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We Need to Level with the Public About Coronavirus Risks

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infection fatality rate covid19

One of the most critical things we do in medicine day in and day out is to discuss risks with patients. A good doctor has these talks a dozen or more times a day. Why? Because both medical care and life has risks. So as the data is published on how lethal COVID-19 really is or isn’t, it’s time to level with the Average American patient about the risk of dying from this disease. New German data again shows that the risks to the average person are generally being overexaggerated by most in the media. Let’s dig in.

What We Know from Other Sources About COVID-19 Risks

The single biggest number that everyone is concerned about with the novel coronavirus is the IFR or Infection Fatality Rate. Why? It’s a great way to convey to the average person how much risk there is of dying if they get infected. That simple statement of odds can then provide them with some sense of their personal risk.

Last week and the week before, two data points were shared about the coronavirus infection fatality rate. One was out of Stanford which pegged your odds of dying at about 1 in 500 and another out of New York that pegged it at about 1 in 200 (1-4). While these numbers were different, they were more similar than the prior crude mortality rate of 3-4% that was reported in the media. Where did they get that number? Through a misreading of a March document published by the World Health Organization (5). Here’s what that document actually said:

“While the true mortality of COVID-19 will take some time to fully understand, the data we have so far indicate that the crude mortality ratio (the number of reported deaths divided by the reported cases) is between 3-4%, the infection mortality rate (the number of reported deaths divided by the number of infections) will be lower.” 

Hence, even the WHO has been reporting that the real risk of dying from COVID-19 if infected with the SARS-CoV-2 virus would be lower than the crude mortality rates once the dust settles.

The German Data

Germany has been arguably one of the world’s coronavirus testing superstars. Early on when the U.S. had tested barely a few thousand people per million citizens, it had already tested 20,000 per million. Last month, researchers at the University of Bonn had begun to release information about the IFR in Germany that was just updated (6). Basically, after testing almost a thousand people in a German town where a festival took place with both RT-PCR nasal swabs and ELISA serum assays and then estimating the IFR for the whole country, the Germans had it pegged at 0.37%. That also comes with the realization that about 10 times the number of people they thought were infected were actually infected, with 14% showing immunity.

But Wait! Excess Deaths or Dishonest Hospitals?

This week the media has been all abuzz about a Yale study that many have interpreted as showing that in the early part of the U.S. Pandemic there were almost 40,000 extra deaths that weren’t listed as COVID-19 on death certificates but may have been due to COVID-19 (7). They calculated these deaths by looking at the number of deaths that usually occurred during this time and then reviewing the number that actually happened. However, these researchers didn’t review any hospital or medical charts, so this is their “guess” that these are deaths due to COVID-19. The deaths also could have also been due to the fact that the medical care system in many of these places was all but shut down outside of COVID-19 care and many people were terrified to go to the hospital to seek any medical care for anything unrelated to the coronavirus.

There was another interesting article this past week on the phenomenon of dishonest hospital reporting of COVID-19 deaths. An article put out by the Foundation for Economic Education quoted many different physicians and experts who believed that hospital administrators were pressuring physicians to add COVID-19 on death certificates even when there was little credible information that the patient had died of this disease (8). This was thought to stem from the fact that the CARES act added a 20% COVID-19 kicker to hospital payments (9). In addition, it guaranteed hospitals that amped up reimbursement for uninsured patients in the way of direct government reimbursement. The act also included unusual things like advance payments.

Hence, as a physician, my opinion is that we likely have far more hospital administrators trying to keep their facilities afloat and people dying because they are terrified to go into hospitals than we do uncounted COVID-19 deaths. If anything, the incentive right now if you’re unsure about the cause of death is to code it as COVID. Any physician or administrator who has been in medicine for more than a few years will understand how medicine bends itself to whatever insurance reimbursement schema is devised.

Leveling with the American and Worldwide Public

The real risk of dying from COVID-19 is coming in consistently at 0.15-0.5%.  If we take the median number, that’s the German data with a risk of dying from COVID-19 of about 1 in 300. Hence, it’s time to begin getting the word out.

Would you accept a 1 in 300 risk of dying? Put in terms of a surgical procedure, if I told you that a new procedure would help you keep walking after an accident and had a 90% chance of success with a 1 in 300 chance of mortality, would you allow that procedure to happen? Let’s say the benefit wasn’t as great or you weren’t as disabled, would you still take the risk? Those are the kind of questions we all should be asking ourselves.

The upshot? This is a bad bug that has caused lots of deaths and overwhelmed selected health systems like Italy and New York. As I have said before, we need to have a heavy heart and a clear mind. However, now that our health systems are ready and testing is ramped up here, it’s time to level with the world that the real fatality rate per infection is not nearly as high as previously reported.

_____________________________________

References:

(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) New York Governor Press Briefing on April 23rd, 2020. https://www.pscp.tv/w/1DXGyeNNvmVGM Accessed 4/25/20.

(5) World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report – 46. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200306-sitrep-46-covid-19.pdf?sfvrsn=96b04adf_4 Accessed 5/5/20.

(6) Streeck, et al. The University of Bonn. Infection fatality rate of SARS-CoV-2 infection in a German community with a super-spreading event. https://www.ukbonn.de/C12582D3002FD21D/vwLookupDownloads/Streeck_et_al_Infection_fatality_rate_of_SARS_CoV_2_infection2.pdf/%24FILE/Streeck_et_al_Infection_fatality_rate_of_SARS_CoV_2_infection2.pdf Accessed 5/5/20.

(7) Weinberger D, et al. Estimating the early death toll of COVID-19 in the United States.
medRxiv 2020.04.15.20066431; doi: https://doi.org/10.1101/2020.04.15.20066431

(8) The Foundation for Economic Education. Physicians Say Hospitals Are Pressuring ER Docs to List COVID-19 on Death Certificates. Here’s Why. https://fee.org/articles/physicians-say-hospitals-are-pressuring-er-docs-to-list-covid-19-on-death-certificates-here-s-why/ Accessed 5/5/20.

(9) US Department of Health and Human Services. CARES Act Provider Relief Fund. https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/index.html Accessed 5/5/20.

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17 thoughts on “We Need to Level with the Public About Coronavirus Risks

  1. Sargeant Skate

    All good points, but what is the rate for those over 65 with other comorbidities and weighted average based on each?

    1. Chris Centeno, MD Post author

      Nobody knows those answers yet, but I will be blogging soon on what we know.

  2. Tomas Jablonski

    I don’t think that the most important metric is the chance of dying once you get infected. That’s like saying that the chance of dying after you have a car accident is the most important metric, without looking at how likely it is to have an accident to start with!

    For me, the most important metric is the chance of dying because of the Covid19 infection. That’s a quite different metric. Let’s say that the chance to die after an infection with a certain ‘bug’ is 1 in 10, while a chance to get infected with it is one in a million. The total chance of dying because of such bug would be 1 in 10 * 1,000,000 = one in 10,000,000. I would not be worried at all! But, if the chance of dying after an infection is, as before, one in 10 but the chance of getting infected is also one in 10, then the chance of dying from this bug is one in 100 (one in 10 * 10) – quite a lot more worrying. Covid19 may be much less likely to cause death after an infection according to these latest stats, but the other side of the same coin is that many more people are being infected, which means that it is much more likely to get infected than what we thought a few weeks ago. I am primarily interested in a total chance of dying because of Covid19, which combines a chance of dying after infection with the chance of being infected with it to start with.

    1. Chris Centeno, MD Post author

      Tom, this is just gibberish, not to mention a fake email. You like most everyone else will become infected. The social distancing doesn’t change the total number of deaths, it just pushes them out. Hence, your risk of dying if infected is, in fact, a big deal.

  3. DavefromLA

    Thanks for the time and energy you put into this Dr. Centeno. Even though this appears to be a bad bug and not very lethal as you note, an issue for me (and many others) in the months ahead is all the hysterical headlines, predictions and models I’ve been reading that have conditioned me to fear this virus more than I perhaps should. And I keep reading about a vaccine that is being worked on for this, but a Covid-19 vaccine will not be able to prevent this, correct, just alleviate the symptoms if we catch it?

    1. Chris Centeno, MD Post author

      If we get a good vaccine, you would still get it but have the antibodies to easily fight it.

  4. Ralph Yount

    I’ve read your blog for years and I have experienced good success with your treatment protocol.
    71,982 people are dead as of May 6, 2020 in the United States. Oops, now it’s 72,233 dead. Rick Bright, who was head of the Biomedical Advanced Research and Development Authority at the CDC, and who has filed a whistleblower complaint over his firing with the Office of Special Counsel, testified today that we should expect 100,000 dead by June 1, 2020. If we accept your “1 in 300 die” theory, and if all Americans get infected, then we have 1,100,000 dead in the US if all people here get infected. This is the heavy heart you are talking about. This also looks at the issue with a clear mind.

    We must maintain social distancing, hand washing and face covering.

    Finally, you use data from the Foundation for Economic Education (FEE) to support your belief that the deaths reported by hospitals are inflated so they can increase the federal dollars they receive. FEE is described by Greenpeace as a Koch Industries climate denial front group. It has also been described by Greenpeace and others as a libertarian think tank. The organization has a political agenda which is right of center.

    1. Chris Centeno, MD Post author

      Ralph, the financial incentive for hospitals to report COVID on the discharge summary/problem list are real and cited in the blog on the HHS website. On FEE, I had never heard of them before, but they have been around since 1946. As to the veracity of the quotes in that FEE article, I can’t say. What I can say is that in medicine, anytime you incentive a thing then that thing happens in spades. I have been witnessing that phenomenon as long as I have been a doctor, which is since 1990. Applying a stat like “1 in 300” to a population doesn’t work. For example, let’s say we get to 25% infected and recovered (which is where NYC is right now), we now have 25% of the population that likely in the short run can’t get this thing, so the virus dies when it hits that host. Hence, the dynamics of viral spread get worse the farther you get into the pandemic. So that’s why the worst existing models have about 100K-150K deaths by August. Just for perspective, 100K US citizens died in the 1968 pandemic, which would be almost 200K with today’s population numbers. So thus far, that flu pandemic beats this one on deaths in the 2019-2020 season.

    2. Chris Centeno, MD Post author

      Ralph, also check out the 1958 Asain Flue pandemic which killed 116,000 Americans, which would be 250K today: https://www.cdc.gov/flu/pandemic-resources/1957-1958-pandemic.html

  5. PL

    Did you see this? https://www.youtube.com/watch?v=-s15mh2-ncE
    I hear so much I don’t know what to believe, but she seems very believable.

    1. Chris Centeno, MD Post author

      Whatever that video was, it looks like it got censored…

  6. Sharon Anderson

    I think your response to Tom Jablonski was rude. Why would you call his comments gibberish? And do you have reason to believe that it was a fake email? Also Ralph Yount is accurate about FEE being a group that promotes climate denial, not exactly the first group I would look to for factual information. Accusing hospitals of lying about COVID-19 deaths during this pandemic based on your personal opinion without proof is not helpful. I am grateful that fatality rates are lower than was first feared. As we understand this disease better we can slowly return to something closer to normal while protecting the most vulnerable among us.

    1. Chris Centeno, MD Post author

      Sharon, I’m not political, so I’m not really concerned about past political positions a group has taken. The concept of reimbursement impacting physician behavior is well-vetted, see https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/648266 From that article: “Under fee-for-service reimbursement, in which physician compensation is primarily a function of the supply of services and procedures, physicians have an implicit financial incentive to increase the quantity of medical services, provided the demand for medical care is inelastic and the price is greater than the average cost of medical care. Furthermore, economic theory suggests that the likelihood of providing such services increases when out-of-pocket expenditures for patients are low, because most of the cost of the services is passed on to a third party (insurers) for payment. The effects of different reimbursement schemes on physician and consumer behavior are summarized in Table 2.” Hence, if you incentivize physicians to add COVID to the problem list by throwing in a 20% payment kicker, you will get COVID on the problem list which will end up on the death certificate.

  7. bob swenk

    This subject was mentioned in another comment but it would be a very meaningful exercise to bring age/disease factors into that 0.015-0.5%… Data has been showing some 90%+ deaths with age 65 and older (mostly 80 yr+) with the preponderance of these having other health factors contributing. The public should know that for the healthy, especially under 65 population, there is xx% chance of dying when you get covid19. I expect that this would be more like .01% or 1 in 10,000 for this age group…

    https://www.forbes.com/sites/niallmccarthy/2020/03/19/how-the-coronavirus-is-impacting-different-us-age-groups-infographic/#1f47282c1fd4

    1. Chris Centeno, MD Post author

      Agree, but getting taht news out there en masse would reduce corporate news media profits…

  8. Peter

    Is there a typo? ..”The real risk of dying from COVID-19 is coming in consistently at 0.015-0.5%.”. Should it be 0.15-0.5% ?

    1. Chris Centeno, MD Post author

      Yes, thanks for catching that typo!

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