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COVID-19 Death Rates Oct 14, 2020 19:56:09 GMT

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Post by Admin on Oct 14, 2020 19:56:09 GMT

During this pandemic, people in the United States are dying at rates unparalleled elsewhere in the world.

A new report in the Journal of the American Medical Association finds that in the past five months, per capita deaths in the U.S., both from COVID-19 and other causes, have been far greater than in 18 other high-income countries.

"It's shocking. It's horrible," says Dr. Ezekiel J. Emanuel, a professor of health policy and medical ethics at the University of Pennsylvania and one of the authors of the study.

"The United States really has done remarkably badly compared to other countries," he says. "I mean, remarkably badly."

The study looks at per capita death rates in 2020 in 18 countries with populations larger than 5 million people and per capita gross domestic product levels above $25,000 per year. It breaks out deaths attributed to COVID-19 and examines how total deaths in the U.S. are higher than normal this year. This so-called "all-cause" mortality takes into account fatalities that may have been due to the coronavirus but were never confirmed or were due to other factors such as people not seeking medical care during the crisis.

Overall deaths in the United States this year are more than 85% higher than in places such as Germany, Israel and Denmark after adjusting for population size. Deaths in the U.S. are 29% higher than even in Sweden, "which ignored everything for so long," Emanuel says. Sweden made a point of refusing to order strict social restrictions and never went in to a full lockdown. "We have 29% more mortality than we should have if we'd followed Sweden's path and Sweden virtually did nothing."

Even looking just at confirmed COVID-19 deaths, the number of people dying since May 10 — again after adjusting for population size — is on average 50% higher than every other country in the study. In addition, the rate people are dying in the U.S. has stayed far above everywhere else. Emanuel says the current elevated mortality rates are important because they eliminate the chaotic early months of the pandemic when testing, treatment and reporting varied dramatically around the globe.

The rate of COVID-19 deaths in the U.S. since June 7 is 27.2 per 100,000 people. In contrast, in Italy, the death rate is down to 3.1 per 100,000.

"It's not like Italy has some secret medicine that we don't," Emmanuel says. "They've got the same public health measures we've got. They just implemented them effectively and we implemented them poorly." If the U.S. had managed to keep its per capita death rate at the level of Italy's, 79,120 fewer Americans would have died.

This study is important for illustrating just how bad the death rate from COVID-19 has been in the U.S. compared with in other countries, says Theo Vos, a professor at the Institute for Health Metrics and Evaluation at the University of Washington in Seattle.

"The U.S. is in the company of a few other countries with very high rates of deaths assigned to COVID," says Vos who was not involved in the study. "Only Belgium looks worse." But he points out that once you look past the initial phase of the outbreak, the U.S. ends up looking worse than Belgium.

"Early on in the epidemic, many countries had a lack of testing possibilities. And a lot of deaths occurred early on where there was no formal diagnosis," he says. "So Belgium decided 'we're going to count all of them.' While in other countries like the Netherlands or the U.K. and the U.S. quite a few deaths have not been recognized as COVID."

He says this is why looking at overall deaths since the start of the pandemic, not just official COVID-19 deaths, is important. On that measure, the U.S. is now consistently reporting roughly 25% more deaths than these other wealthy nations.

Vos is from the Netherlands, and even though he works for the University of Washington, he recently moved back. He says looking at how death rates are changing over time is important because this pandemic is far from over.

"I now live in a country that's seeing the biggest increase in the number of cases of almost any place in the world currently," he says. Second waves of infections are hitting many places in Europe right now including France, Spain, Belgium and the U.K. Vos expects this to get even worse as more people spend more time indoors in the colder months.

Last Edit: Oct 14, 2020 19:57:59 GMT by Admin

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COVID-19 Death Rates Oct 15, 2020 5:21:44 GMT

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Post by Admin on Oct 15, 2020 5:21:44 GMT

COVID-19 and Excess All-Cause Mortality in the US and 18 Comparison Countries
Alyssa Bilinski, MSc1; Ezekiel J. Emanuel, MD, PhD2

JAMA. Published online October 12, 2020. doi:10.1001/jama.2020.20717

The US has experienced more deaths from coronavirus disease 2019 (COVID-19) than any other country and has one of the highest cumulative per capita death rates.1,2 An unanswered question is to what extent high US mortality was driven by the early surge of cases prior to improvements in prevention and patient management vs a poor longer-term response.3 We compared US COVID-19 deaths and excess all-cause mortality in 2020 (vs 2015-2019) to that of 18 countries with diverse COVID-19 responses.

Methods
We compared the US to Organisation for Economic Co-operation and Development countries with populations exceeding 5 million and greater than $25 000 per capita gross domestic product. For each country, we calculated the COVID-19 per capita mortality rate and grouped countries by mortality: (1) low (COVID-19 deaths, <5/100 000), (2) moderate (5-25/100 000), and (3) high (>25/100 000).1 We used Poisson regression for comparisons across countries.

We calculated the difference in COVID-19 deaths between each country and the US through September 19, 2020 (week 38) under 3 scenarios: if the US had a comparable per capita COVID-19 mortality rate to each country from the start of the pandemic (February 13) or if the US mortality rate became comparable to other countries beginning May 10 or June 7, to allow lag time for policy interventions.3 (See the Supplement for formulas.)

We also considered all-cause mortality per capita for countries with publicly available data through July 25, 2020 (week 30). This measure is robust to country-level differences in COVID-19 death coding and captures indirect pandemic effects. We estimated excess all-cause mortality (the difference between mean 2020 deaths and deaths in corresponding weeks of 2015-2019) for each country and the US, compared rates across countries using Poisson regression with country and week fixed effects (Supplement), and estimated the difference in excess all-cause mortality between each country and the US as described above. We used R software (version 4.0.2) for all analyses.

Results
On September 19, 2020, the US reported a total of 198 589 COVID-19 deaths (60.3/100 000), higher than countries with low and moderate COVID-19 mortality but comparable with high-mortality countries (Table 1). For instance, Australia (low mortality) had 3.3 deaths per 100 000 and Canada (moderate mortality) had 24.6 per 100 000. Conversely, Italy had 59.1 COVID-19 deaths per 100 000; Belgium had 86.8 per 100 000. If the US death rates were comparable to Australia, the US would have had 187 661 fewer COVID-19 deaths (94% of reported deaths), and if comparable with Canada, 117 622 fewer deaths (59%).

While the US had a lower COVID-19 mortality rate than high-mortality countries during the early spring, after May 10, all 6 high-mortality countries had fewer deaths per 100 000 than the US. For instance, between May 10 and September 19, 2020, Italy’s death rate was 9.1/100 000 while the US’s rate was 36.9/100 000. If the US had comparable death rates with most high-mortality countries beginning May 10, it would have had 44 210 to 104 177 fewer deaths (22%-52%) (Table 1). If the US had comparable death rates beginning June 7, it would have had 28% to 43% fewer reported deaths (as a percentage overall).

In the 14 countries with all-cause mortality data, the patterns found for COVID-19–specific deaths were similar for excess all-cause mortality (Table 2). In countries with moderate COVID-19 mortality, excess all-cause mortality remained negligible throughout the pandemic. In countries with high COVID-19 mortality, excess all-cause mortality reached as high as 102.1/100 000 in Spain, while in the US it was 71.6/100 000. However, since May 10 and June 7, excess all-cause mortality was higher in the US than in all high-mortality countries (Table 2).

Discussion
Compared with other countries, the US experienced high COVID-19–associated mortality and excess all-cause mortality into September 2020. After the first peak in early spring, US death rates from COVID-19 and from all causes remained higher than even countries with high COVID-19 mortality. This may have been a result of several factors, including weak public health infrastructure and a decentralized, inconsistent US response to the pandemic.4,5

Limitations of this analysis include differences in mortality risk: the US population is younger but has more comorbidities compared with the other countries.6 In addition, since late August death rates have increased in several countries, and how mortality will compare with the US throughout fall remains unknown.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
Article Information
Corresponding Author: Ezekiel J. Emanuel, MD, PhD, Perelman School of Medicine, University of Pennsylvania, Medical Ethics and Health Policy, 423 Guardian Dr, Blockley Hall, Ste 1412, Philadelphia, PA 19104 (MEHPchair@upenn.edu).

Accepted for Publication: October 2, 2020.

Published Online: October 12, 2020. doi:10.1001/jama.2020.20717

References
1.
COVID-19 data. European Centre for Disease Prevention and Control. Accessed September 25, 2020. www.ecdc.europa.eu/en/covid-19/data
2.
Viglione G. How many people has the coronavirus killed? Nature. 2020;585(7823):22-24. doi:10.1038/d41586-020-02497-w
3.
Lyu W, Wehby GL. Shelter-in-place orders reduced COVID-19 Mortality and reduced the rate of growth in hospitalizations: study examine effects of shelter-in-places orders on daily growth rates of COVID-19 deaths and hospitalizations using event study models. Health Aff (Millwood). 2020;39(9):1615-1623. doi:10.1377/hlthaff.2020.00719
4.
Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis. 2020;20(6):669-677. doi:10.1016/S1473-3099(20)30243-7
5.
Maani N, Galea S. COVID-19 and underinvestment in the public health infrastructure of the United States. Milbank Q. 2020;98(2):250-259. doi:10.1111/1468-0009.12463
6.
Chaudhry R, Dranitsaris G, Mubashir T, Bartoszko J, Riazi S. A country level analysis measuring the impact of government actions, country preparedness and socioeconomic factors on COVID-19 mortality and related health outcomes. EClinicalMedicine. 2020;25:100464. doi:10.1016/j.eclinm.2020.100464

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COVID-19 Death Rates Oct 23, 2020 20:38:18 GMT

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Post by Admin on Oct 23, 2020 20:38:18 GMT

Fewer New Yorkers are dying from the coronavirus than health experts had anticipated, a new study shows. Regional death rates have dropped from the highs seen at the start of the outbreak, partially due to a shift in the population contracting the disease toward those who are more resilient.

After New York became the epicenter for the pandemic in early March, with tens of thousands dying from COVID-19, experts had expected that the infection would remain as deadly in the following months.

Instead, a new investigation showed that by mid-August the death rate in those hospitalized with coronavirus-related illness had dropped from 27 percentage points to about 3 percentage points. Led by researchers at NYU Grossman School of Medicine, the study showed that a younger, healthier group of people were getting infected and were arriving at the hospital with less-severe symptoms than those infected in the spring.

However, the researchers’ analysis showed that these factors accounted for only part of the improvement in survival. The rest, they suspect, resulted from health care providers’ growing experience with the coronavirus. For example, physicians learned that resting COVID-19 patients on their stomachs rather than their backs and delaying the use of ventilators as long as possible were more effective practices, say the study authors. Drugs likely helped as well. In addition, other factors such as decreasing hospital volumes, less exposure to infection, and earlier testing and treatment, may have played a role.

“Our findings suggest that while COVID-19 remains a terrible disease, our efforts to improve treatment are probably working,” says study lead author Leora Horwitz, MD, an associate professor in the Department of Population Health at NYU Langone Health. “Even in the absence of a silver-bullet treatment or vaccine, we are protecting more of our patients through a host of small changes,” says Horwitz, who is also director of the Center for Healthcare Innovation and Delivery Science at NYU Langone.

New York was among the first states to grapple with a severe outbreak of COVID-19. By contrast, death rates in more recent waves in southern and western regions of the country, which also had younger, healthier coronavirus patients, have been lower, says Horwitz. However, it had remained unclear whether the virus was less deadly due to the different patient demographics or improved care.

Horwitz says the new study, publishing online next week in the Journal of Hospital Medicine, is the most detailed analysis to date of coronavirus death rates over time. By accounting for age, obesity, and other key factors, the researchers were able to eliminate some explanations from the analysis.

For the investigation, the research team analyzed 5,263 patient records of people treated for COVID-19 at NYU Langone hospitals in New York City and Long Island between March 1 and August 8. Using a range of risk factors for the disease as well as indicators of the severity of the illness upon hospitalization, the study authors developed a model that predicted likelihood of death for each patient.

According to the findings, the likelihood of death was on average 22 percentage points lower in August than in March for most critically ill patients.

The average age of hospitalized COVID-19 patients also dropped from 63 to 47. In March, while 73 percent had chronic conditions like lung disease and diabetes, by mid-June only about 65 percent had such risk factors.

“Other pandemic hotspots should take hope from the lessons learned here in New York,” says study senior author Christopher Petrilli, MD, an assistant professor in the Department of Medicine at NYU Langone. “If we can do better at managing the disease, they can too.”

Still, he adds that the research team next plans to expand the investigation to hospitals outside of New York.

Petrilli also cautions that while death rates are improving, COVID-19 still causes symptoms in some people that continue long after hospital patients are sent home, including fatigue, blood clots, and lung damage.

Last Edit: Oct 23, 2020 20:39:56 GMT by Admin

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COVID-19 Death Rates Oct 23, 2020 23:02:40 GMT

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Post by Admin on Oct 23, 2020 23:02:40 GMT

Deaths have fallen among hospitalized COVID-19 patients this year, which could indicate that doctors have a better understanding of how to treat the disease and that coronavirus mitigation strategies are working.

The decline happened across all patient groups, including older adults and people with underlying conditions, according to two peer-reviewed studies that will soon be published in the Journal of Hospital Medicine and Critical Care Medicine.

“We find that the death rate has gone down substantially,” Leora Horwitz, one of the study authors and a population health scientist at New York University, told NPR.

At the same time, the death rate is “still higher than many infectious diseases, including the flu,” she said. “It still has the potential to be very harmful in terms of long-term consequences for many people.”

Horwitz and colleagues looked at death rates among 5,000 hospitalized patients at NYU Langone Health from March to August. They found that mortality dropped 18 percentage points during that time. Patients had more than a 25% chance of dying at the beginning of the pandemic, which has decreased to about 7%.

The research team calculated for factors such as age and other diseases to determine whether the drop in deaths was related to the trend of younger, healthier people being diagnosed with COVID-19 later in the pandemic. They found that death rates have declined for all groups. An early version of the research appeared as a preprint in August and will be published next week1.

In another study conducted in England, similar declines in death rates were observed among 21,000 hospitalizations between March and June. Mortality dropped by about 20 percentage points, including different ages, racial groups and underlying conditions. An early version of the research also appeared as a preprint in August and will be published soon2.

“Clearly, there’s been something [that’s] gone on that’s improved the risk of individuals who go into these settings with COVID-19,” Bilal Mateen, one of the study authors and a data scientist at the Alan Turing Institute in the UK, told NPR.

Across the country, doctors and other health care professionals are noticing the signs of severe COVID-19 sooner and have developed standard treatments to help patients with blood clots and immune issues, NPR reported.

COVID-19 safety measures — such as social distancing and face masks — have likely also decreased the viral load that people encounter, which can reduce the severity of the disease, Horwitz and Mateen told NPR. Now researchers and public health officials are watching the surge in COVID-19 cases to understand coronavirus-related death rates for this fall and winter.

“I do think this is good news,” Horwitz said about the research. “But it does not make the coronavirus a benign illness.”

1. www.medrxiv.org/content/10.1101/2020.08.11.20172775v1

2. www.medrxiv.org/content/10.1101/2020.07.30.20165134v2

Last Edit: Oct 23, 2020 23:04:05 GMT by Admin

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COVID-19 Death Rates Oct 24, 2020 22:26:09 GMT

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Post by Admin on Oct 24, 2020 22:26:09 GMT

The first source of death data is called case surveillance. Health care providers are required to report cases and deaths from certain diseases, including measles, mumps and now COVID-19, to their state’s health department, which, in turn, passes this information along to the CDC, Anderson says. The surveillance data are a kind of “quick and dirty” accounting, says Shawna Webster, executive director of the National Association for Public Health Statistics and Information Systems. The states gather all the information they can on these diseases, but this is the first pass of the accounting—no one has time to double-check the information or look for missing lab tests, she says. For that, you have to look for the next source of information: vital records.

This second line of evidence comes from the National Vital Statistics System, which records birth and death certificates. When somebody dies, a death certificate is filed in the state where the death occurred. And after the records are registered at a state level, they are sent to the National Center for Health Statistics, which tracks deaths at a national level. Death certificates are not filed in the system until outstanding test results are in and the information is as complete as possible. By the time a record gets to the vital records system, “it is as close to perfect as it’s going to get,” Webster says.

A physician, medical examiner or coroner fills out the cause of mortality on the death certificate, and they are instructed to include only those conditions that caused or contributed to death, Anderson says. One field lists the sequence of events leading to the death. “What we’re really trying to get at is the condition or disease that started the chain of events leading to the death,” Anderson says. “For COVID-19, that might be something like acute respiratory distress due to pneumonia due to COVID-19.” A second part of the certificate lists other significant conditions that may have contributed to the death yet were not part of the sequence of events that led up to it, he says. These are called comorbidities, and while they can be contributing factors, they cannot be directly involved in the chain of cause and effect that ended in death. Preexisting medical conditions such as diabetes or heart disease are common comorbidities, and they can make a person more vulnerable to the coronavirus, Anderson says, “but the fact is: they’re not dying from that preexisting condition.”

“When we ask if COVID killed somebody, it means ‘Did they die sooner than they would have if they didn’t have the virus?’” Lessler says. Even such a person with a potentially life-shortening preexisting condition such as heart disease or diabetes may have lived another five, 10 or many more years, had they not become infected with COVID-19.

The 6 percent number touted by Trump and QAnon comes from a weekly CDC report stating that in 6 percent of the coronavirus mortality cases it counted, COVID-19 was the only condition listed on the death certificate. That observation likely means that those death certificates were incomplete because the certifiers only gave the underlying cause of death and not the full causal sequence that led to it, Anderson says. Even someone who does not have a preexisting condition and dies from COVID-19 will also have comorbidities in the form of symptoms, such as respiratory failure, caused by the coronavirus. The idea that a death certificate with ailments listed in addition to COVID-19 means that the person did not really die from the virus is simply false, Anderson says.

The surveillance and vital statistics data provide a pretty good picture of how many deaths are attributable to the coronavirus, but they do not capture all of them, and that is where the final line of evidence come in: excess deaths. They are the number of deaths that occur above and beyond the historical pattern for that time period, says Steven Woolf, a physician and population health researcher at the Virginia Commonwealth University School of Medicine. In a paper published in JAMA this month, Woolf and his colleagues examined death records in the U.S. from March 1 through August 1 and compared them with the expected mortality numbers. They found that there was a 20 percent increase in deaths during this time period—for a total of 225,530 excess deaths—compared with previous years.

Two thirds of these cases were attributed to COVID-19 on the death certificates, and Woolf says there are two types of explanations for the rest: Some of them were COVID-19 deaths that simply were not documented as such, perhaps because the person died at home and was never tested or because the certificate was miscoded. And some of the extra deaths were probably a consequence of the pandemic yet not necessarily the virus itself. For instance, he says, imagine a patient with chest pain who is scared to go to the hospital because they do not want to get the virus and then dies of a heart attack. Woolf calls this “indirect mortality.” “The deaths aren’t literally caused by the virus itself but the pandemic is claiming lives,” he says.

The numbers in Woolf’s study come from provisional death data, the kind that the CDC has not yet checked for miscoding or other issues, so it comes with some degree of imprecision. What builds his confidence in these results, however, is the fact that they have been replicated numerous times by his group and others. “All serious analyses of these data are showing that the number of deaths we’re hearing on the news is an undercount,” he says.

Last Edit: Oct 24, 2020 22:27:12 GMT by Admin