sneha Sinha et al.}
\firstPage{416}
\articleType{Review Article}
\receivedDate{08 Jul 2020}
\acceptedDate{16 Jul 2020}
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\title{Causes of deaths in COVID-19 patients}
\author{Akshata~Sharma\textsuperscript{1},  
            Sneha~Sinha\textsuperscript{*}\textsuperscript{1},  
            Kimaya~Kakde\textsuperscript{1}, 
            Pavan~Bajaj\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India}~\\{\textsuperscript{2}Department of Periodontics, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India}}

\begin{abstract}
COVID-19 is the newly emerged coronavirus disease with its first few cases in December 2019 in China and has been spreading in an unstoppable manner since then. Its causative organism is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is a colossal pandemic worldwide including various parts of India resulting in several cases and a considerable number of deaths (21,000 deaths in India of the disease). The patients mainly die of respiratory failure, although the pathways and the different responses to supportive treatment are still being assessed for a better understanding. Patients of age 65 or above, immuno compromised patients, and who already suffer a medical condition are at high risk of development of severe complications due to COVID-19, and thus need to be hospitalised. The exact course of the virus and its pathway, disease are still being understood by the scholars to reduce the spread and mortality caused by it. This review describes the possible causes of death in the patients suffering from COVID-19, high-risk groups of COVID-19 infection, the current status of the infection spread in the country and the progress in the management strategies of patients. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}COVID-19,\newline coronavirus,\newline respiratory failure,\newline cardiovascular,\newline immunocompromised
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sneha~Sinha~\\ Phone:\ 7719014919~\\  Email:\ jeannie.sneha97@gmail.com
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\section{Introduction}
COVID-19 is the name which has been given to the most newly emerged coronavirus disease which saw its first few cases in December 2019 in China and has been spreading in an unstoppable manner since then. The causative organism of this disease is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is also identified in China following the occurrence of the disease. Currently, it has become an enormous pandemic worldwide, including various parts of India resulting in several cases and a considerable number of deaths. Even with a low case fatality rate, i.e. sum of deaths in positive cases divided by sum positive cases, the virus has managed to cause havoc as the spread of the disease is so quick that the actual number of deaths is still considerably high. \unskip~\citep{839148:19883386}

The virus is quickly spreading, and thus, it requires a combined effort of the whole population in the form of proper sanitation practices and social distancing measures. Home quarantine is being practised in most parts of the world as a necessary preventive measure and bringing down the rate of infection. On average, the total count of COVID-19 patients across the country has reached 7-8 lakhs. Amongst these, the number of cases active is around 2,80,000, whereas around 4,70,000 have recovered. However, there have been about 21,000 deaths pertaining to the disease (as per the data on the date 08/07/2020). \unskip~\citep{839148:19883389} With an alarming increase in mortality, it becomes crucial to understand what can cause death in the patients who are found to be positive for the coronavirus. It is believed that the patients mainly die of respiratory failure, although the pathways and the different responses to supportive treatment are still being assessed for a better understanding \unskip~\citep{839148:19883393}.

\textbf{Death In COVID-19}

COVID 19 is a disease, in which adults with 65years and above, and health practitioners working in hospitals have chances of being at a higher risk from severe illness due to COVID-19, based on current information available \unskip~\citep{839148:19883386}. As stated by Rossella Porcheddu(JIDC) mortality and severity of the disease are linked with age and the co-morbidities, having strategies to ensure adequate protection from the infections to a group who are at higher risk, and access to the medical care in due time when infected is vital for improving chances of survival. Additionally, rigorous medical history taking, and scoring for frailty, may indicate the highest risk groups \unskip~\citep{839148:19883392}.

On understanding the pathway of fatality in Covid 19, patients at higher risk must be known before coming to the underlying medical conditions. Adults above 65years and health practitioners or people working in a health care facility for the long term are at a higher risk for chronic severe illness due to Covid 19.

As given by CDC, COVID-19 can affect the respiratory tract of patients having moderate to severe asthma who are at a high risk of getting infected from the virus, causing an asthma attack. It can become a cause of pneumonia and acute respiratory disease \unskip~\citep{839148:19883390}.

 The patients of all age groups with the following medical conditions (not controlled properly) seem to be at a higher risk for the development of severe complications because of COVID-19 illness\unskip~\citep{839148:19883386}: 

-diabetes,\unskip~\citep{839148:19883384}

- long term lung disease, 

-severe heart conditions,

-chronic kidney \unskip~\citep{839148:19883391} disease treated with dialysis,

-obesity,

- chronic liver infection or

- immune-compromised such as cancer \unskip~\citep{839148:19883387} patients, 

-smoking, 

-bone marrow or organ transplant,

- long-term use of corticosteroids and other immune weakening prescription. Although the risk of serious illness from Covid-19 for HIV patients is not known but as we all know HIV, AIDS is an immunocompromised disease which can lead to further complications in managing the on-going infection \unskip~\citep{839148:19883388}.

According to the CDC, COVID-19 can have an effect on any group, older the age, higher the risk of getting the severe disease. 80\% of deaths accounted in the U.S. is observed in adults of age 65 years or old. The chances of death are the highest amongst people who are 85 years or old. This happens because immune systems of the older adults deteriorate with age; thus, fighting off infections becomes difficult. This is also because adults at old age usually suffer from long term diseases which might multiply the risk of ill health from the COVID-19 \unskip~\citep{839148:19883390}.

On the sources of the data collected, viral respiratory infections, or viral illnesses like flu can harm the respiratory system making the functioning difficult for the heart. COVID-19 can aggravate chronic lung illnesses and severe heart disease leading to worsening of COVID-19, causing severe illnesses and death, later.

For individuals who have diabetes with sugar levels in the blood higher than the usual, or dialysis patients with or without coexisting conditions such as diabetes who are undergoing treatments and procedures to manage kidney failure are on the front of higher risk to the infection and severe illness due to lack of capacity of the immune system which can cause a casualty.

 A primary symptom of the disease, COVID-19 is ARDS ( acute respiratory distress syndrome), increased in the patients with obesity(severe) and may also have multiple serious long-term conditions which cause difficulties for a doctor in providing respiratory help for severely ill patients. In patients who are on long term medications along with the medicine which is used to treat COVID 19 can put a strain on the liver and or in patients with severe liver disease, weakened immune system is observed which makes the body less potential to fight COVID-19, increasing the risk for severe illness and later to fatality \unskip~\citep{839148:19883386}.

In the previous viral pandemic like Spanish flu (1918), respiratory failure was the leading cause of death, and so is in this pandemic \unskip~\citep{839148:19883393}. Although most patients may also be carried by invasive perfunctory ventilation until the lungs are recovered. In the worst situations, the application of the ECMO (extracorporeal membrane oxygenation) system manages the exchange of gas for many days. Often, there can be complications like shock and multiple organ failure along with respiratory failure, but the course of the disease is not yet well explained \unskip~\citep{839148:19883394}. The reported deaths probably have decreased lymphocyte count or the D-dimer levels or may have increased C-reactive protein or secondary bacterial infection, however, the role of these or the actual process of death has not been well defined yet \unskip~\citep{839148:19883385}.

Death from COVID-19 can be interpreted while considering several different scenarios. First, patients in ICU can die despite complete intensive support like ventilation, the vasopressors, the ECMO, and renal transplant therapy. In the second scenario, life-sustaining treatments are limited due to poor expected outcomes concerning the old age groups, the frailty, the co-morbidities or the profound disability. It can also be an effect of the distributive limitations of the lack of personnel or hospital beds or other necessities. Compilation of both of the given factors also subsists. 

In another case, deaths of those admitted in the ICU who are not directly associated with Covid19, specifically in areas where the rate of infection is high or patients admitted due to acute brain injury or severe brain trauma can be tested positive for Covid19 during a stay in hospital and later die due to initial damage. This death will also be attributed to Covid19 and accounted for statistics \unskip~\citep{839148:19883386}.
    
\section{Discussion}
COVID-19 patients with severe disease require hospitalisation to ensure their management. A special treatment for COVID-19, which has been approved by the FDA, does not exist currently \unskip~\citep{839148:19883386}. Inpatient management of severely ill patients revolves around most commonly occurring complications which are septic shock/sepsis, hypoxemic respiratory malfunction/ARDS, kidney injury, cardiomyopathy and also arrhythmia. It may have complications from the long-term standing hospitalisation, which include secondary infections(bacterial), gastrointestinal bleeding, thromboembolism, and critical illness polyneuropathy/myopathy. If a patient fails to receive or respond to management of any of these complications, death may occur. The cause of death also depends on the risk factors present in a particular patient as it may compromise the patient's immunity which will deteriorate their ability to fight the disease: old aged patients and those having an underlying medical condition, primarily under risk for developing complications. 
    
\section{Conclusion}
Much more data is required for better interpretation of case fatality rates. They are firstly the severity of organ failure and its type, the actual contributions of failure of the cardiovascular or respiratory system. Secondly, the process by which death occurs in patients, like the limitation of therapeutics as well as relative aid of factors in patients or environmental factors (Eg, beds, lack of facilities, etc.). Lastly, the actual input of SARS-CoV-2 towards infection could be a secondary effect in some patients. Thus, further scale literature about the same will aid in providing a better idea of all the causes of mortality because of the SARS-COV-2 infection and explore their probable managements and preventing them as far as possible. 

\textbf{Financial Support}

No source of funding.

\textbf{Conflict of Interest}

The Authors have no conflict of interest.
    

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