Wednesday, May 20, 2020

COVID-19: How Bad Is It Today?

Many of us begin each day now by checking the latest numbers for the COVID-19 pandemic.  Today, it's reported that the total number of deaths worldwide is 322,483 and for the United States 91,921.  Some epidemiological models are predicting over 110,000 deaths for the U.S. by early June.  Dr. Fauci has predicted the final number of deaths for the U.S. could approach 200,000.

Those are disturbing numbers.  But the obvious question is: Compared with what?

In 2017, 50 million people died around the world.  The leading causes of death were cardiovascular diseases (17.80 million) and cancers (9.56 million).  Other causes included road injuries (1.24 million), suicide (800,000), homicide (400,000), and drowning (295,000).  Compared with these numbers, the numbers of deaths from COVID-19 don't seem so shocking.  Instead of worrying about the SARS-CoV-2 virus, I should be worried about dying in a car accident every time I drive to the grocery store.

But then maybe the appropriate comparison is with death rates for infectious diseases.  For most of human history, infectious disease was the leading cause of death.  Only in the last 100 years, have the degenerative diseases taken the lead, as the death rate for infectious disease has fallen dramatically (at least for the developed countries).  Nevertheless, even when infectious diseases are not the leading cause of death, they can still be shockingly deadly when their outbreaks become severe.

So how does COVID-19 compare with other pandemics and epidemics over the past 100 years?

The yearly death rate worldwide for a typical seasonal flu ranges from 290,000 to 650,000.  In 2017-2018, the U.S. had a high severity season in which over 80,000 people died from the flu.  So, clearly, COVID-19 is going to be worse than a typical seasonal flu.

The worst flu pandemic was the H1NI flu outbreak in 1918-1920, which killed 20-50 million people around the world and about 675,000 in the U.S.  The equivalent death toll today for the U.S. as a proportion of the population would be 2,145,000.  There is no reason to believe that the deaths from COVID-19 will be anywhere close to that.

In 1957-1958, the Asian Flu pandemic killed 1.5 million people worldwide and 116,000 in the U.S.  The equivalent numbers as a proportion of the population today would be 3.9 million deaths worldwide and 220,430 deaths in the U.S.  It seems unlikely that COVID-19 will surpass those numbers.

In 1968-1969, the Hong Kong Flu pandemic killed over 1 million people worldwide and over 100,000 in the U.S.  The equivalent numbers today would be 2.2 million worldwide and 164,500 in the U.S.  It seems possible that the death toll for COVID-19 could surpass that number for the U.S.

In 2009-2010, the Swine Flu pandemic (caused by a new strain of the H1N1 flu virus) killed about 280,000 people worldwide and about 13,000 in the U.S.  COVID-19 is much deadlier than that.

Although COVID-19 is often said to be "unprecedented," these numbers show that previous pandemics of infectious disease have been at least as deadly and in some cases much more deadly than COVID-19.  It is surely "unprecedented," however, in one respect--in that the shutdown of all "non-essential" social and economic activity has never been done before.  In these other pandemics, some schools, factories, and workplaces were shut down temporarily, and sick people were expected to quarantine themselves in their homes, but there was no general governmentally mandated shutdown like that initiated in March and April.

Previously, it had always been assumed that the human costs of such a shutdown would far exceed the human benefits for controlling a pandemic.  Do we have any reason to believe that this assumption was mistaken?  Has anyone proven that the likely benefits of such a shutdown to mitigate the COVID-19 pandemic are much greater than the likely costs?

As I have indicated in a previous post, I can't find any evidence that anyone has actually tried to perform such a cost-benefit analysis in any rigorous way.

Isn't it incomprehensible that we have decided to intentionally create a global Great Depression that will devastate human life without weighing the likely human suffering this will bring?


In his comment on this post, Roger Sweeny has made a good point--that the COVID-19 death numbers in the United States are probably more reliable than the flu death numbers, because the flu death numbers are only statistical estimates by the CDC, and the experience of doctors suggests that far fewer people die from seasonal flu than is reported by the CDC.  If this is true, then there is no comparison between flu deaths and COVID-19 deaths, because COVID-19 is much more deadlier.

The CDC's guidelines for certifying deaths due to COVID-19 look rigorous to me.  In filling out death certificates, doctors and coroners must distinguish between the "cause of death" (Part 1) and "significant conditions contributing to death" (Part 2).  And under Part 1, they must begin with the "immediate cause" and then move back through the list of conditions leading to that cause ending with the "underlying cause"--the disease or injury that initiated the events resulting in death.  So, to certify a death due to COVID-19, this must be identified as the underlying cause.

Here is one of the hypothetical scenarios presented in the CDC guidelines:
"A 77-year-old male with a 10-year history of hypertension and chronic obstructive pulmonary disease (COPD) presented to a local emergency department complaining of 4 days of fever, cough, and increasing shortness of breath.  He reported recent exposure to a neighbor with flu-like symptoms.  He stated that his wheezing was not improving with his usual bronchodilator therapy.  Upon examination, he was febrile, hypoxic, and in moderate respiratory distress.  His chest x-ray demonstrated hyperinflation and his arterial blood gas was consistent with severe respiratory acidosis.  Testing of respoiratory specimens indicated COVID-19.  He was admitted to the ICU and despite aggressive treatment, he developed worsening respiratory acidosis and sustained cardiac arrest on day 3 of admission."
"In this case, the acute respiratory acidosis was the immediate cause of death, so it was reported on line a.  Acute respiratory acidosis was precipitated by the COVID-19 infection, which was reported below it on line b, in Part 1.  The COPD and hypertension were contributing causes but were not a part of the causal sequence in Part 1, so those conditions were reported in Part 2."
In some cases, COVID-19 can only be identified as the "probable" underlying cause:
"In cases where a definite diagnosis of COVID-19 cannot be made, but it is suspected or likely (e.g., the circumstances are compelling within a reasonable degree of certainty), it is acceptable to report a COVID-19 on a death certificate as 'probable' or 'presumed.' In these instances, certifiers should use their best clinical judgment in determining if a COVID-19 infection was likely.  However, please note that testing for COVID-19 should be conducted whenever possible."
There have been reports--broadcast by Fox News--that hospitals and doctors are fraudulently inflating the numbers of COVID-19 cases and deaths because of the financial incentives from Medicare--$13,000 for every COVID-19 patient and $39,000 for every COVID-19 patient on a ventilator.  Although there might be some cases of such fraud, it's unlikely to be widespread because there are severe penalties for deceptively "upcoding" patients to increase Medicare payments.

1 comment:

Roger Sweeny said...

Those flu death statistics may not be reliable. They may be exaggerated noble lies. The title of a post from Scientific American, April 28, 2020 sets out its thesis: "Comparing COVID-19 Deaths to Flu Deaths Is like Comparing Apples to Oranges: The former are actual numbers; the latter are inflated statistical estimates". Of course, COVID-19 death statistics have their own problems. Was the person tested or just presumed to die of the disease? Did COVID cause the death or did the person just have it when he died? I don't know what to make of a statement like, "There were X COVID-related deaths."

"When reports about the novel coronavirus SARS-CoV-2 began circulating earlier this year and questions were being raised about how the illness it causes, COVID-19, compared to the flu, it occurred to me that, in four years of emergency medicine residency and over three and a half years as an attending physician, I had almost never seen anyone die of the flu. I could only remember one tragic pediatric case.

"Based on the CDC numbers though, I should have seen many, many more. In 2018, over 46,000 Americans died from opioid overdoses. Over 36,500 died in traffic accidents. Nearly 40,000 died from gun violence. I see those deaths all the time. Was I alone in noticing this discrepancy?

"I decided to call colleagues around the country who work in other emergency departments and in intensive care units to ask a simple question: how many patients could they remember dying from the flu? Most of the physicians I surveyed couldn’t remember a single one over their careers. Some said they recalled a few. All of them seemed to be having the same light bulb moment I had already experienced: For too long, we have blindly accepted a statistic that does not match our clinical experience.

"The 25,000 to 69,000 numbers that Trump cited do not represent counted flu deaths per year; they are estimates that the CDC produces by multiplying the number of flu death counts reported by various coefficients produced through complicated algorithms. These coefficients are based on assumptions of how many cases, hospitalizations, and deaths they believe went unreported. In the last six flu seasons, the CDC’s reported number of actual confirmed flu deaths—that is, counting flu deaths the way we are currently counting deaths from the coronavirus—has ranged from 3,448 to 15,620, which far lower than the numbers commonly repeated by public officials and even public health experts.

"There is some logic behind the CDC’s methods. There are, of course, some flu deaths that are missed, because not everyone who contracts the flu gets a flu test. But there are little data to support the CDC’s assumption that the number of people who die of flu each year is on average six times greater than the number of flu deaths that are actually confirmed. In fact, in the fine print, the CDC’s flu numbers also include pneumonia deaths.

"The CDC should immediately change how it reports flu deaths. While in the past it was justifiable to err on the side of substantially overestimating flu deaths, in order to encourage vaccination and good hygiene, at this point the CDC’s reporting about flu deaths is dangerously misleading the public and even public officials about the comparison between these two viruses. If we incorrectly conclude that COVID-19 is “just another flu,” we may retreat from strategies that appear to be working in minimizing the speed of spread of the virus."