Opinion Paper

COVID-19 death: A novel method of improving its identification when a patient has multiple diagnoses

Nnabuike C. Ngene, Jagidesa Moodley
Southern African Journal of Infectious Diseases | Vol 37, No 1 | a349 | DOI: https://doi.org/10.4102/sajid.v37i1.349 | © 2022 Prof Jack Chibuoke Moodley, Jagidesa Moodley, Jagidesa Moodley | This work is licensed under CC Attribution 4.0
Submitted: 08 October 2021 | Published: 26 April 2022

About the author(s)

Nnabuike C. Ngene, Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and, Department of Obstetrics and Gynaecology, Leratong Hospital, Krugersdorp, South Africa
Jagidesa Moodley, Women’s Health and HIV Research Group, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

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Assigning a primary cause of death to a deceased patient who had multiple principal diagnoses including coronavirus disease 2019 (COVID-19) is challenging because of the difficulty in selecting the most appropriate cause. To proffer a solution, the authors reviewed the literature on assigning a primary cause of death. In 2015, the Nnabuike-Jagidesa (NJ) model II was devised to improve the International Classification of Diseases and related health problems, 10th revision (ICD-10) guideline on how to assign a primary cause of death. The NJ model II stipulates that when there are multiple diagnoses with no plausible explanation that one of the illnesses could have resulted in the other clinical conditions, the single most appropriate primary cause of death is the condition with the highest case fatality ratio in that setting. In the index report, the authors opine that if the case fatality ratios are similar, the following objective criteria (listed in the order of priority) should be used to assign a primary cause of death: condition with the highest infection fatality ratio, condition that was the main indication for the last acute surgical or invasive procedure performed (during the course of the same ill-health) before the death and the disease that theoretically affects the highest number of body organs. Additionally, a clinical descriptor should be used when none of the objective criteria are satisfied. This novel approach, termed the modified NJ model II, is expected to improve the objectivity and reproducibility of the assigned primary cause of death in a deceased who had multiple diagnoses, which may include COVID-19.


cause of death; COVID-19 death; death statistics; modified NJ model II; principal diagnosis


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