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.
(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.