MUSINGS: COVID-19 mortality, age distribution, underlying health conditions and hope beyond...

As I publish this, it's April 5, 2020. We are in the midst of the coronavirus/SARS-COV-2/COVID-19 pandemic. The world is afraid. Borders are shut. Stores are closed. Concerns with crime increasing as a sign of social stress and perhaps distress.

We're also at a bit of a loss in terms of leadership through this. Again, speaking from a North American perspective, there is no "vision" of what the future might hold or any talk as far as I am aware of plans to relax restrictions. If anything, it's the opposite, an atmosphere of rule by fear with threats of further shutdowns. As I expressed in the second half of March, we are in a state of fear, with "abundance of caution" being as good a catchphrase as any of what's happening here; uniformly expressed among governments and public health experts.

In all this, let's look at some statistics and think about this more, shall we?

First, here's some of what we probably all know:

1. It's a pandemic. The numbers of infected people are growing. WorldOMeter tells me that we are well past 1.1 million people infected worldwide. No country is spared. You cannot really run from this as some might (I've heard of people going back to Asia for example). And these numbers are just the people who were tested and found to be positive; countless have already been infected, and many likely already past their symptomatic phase and recovered.

2. We cannot test everyone. There is essentially no medical test in this world with 100% sensitivity and specificity. Statistically there will be "false negatives" using the swab test. Most importantly, the standard RT-PCR test for COVID-19 has a false negative rate of up to 30%. If we're filtering coffee and up to 30% of the coffee grounds pass through, that would be rather terrible, right?

By this point, even with tight contract tracing and smartphone apps that collect data on cases, a place like Singapore suddenly had 75 cases reported in 4 clusters on April 3, 69 of whom not travel related - so it's spreading in the community. That is of course what is expected when a population remains
naïve to a highly contagious pathogen. An unending "war" against clusters and "hot spots" until either herd immunity increases a population's resilience, or when a vaccine is available and large proportions of the population get immunized. It's going to be a worrisome "Whack-A-Mole" situation until either of these things happen.

To make matters worse, with up to 50% of those infected being asymptomatic, the potential of spread for 10 days or more, one has to really start wondering how much effort it's worth to broadly track down cases and enforce quarantine by this stage with such numbers in North America and Europe.

3. A vaccine is going to be at something like 12-18 months away.

4. Yes, like any contagious illness, anyone can get the illness. Here are the New York City statistics up to April 3:

Remember that these stats are related to who gets tested. Clearly these numbers are also correlated to the folks who are symptomatic and going for testing in the community or showing up in hospitals. Notice that the rate for kids <18 is remarkably low! Only 57/100,000. Also, those <45 years old are at significantly lower rates than >45. This may be evidence that asymptomatic infections are more common in the younger adults.

5. Yes, the health care resource utilization will be large. Hospitalization rates are high including young adults. In the data, we can't tell though if the hospitalizations include overnight ER visits vs. inpatient stay for days vs. ICU with ventilation - this makes a huge difference in terms of treatment needs.

Again, NYC:

This is where we start to see a more drastic age distribution. Notice that hospitalization rate for those <45 years old is very low overall. It almost quadruples for the 45-64 year olds and then the rate doubles again for those >65.

6. Let's talk about the big one - DEATH RATES - those >65 and with underlying health conditions. By April 3rd, there were almost 1900 deaths in NYC. They are already well into the surge of cases. Based on NYC, who are the people who died?

Remember that I wrote weeks ago, we are very fortunate that kids and teens are spared. Below 65, the number is also low, death rates go up 3x for the 65-75 year olds, and 7x for those 75+!

As I said before as well, infectious diseases like this and influenza do discriminate based on age.

There is also another population who must be careful - those with underlying medical conditions - check out this chart from the NYC Daily Data Summary:

Interesting isn't it? Even if we take out those who have "underlying conditions pending", and we just look at the total of 1,313 people who died with known data, only 28/1,313 who died or 2.1% are otherwise health people without "diabetes, lung disease, cancer, immunodeficiency, heart disease, hypertension, asthma, kidney disease, and GI/liver disease".

Furthermore, isn't it interesting that of the >65 year old patients, those without the underlying conditions did not die at a higher rate either!

Notice that these NYC findings are consistent with elsewhere. Here's the Italy and China data showing the strong age distribution towards the older population:

For a more up to date data set of Italy, here's the age distribution as of April 3rd:

As you can see, the highlighted portion represents those >60 years old. That is the vast majority of deaths. Notice the massive increase from 70+.

And likewise here's some Canada data from the province of Ontario - everyone can contract the illness but it's by and large those who are older (specifically >60, probably >65 if the data were more detailed) that actually will die from this condition:

So what now?

Knowledge is power, right? When we know what's going on, that should help us make informed decisions about the path forward. It should hopefully reduce some anxiety especially when it comes to the primal fear of death. And in this regard, I think the facts are very useful in reminding us of 3 things:

1. Because the rate of hospitalization is high including those 45-64, it's good that we're doing the social/physical distancing for a number of weeks now. It has been 20+ days now since the US Coronavirus Task Force's "Slow the Spread" campaign from March 16. Obviously this was too late for New York City where peak daily growth rate was around March 20th (remember, there is a lag time between infection and onset of symptoms typically 5-10 days):

Since deaths are a lagging statistic, even if not worked through at the hospital level, there is reason to be optimistic that the "light at the end of the tunnel" is approaching for NYC (indeed, earlier today, there is good news of number of deaths dropping in NYC for a few days plus lower new hospitalizations).

Good to see that Italy is experiencing a drop in critical care cases now which is probably one of the last lagging indicators of improvement. In order to achieve this, it must mean that the inflow of cases into the ICU is slower than discharge now; people are leaving the ICU either better or have succumbed to the illness and unfortunately died.

2. For cities that have implemented the measures early and which have not turned into major "hot spots" by now, I think it's not unreasonable to be optimistic that the mitigation measures have worked to significantly reduce the growth rate.

While early, looking at the numbers locally here in Canada, so far there doesn't seem to be anything alarming as a whole. Sure, some cities will be strained for resources but I don't think this will be across the board. I know that in Vancouver, contingency plans upon contingency plans have been put in place. The convention center is getting ready with a few hundred beds if needed for hospital overflow. COVID-19 positive shelters are in place for the homeless with illness that do not need hospital stays. More than 22 local nursing homes have been affected in Metro Vancouver and precautions so far appear to be working so as not to result in high mortality for the most part.

Over the next week, I suspect if we do not see a major surge into Easter with many of the large cities, this would be a sign that mitigation has worked for this first COVID-19 "wave".

3. Remember, given that a vaccine is >12 months away, and it would be ridiculous to think that we can "eradicate" this virus given how ubiquitous it is. The only value of social/physical distancing is to reduce the surge in hospitals and prevent resources being overwhelmed.

Over the next year, accept that the majority of us will get infected. The only way we will feel somewhat secure is once there is adequate herd immunity in the population (which likely includes a large number of asymptomatic infected individuals). While there will be "hot spots" here and there, the extent of these "surges" in numbers probably will not be as extreme as what we're seeing currently, the result of delayed vigilance in reducing the rate of spread. So long as the hospital system can handle the numbers and terrible decisions like triaging ventilators do not need to happen due to scarcity, that is as good as it gets.

For the good of the many...

I know that over the last month, "distancing" has taken a toll. But given what we've seen with regions like Wuhan, Italy, and New York, I agree that it is a necessary sacrifice. This has also given us time to examine the data like that above and understand this "enemy", coming to terms with what it is and what it does over the populations of millions.

If in the next couple weeks, the "surge" can be overcome without massive difficulty, I think we can say that the mitigation procedure with social distancing has worked for the good of many who might have been affected to an even greater degree if such measures were not put into place.

The question is - are we still afraid?

I suppose that answer for each of us will depend on our own risk factors. In USA and Canada, those above 65 years old represents about 15% of the population who will have to be more cautious. Likewise, for those with underlying conditions as listed above will need to be more vigilant. For example, in Canada we have a 7% rate of diabetes in a population, yet a "brittle" diabetic with highly elevated HbA1c will obviously have a different risk profile compared to a person with diet-controlled Type II diabetes in otherwise good health.

For the public good, as a population, these last few weeks has resulted in indiscriminate use of public health and government policy with the threat of law enforcement and fines for violators in many districts against those not distancing themselves. However, knowing the risk factors posed by this illness, there will come a time where prolonged blunt policies will inevitably be doing harm to the quality of life of many unnecessarily.

I believe that the time is coming where each of us will need to be more mindful of individual responsibility rather than depending on blunt, broad public policy.

The policy of doing everything to escape death...

Instead of a blunt policy inspired by a fear of "reducing death" as the main driver, and as the initial wave passes in the weeks ahead, we must start asking the question of what policies will need to be implemented to embrace life, overcome fear, and emphasize the quality of life versus quantity.

In fact, I think this question is of relevance even now. Already, we are hearing stories of the thousands of seniors who have already died in Italy, New York, and China spending their last moments alone in an ICU, without the opportunity to say goodbye to their loved ones. As this disease continues in the months ahead and as the virus I believe inevitably work its way to the point where most will be infected in Europe and North America, are we to maintain this barrier indefinitely?

If the current projections are right, and something like 100-240k Americans die, the vast majority of whom are seniors >65 years old as per the data above, is this how public health and citizens of the free world would want significant members of the Silent Generation (born 1925-1945) and older Baby Boomers (1946-1964) to say "goodbye"?

I seriously hope not. That would truly be a heartless outcome for all who deserve better.

As I hinted at in my comments in mid-March, I do believe that we all need to think about the inevitability of mortality and consider the question, "Are there fates worse than death?" While this answer is highly subjective and will depend on one's philosophy, values, perhaps faith, for me, I would say "Yes" as one who have worked for many years in the medical system and involved in the care of many who have severe, often progressive illnesses. In fact, among medical circles, it has been spoken of fatalistically since the days of William Osler that pneumonia was the "friend of the aged" in that the process of death was not accompanied by prolonged suffering. Of course this was in the late 1800's and early 1900's before the advent of modern vaccines and antibiotics; in many ways, we are at that same place today with this novel coronavirus where we have no proven effective treatment and a vaccine is not in our immediate future.

If I were 60 years old, otherwise healthy, then please, by all means do CPR if you have to and hook me up to a ventilator in the ICU. But if I were close to 80, have had heart troubles, and facing catastrophic oxygen desaturation as my lungs filled with fluid from COVID-19 pneumonia, to send me to an ICU, intubated, connected to a ventilator with likely poor prognosis, poor prospect of seeing loved ones again or speaking any last words to my grandchildren might be a fate worse than what should always be a dignified death.

I know. Nobody wants to talk about dying. It would be very bad for the public image if the public health doctor suggested anything else but preservation of life apparently at all cost. No politician would want to be seen as hinting that any life lost would be "acceptable". But just the same, death does come for all of us whether we want to think about it or not especially as we get older or develop chronic conditions.

The question is, what wise choices are we to make for ourselves especially in the face of death? Unless we can appreciate this, much of the talk in the news media would be nothing more than superficial. In all these discussions in the news about the number of ventilators and whether it's "enough", let's make sure that we do not lose track of such important details like who they're using the tens of thousands of machines for, whether patients and families understand the implications, and ultimately to what end, and sometimes, for what benefit.

A policy of life...

Nobody knows when the initial "hit" will definitively pass for most cities, and I'm sure this will vary depending on where you live. My suspicion is that it would not be long from now for most of us living in large centers. And from there onwards, I suspect the cases will ebb and flow with "hot spots" started in a mall, perhaps another in a condo building, another from a church gathering... These are to be expected as the virus makes its way through the population.

Remember that viruses are not "smart", and I think anthropomorphizing this "enemy" is simply silly. In fact, they are not even "alive" in that they do not have their own metabolic machinery. What matters in all this is actually how we as humans choose to respond to it knowing the facts highlighted above.

For me, everything going forward points to these 5 factors:

1. We need to protect the vulnerable who actually could die. Remember though that the elderly, and those with underlying conditions are a minority among our midst. Be mindful of them if we're in the healthy, young cohort. These are the individuals who would benefit most from social distancing measures, hand washing, use of masks to reduce droplet spread, etc... again, we need to balance this with quality of life because the risk of death for this population will remain high indefinitely.

Depending on risk tolerance, protective measures towards the vulnerable will need to continue until herd immunity is strong if enough are infected (how much is needed is dependent on contagiousness and the R0 value I'm sure we've all heard about already) or a vaccine is available - whichever comes first. It makes no sense to open and close businesses and disrupt life of large numbers of people.

2. While life will not be "normal" for months, I do believe that societal productivity must resume gradually. Otherwise as a matter of "public health", one will see the unintended consequences of such drastic actions harming more than helping society.

Continued job losses, financial distress with mounting debts, erosion of supply chains, loss of small business viability, resultant emotional instabilities among some, unhealthy coping like increased alcohol consumption, reduced physical activity, are being felt and I am seeing this in my work beyond medical concerns around COVID-19 already. To protect the few from death, are public health measures willing to lower the standard of life and health for the many for long periods of time? In countries where liberty is a foundation of the society, how long can this last without any significant social push-back?

For those <17 years old, the data show that they barely require hospitalizations and as a general rule do not die unless there are clear health issues. For the kids, what is happening with their maturation and learning of social skills? What is happening to the quality of education? This is the mirror effect of the fear of the elderly dying on the young if conditions persist chronically without hope of normalization.

By the way, when I say "few" people die from COVID-19, that is of course a relative statistic. Yes, I know that as of April 5th, almost 16,000 people have died in Italy but it is gradually declining in numbers. However if you take a step back and look at the death rate of Italy over the years, this is what you see:

About 10.5/1000 (~1%) individuals die there in the last 4 of 5 years due to them having one of the oldest populations in the world with about 23% seniors. In a population of about 60.5 million people, this means that more than 630,000 people died annually. All the people who have died with COVID-19 thus far constitutes just over 2.5% of those who would have died in any other year. Remember that it's not even as severe as this because many of those who died probably would have succumbed to another illness. Yes, this is bad from the hospital perspective when it all happens over less than a month and governments need to boost resources, but beyond this, logically, the numbers are far from catastrophic.

3. IMO, discussions about further restricting freedoms and implementing all kinds of privacy encroaching technologies like smartphone tracking are not likely of significant benefit for the public good. The job is to slow down spread. The rules are already in place. Police officers already have the power to deal with jerks who purposely spread the virus and officers can break up parties when they have to using their emergency powers. There is no need "lock down" the Western world further...

Remember, this virus is actually not that virulent and only few will actually die! Governments should not act like this is some kind of existential threat.

4. Allow the virus to work its way through the system (EDIT: I used the word "endemic" here before which is not technically correct and refers to longterm R0 around 1) in a slowed fashion. "It's in the cards" as they say. With hundreds of thousands of known active cases in the US, and many more unknown, other than in special cases, there is no point doing mass contact tracing now. Limit testing to symptomatic people for confirmation and quarantine, for health care professionals of course so as not to spread further in hospitals and nursing homes among the vulnerable.

Myself and most of my colleagues working in hospitals fully expect that over the next months, there will be high exposure and contraction of the illness. Yes, we are concerned and do not want to bring this home to loved ones. But honestly, as professionals, there's no need to freak out. Hysterical doctors and nurses interviewed in the news might attract clicks and views, but do realize that most of us probably are not impressed by this kind of emotionally-driven reporting.

Remember, it's highly contagious for all but not highly virulent for most.

5. As I expressed recently, so long as hospital systems can handle the patients who need intensive care, we must look at a step wise reopening of social life, business, and allow the financial system to recover. Let the younger people work.

I've been hearing people talk about new antibody tests as almost some kind of "certification" before people can go back to work again. Sure, this could be good for healthcare workers, direct care-givers, and perhaps other limited cases. Also, this would be an important research tool to understand baseline prevalence of the illness in the community already including those that were asymptomatic. But this will not ensure viral particles are absent on clothing, dirty hands, shopping bags, etc. Let's just say that I'm more than a little suspicious about a push for fancy testing, apps on phones, etc. as simply a cash grab taking advantage of the fear currently and ultimately there is little actual benefit for most.

The only things that could help are supportive care (which we already have and making sure those who need a hospital bed, IV, ventilators available), a vaccine (Gates apparently funding some trials), and it would be nice to get confirmation of some useful medications like potentially hydroxychloroquine, remdesivir, etc. I see Italy might be using hydroxychloroquine on a mass scale now.

Realize that even if Gates, et al. do find a useful vaccine, it will likely be of little impact for this specific strain since it'll likely have affected most by the time the vaccine is ready for use anyway. It could form the basis of future coronavirus protection in yearly "flu vaccines" we get of course.

Allowing SARS-CoV-2 immunity to gradually become common in a population will convey herd immunity to Europe and North America (likely to other parts of the world also). This actually could put Asian countries who implemented rather draconian measures like China at a social and economic disadvantage in the months ahead. While it's remarkable that they used such strong measures to control the virus that they were able to contain the spread, they are now "stuck" with needing to control every "leak in the dam" with travelers into the nation and persist with strong contact tracing for fears of another massive epidemic sweeping through their highly dense cities and wreaking havoc. My fear in terms of suffering is more for Asia (the billions in China and India) and the developing world than for us here in the months ahead.

In North America, we appear to have an opportunity now to "take the hit" and allow the disease to spread in a more controlled fashion. This potentially will have a positive impact for the rest of the year relative to other places as it will allow us to have a smoother trajectory back to "normal".

Postscript:
The almost "post apocalyptic" vision of post-pandemic New York in this article is shockingly pessimistic to me!

Yes, there will be hard times ahead and I'm not saying that the future rebound in life and the economy will be like it was in late 2019; most likely it will not. In the years ahead, I don't think the thoughtful historian will put all the blame on COVID-19 for how the world has changed. Rather, if we are to be going down a path of economic and even social decline, numerous factors will need to be considered including the strength and viability of financial systems, bloated projections of growth, political discord, and certainly the choices in public health that governments and health care systems will be making over the next few month.

My friend in Germany recently E-mailed me about implementing their "digital contact tracing" system after Easter (based on papers like this claiming that apps can reduce viral spread) and already in use in places like Singapore (TraceTogether). Remember people, be careful with the liberties we give up in times of distress! Are we sure that what is being done will actually have broad value for citizens with a clearly mandated social contract?

Hope, advocate, maybe even pray for wisdom above all else. Have a voice in your local leadership and honestly, openly examine the facts not with fear, but courage.

Stay healthy everyone.