With the announcement today that another three men died of COVID-19 at their homes in Western Sydney, many are wondering why some patients are not within the reach of the healthcare system when their condition deteriorates.
The men — aged in their 30s, 60s, and 80s and all unvaccinated — died on separate days during the previous week after “deteriorating at home”, NSW Chief Medical Officer Kerry Chant said on Thursday,
It follows the COVID-19 death of mother-of-three Ianeta Isaako at her home in Emerton, in Sydney’s west, earlier this week. The 30-year-old is the youngest woman in Australia to die from COVID-19. Her death, like that of the three men, has been referred to the coroner.
While the vast majority of the 79 people who have succumbed since the beginning of the current NSW outbreak have died in hospital, a proportion have been at home when the virus took their lives.
According to information provided by NSW Health, at least eight people have died at home from COVID-19 since 16 June.
These deaths include young people, like Ms Isaako and 27-year-old Aude Alaskar, and older people who, in some cases, declined additional support. All have been residents of south-west or west Sydney, which is bearing the brunt of the deadly outbreak.
What happens after you test positive?
At the very beginning of the pandemic, everyone who tested positive for the virus was admitted to hospital for observation — but at this stage in the outbreak, there is simply not enough room for everyone with mild COVID-19 symptoms to be admitted to hospital.
Most people with COVID-19 will only experience mild symptoms and will be able to recover at home. In this instance, health authorities will keep in regular contact via phone calls and text, taking note of any changes to the patient’s symptoms and physical and mental wellbeing.
NSW Health is also working to have the details of positive cases communicated to police, Dr Chant said earlier this week, so they could undertake in-person welfare checks.
Meanwhile, patients who are unable to isolate within their household or living environment may be offered a place at a special health accommodation facility, a set up similar to hotel quarantine, while those with serious symptoms or high risk factors will be admitted to hospital.
As of Thursday, there were 698 people with COVID-19 requiring hospitalisation of more than 12,000 active cases in the state, or roughly around 5 per cent of cases.
While health authorities conceded the healthcare system was already under pressure on Thursday, they urged people not to try and “soldier on” and delay seeking help.
“We’re doing everything we can to make sure the care is there for you when you need it,” said Clare Skinner, an emergency doctor working in NSW public hospitals who said she was concerned people were avoiding seeking medical treatment.
“If you have an emergency, please come to the emergency department.”
Why weren’t these people in hospital?
With investigations referred to the coroner, there are limited details about the exact circumstances of the eight deaths.
But generally there appears to be two key factors that may contribute: a reluctance to seek out health care and a virus that can rapidly, and unexpectedly, worsen.
According to NSW Health, a number of the people who have died at home had declined additional support, whether it be at hospital or at the special health accommodation. This may be for a number of reasons, such as a desire to remain with young or elderly family members, a fear of authorities or not wanting to be alone.
This was the case in the lead up to the death of western Sydney resident Saeeda Akoobi Joujo Shuka, 57, who became the first person to die of COVID-19 at her residence during this outbreak after she “made the decision to stay home” late last month.
Her sons had also contracted the virus and the family “were offered transport to an alternative facility to support them with their isolation and care” but had declined, Dr Chant said at the time.
About two weeks later, after a man in his 60s with COVID-19 was brought to hospital after he had already died, Health Minister Brad Hazzard said authorities were particularly concerned about refugee families.
“What we’re seeing in particular is refugee family groups, and often large families, and often there might only be one or two people in the family who are income earners, we’re seeing a reluctance for them to come to health authorities and say, ‘we have a problem in our household’,” he said.
“They worry that they’ll be treated the way they might have been treated back home in their own countries.”
Mohammad Al-Khafaji, chief executive of the Federation of Ethnic Communities’ Councils of Australia, said the deaths revealed an urgent need to improve health literacy in vulnerable multicultural communities.
One of the key issues, he said, was a lack of understanding about the cost of health care. “They’re afraid that if they call an ambulance it will create a burden for them and they will have to pay thousands of dollars out of their own pockets,” he said.
NSW Health has confirmed no one with COVID-19 will be charged for calling an ambulance or hospital care, but Mr Al-Khafaji said the message isn’t getting through to everyone who needs to hear it.
“Health authorities need to be better at communicating and telling those vulnerable communities that it is OK to come forward for help, and these are the conditions … we need to work hand in glove with them to try and understand what their concerns are.”
No warning signs
In some cases, however, the warning signs that a patient is about to deteriorate are nowhere to be seen.
Twenty-seven-year-old Aude Alaskar was being monitored daily by his local health district and had only shown mild symptoms for the duration of his illness.
On day 13, however, he “suddenly deteriorated” and collapsed on his way to the shower at his Warwick Farm unit in Sydney’s south-west. According to friends and family, he was fit and healthy with no underlying health conditions.
Following the death, Dr Chant said it was important to remember that “your health status can deteriorate and you can have sudden death with COVID”.
While the details of the three deaths announced on Thursday are yet to emerge, Dr Chant said all three of the men were receiving care from the Western Sydney Health District in the community.
What causes people to deteriorate quickly?
According to Emeritus Professor Gerard Fitzgerald, a specialist in emergency medicine at the Queensland University of Technology, there isn’t a straightforward answer.
Two possible causes are secondary bacterial pneumonia, which can overcome people “very quickly”, or an “overwhelming inflammatory response to the virus which is unexpected”, he said. COVID-19 is also known to cause viral infections in the heart, which may lead to dysrhythmia.
“That is something that is totally unexpected and unpredictable, and probably rare,” Professor Fitzgerald added. “But certainly there is evidence that this virus causes not only viral pneumonia, but viremia, which means that there’s a widespread virus infection throughout the whole body system.”
He described the likelihood of these complications as “very rare, sudden, and unexpected”, underscoring that for the majority of people with COVID-19, at-home treatment is still the appropriate response.
There is also little that can be done to predict whether someone who is otherwise healthy may experience these complications. “Oftentimes it just happens out of the blue,” Professor Fitzgerald said.
This week Dr Chant specifically urged people with COVID-19 to monitor for symptoms of dizziness or breathlessness, especially in younger people, and immediately call for help if they experience them.
“If someone presents early, and gets good oxygen uptake, that may prevent them from deteriorating,” she said.
“Although our system is clearly under stress, the best thing you can do is present early for care, so please do not hesitate.”