This week has been interesting. On the one hand, hard data is emerging showing that the Coronavirus is not nearly as deadly as the numbers previously reported and that the virus is wimpy when exposed to sunlight, but none of that data seems to be quelling the irrational panic. So let’s look at this data with a heavy heart for the fallen, but with a very clear mind.
The Fatality Data
Fatality rates for Coronavirus of 3-7 percent have been thrown around for months. This makes the average person believe that if they contract COVID-19 then they have a 1 in 15 to 1 in 30 chance of dying. This, of course, is enough to stoke irrational fear in any rational person. However, scientists have been saying for months that given that most people that get infected with the Coronavirus have no symptoms, these fatality rates are way overestimated. Let’s dig in.
The 3-7% mortality rate numbers have been due to the fact that we’re only testing the sick that show up to doctor’s offices or hospital emergency departments and not everyone who had the disease. However, both California and New York made efforts this week to publish the rate of asymptomatic/minimally symptomatic infection in their communities to try to get a better sense of the real fatality rate.
While I reported on this a few days back, I can now report a more accurate number since it’s been about three weeks since this data was reported. Hence we now have enough time for the critically ill to show up in the fatality data. Hence, the new mortality rate for Coronavirus in Santa Clara County California based on the reported data from Stanford University scientists and their public health department is 0.15%. (1,2)
New York’s Data
The difference between California and New York City is that the later experienced true health system overload where the former did not. Meaning New York had a shortage of PPE, ventilators, ICU beds, and healthcare workers to handle their surge. Hence, we can expect that their fatalities would be much higher.
This week’s reports demonstrated that tests revealed that the Coronavirus has infected 21.2% of New York City’s residents (5). Those that were tested were out of the house shopping in a grocery store. This is an infection rate many times the approximately 3-4% infected in Santa Clara, which makes sense given the public transport and apartment living so common in New York City. I did a rough calculation of the fatality rate when this data came out based on the population of New York City (5 counties) at 0.58%. Governor Cuomo had the statewide death rate at 0.5%, which didn’t include the fewer at-home deaths.
Are COVID-19 Deaths Being Over or Under-Reported?
The idea of whether the COVID-19 deaths are over or under-reported has become something of a political football this past two weeks. We know that health departments and the CDC are asking doctors to code deaths as COVID-19 if they believe that this was the cause, even if testing wasn’t available (from the CDC guidance document) (6):
“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 COVID–19 on a death certificate as
“probable” or “presumed.” In these instances, certifiers should use their best clinical judgement in determining if a COVID–19 infection was likely.”
Hence, as a physician, knowing my colleagues and the fact that many hospitals will get reimbursed from approved Government grants based on the number of COVID patients treated, there would be pressure from hospital administrators to err on the side of COVID-19.
In addition, in epidemiology, there is the concept of “excess deaths”. This tends to get cleaned up after the pandemic is over as it takes a careful review of hospital charts and records. An excess death means that if not for COVID-19, the patient would not have died. However, you can see how all of this could get very complicated very quickly. For example, how should a patient be counted who was in the ICU already for respiratory illness or on their death bed in a hospice facility who contracted COVID-19? These deaths will eventually be subtracted from the COVID-19 total.
On the other hand, the case could be made that since a handful of people have been reported dying at home and that some cities like New York have not yet added these patients into their counts, that the COVID-19 deaths are under-reported. So who’s right? Time will tell.
Stanford’s Scott Atlas, M.D. a senior fellow in healthcare policy wrote an interesting editorial for “The Hill” a nonpartisan website that covers Washington politics where he shared the following information (3):
- The NYC death rate for those 18-45 years old is 0.01%
- Of all fatal cases in NY state, 2/3rds were over 70
- 90% of all fatal cases had an underlying illness
Dr. Atlas also brings up the fact that people without COVID-19 are dying because they are not getting the needed medical care because of our COVID-19 focus.
How Robust is the SARS-CoV-2 Virus?
Early on there were reports that the virus could survive for days on plastic, which caused everyone to promptly disinfect the contents of their wallets. However, the National Biodefense Analysis and Countermeasures Center (NBACC) in Maryland performed some very sophisticated tests on viral durability this past week. They have a unique system where they can suspend a single water droplet containing the SARS-Cov-2 virus in a volume of air or on a surface and alter the temperature, humidity, and simulated sunlight and then retrieve that particle and look at how the virus fared. Here’s a slide from the NBACC White House Presentation on April 23rd:
Basically, in humid summer conditions like those in the Northeast or Southeast, the virus survived for one hour on a nonporous surface (it survives even less time on porous surfaces). However, that’s in the shade, because when you add summer sun into the equation, regardless of the humidity or temperature, it survives only 1-2 minutes! Hence, this virus will not do well outside in the summer.
Stay Shut Down or Open Up?
No matter how you slice this new data, one thing is clear. If you contract COVID-19, there’s likely less than a 1 in 200 chance of dying from it. That’s about half the chances of you dying in a fatal car crash during your lifetime and yet we don’t have a second thought about getting into a car to go to the grocery store or doctor’s office.
So why did we close society down?
- Because of the high death rates being reported of 3-7%. Those were inaccurate.
- Because the healthcare system was unprepared for the surge of cases. That surge has passed and we have flattened the curve. Our healthcare facilities are now prepared. The PPE log jam has broken open. How do I know? Because my office orders from the same medical suppliers as everyone else and we’re having no issues getting PPE.
- We don’t have enough testing! The US is performing about 1 million tests a week right now. Our tests per million inhabitants will soon surpass all other countries in the next 1-2 weeks. In addition, inexpensive finger stick serology tests are flooding US markets right now, which is one of the reasons that California and New York were able to test so many people so quickly.
Sweden has taken a different approach (4). While it has placed some restrictions like recommended social distancing, it’s schools are open and it’s restaurants have also continued to operate by following guidelines. The goal was to allow 60% or more of Swedes to get infected to build immunity. When that happens, it’s called “herd immunity” meaning that the virus burns itself out because it’s more likely than not that it will die in a host laden with antibodies rather than live to infect someone else. The Swedes believe they will get to that point by the middle of May.
What has this meant for Sweden? Their deaths are much higher than neighboring and smaller Denmark (2,192 vs. 418) (7). Swedish cases are fewer per million population than Denmark, but so is their testing. In addition, realize that “flattening the curve” by social isolation doesn’t really change the total number of people that will eventually die from Coronavirus (unless we can find a cure or effective treatment), it just pushes the cases further out and reduces the surge. So based on what we know, Denmark’s deaths will catch up and Sweden’s deaths will likely begin plummeting.
The upshot? The data is coming in and it’s not supporting that the Coronavirus should provoke irrational fear. Now that we know our foe, again, it’s time for sound public health policies based on that data. Let’s all have a heavy heart for those who have perished, but also a very clear mind about what’s real and what’s not.
(1) Bendavid E, et al. COVID-19 Antibody Seroprevalence in Santa Clara County, California. medRxiv 2020.04.14.20062463; doi: https://doi.org/10.1101/2020.04.14.20062463
(2) Santa Clara Public Health. County of Satna Clara Emergency Operations Center. https://www.sccgov.org/sites/covid19/Pages/dashboard.aspx. Accessed 4/25/20.
(3) The Hill. The data is in — stop the panic and end the total isolation. https://thehill.com/opinion/healthcare/494034-the-data-are-in-stop-the-panic-and-end-the-total-isolation. Accessed 4/25/20.
(4) CNBC. Sweden resisted a lockdown, and its capital Stockholm is expected to reach ‘herd immunity’ in weeks. https://www.cnbc.com/2020/04/22/no-lockdown-in-sweden-but-stockholm-could-see-herd-immunity-in-weeks.html. Accessed 4/25/20.
(5) New York Governor Press Briefing on April 23rd, 2020. https://www.pscp.tv/w/1DXGyeNNvmVGM Accessed 4/25/20.
(6) Centers for Disease Control. Guidance for Certifying Deaths Due to
Coronavirus Disease 2019 (COVID–19). Vital Statistics Reporting Guidance. Report No. 3 ▪ April 2020. https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf. Accessed 4/25/20.
(7) Worldometer. COVID-19 CORONAVIRUS OUTBREAK. https://www.worldometers.info/coronavirus/ Accessed 4/25/20.