mortality – R&R – Reachout and Rebuild

COVID is Much Much Worse than the Flu

David Posnett — Sat, 02 May 2020 18:53:42 +0000

I am still getting questions about whether COVID is any worse than the annual flu (even from my family). The simple answer is YES, IT IS MUCH WORSE!

There are a number of recent posts and on-line articles discussing the reasons and I have posted on this site, previously.

Christopher Ingraham writes on May 2, 2020 in WaPo, based on data from Jeremy Samuel Faust, an emergency room physician at Brigham and Women’s Hospital at Harvard Medical School.

“If we measure flu mortality the same way we count COVID-19 deaths, the picture becomes very stark.” Flu deaths are “inflated statistical estimates” and COVID-19 deaths are “actual numbers.” Rather than comparing apples and oranges, one must compare apples to apples. One must start with the number of directly confirmed flu deaths, which the CDC tracks on an annual basis. In the past seven flu seasons, going back to 2013, that tally fluctuated between 3,448 and 15,620 flu deaths:

Note that these numbers are very different from the CDC’s final official flu death estimates. For 2018-2019, for instance, the 7,172 confirmed flu deaths translated to a final estimate of between 26,339 and 52,664 deaths. That’s because the CDC plugs the confirmed deaths into a model to adjust for what epidemiologists believe is a severe undercount.

Then lets add a bar for this season’s non-adjusted and directly observed COVID-19 deaths, which stand at 63,259:

There are not likely to be many more flu deaths, as we are past the worst of the flu season. But COVID-19 mortality continues to rise at a rate of about 2,000 deaths per day.

Using an apples-to-apples comparison, we can say that the coronavirus has already killed eight times as many people as the flu in 2019-2020.

The coronavirus, Faust writes, “is not anything like the flu: It is much, much worse.”

Here are some other related articles and stories:

the original paper by Dr. Faust
COVID-19 No Worse Than the Flu? Hardly
Comparing COVID-19 Deaths to Flu Deaths Is like Comparing Apples to Oranges: The former are actual numbers; the latter are inflated statistical estimates
Why we don’t know the True Death Rate for Covid-19

Coronavirus Kills Men More than Women. Why?

David Posnett — Wed, 15 Apr 2020 02:36:49 +0000

In Italy, men made up nearly 60 percent of people with confirmed cases of the coronavirus and more than 70 percent of those who died of COVID-19. In China men and women were infected in roughly equal numbers, but the death rate among men was 2.8 percent, compared with 1.7 percent among women. The same applies to South Korea and numerous other countries. In New York City, men are dying at nearly twice the rate of women. As of recently, men made up 59 percent of overall hospitalizations in New York City and 62 percent of fatalities. In 13 states with sufficient death numbers for analysis, men died more frequently than women.

Men were also disproportionately affected by SARS and MERS, caused by related, but different coronaviruses. For SARS, in Hong Kong in 2003, the case-fatality ratio was 13.2 % for women and 22.3 % for men. Also, 32% of men with Middle East Respiratory Syndrome (MERS) died, compared with 25.8% of women.

The question is: Why?

At first, risk factors were blamed. For instance, smoking rates among men exceed those among women in much of the world. 2% of Chinese women smoke, compared with more than 50% of Chinese men.

Chinese men also have higher rates of Type 2 diabetes and high blood pressure than Chinese women, both of which increase the risk of complications following infection with the coronavirus causing COVID-19 (SARS Cov2). Rates of chronic obstructive pulmonary disease are almost twice as high among Chinese men as among women.

Women are more proactive about seeking health care than men. Since the start of the outbreak, public health officials have emphasized the importance of washing hands to prevent infection. But studies have found that men — even health care workers — are less likely to wash their hands or to use soap than women. While these 2 considerations might affect the number of diagnoses made and perhaps the rate of hospitalization, they are unlikely to affect mortality in my view.

Moreover, rates of smoking in the US are quite similar comparing men to women (unlike in China): in 2015, 16.7 percent of adult males and 13.6 percent of adult females smoked cigarettes in US. Yet the death rate from COVID-19 is clearly much higher among US men compared to US women.

Let’s consider biological differences. Women have more robust immune systems, some scientists have noted, which helps to fight off infections, although it does make them more prone to autoimmune disorders.

When it comes to mounting an immune response against infections, men are apparently the weaker sex. “This is a pattern we’ve seen with many viral infections of the respiratory tract — men can have worse outcomes,” says Sabra Klein PhD, a scientist who studies sex differences in viral infections and vaccination responses at the Johns Hopkins Bloomberg School of Public Health.

Says Dr. Klein: “We’ve seen this with other viruses. Women fight them off better. Women also produce stronger immune responses after vaccinations, and have enhanced memory immune responses.”

SARS, influenza, Ebola and HIV viruses all affect men and women differently.

Here are some tantalizing findings:

A recent research paper from Huazhong University of Science and Technology in Wuhan, using plasma of 331 confirmed coronavirus patients, found that in the most severe cases, women had higher levels of antibodies than men.
For almost all infectious diseases, women are able to mount a stronger immune response then men. Women with acute HIV infections have 40 percent less viral genetic material in their blood than men. Women are less susceptible to the viruses that cause hepatitis B and C. Men infected with coxsackie virus (which can infect the heart) are twice as likely to die of the disease than women.
Female birds show higher antibody responses to infection than males, especially during mating season. The immune cells that eat up microbes and cellular debris are less active in male lizards than in their female counterparts.
Some 60 genes involved in immune function are located on the X chromosome (according to Dr. Sabra Klein). Genetic females have two of these molecules — one from their mother, one from their father — whereas genetic males have only one. When there are two copies of a gene, one copy is often turned off. But as many as a quarter of X-linked genes can escape this inactivation, giving women a “double dosage” of the genetic instructions needed to fight disease.
One such gene codes for a protein called “toll-like receptor 7,” This receptor recognizes strands of viral RNA (the Coronavirus is an RNA virus)
Generally, female immune cells respond faster and more powerfully to viral attacks, producing higher amounts of interferons — proteins that stop viruses from replicating — as well as antibodies that neutralize the virus
Testosterone, has been shown to tamp down inflammation. Estrogen, meanwhile, can bind to immune cells and activate the production of disease-fighting molecules.
A recent study demonstrates a direct role for estrogen signaling in limiting influenza virus replication in nasal epithelial cells derived from humans
ACE2 is a receptor for SARS Cov2. It allows the virus to gain access and infect cells. ACE2 is regulated differently in men and in women.
Experiments published in 2017, in which mice were exposed to the SARS virus (SARS Cov), showed that male mice developed SARS at lower viral exposures, had a lower immune response and were slower to clear the virus from their bodies. They suffered more lung damage and died at higher rates – see the graph below! When researchers blocked estrogen in the infected female mice or removed their ovaries, they were more likely to die, but blocking testosterone in male mice made no difference, indicating that estrogen may play a protective role.

Solid squares are female mice; open squares are male mice. 12 days after infection, 80% of female mice and only 10% of male mice were still alive. 5000 PFU is the dose of virus used to infect each mouse (PFU = Plaque Forming Unit)

Despite all of this, the coronavirus vaccine trials underway in the U.S. aren’t really considering sex yet, according to Dr. Klein. If past experience holds up, vaccines will be more effective in women than in men!

US Healthcare: no Bang for the Buck

David Posnett — Sat, 19 May 2018 22:36:07 +0000

Health care in the US is more expensive, by far, than anywhere else on this planet. It represents greater than 17.9% of the US GDP. Health spending is projected to grow 1.0 percentage point faster than Gross Domestic Product (GDP) per year over the 2017-26 period; as a result, the health share of GDP is expected to rise from 17.9 percent in 2016 to 19.7 percent by 2026. Other comparable developed countries pay much less:

The question is why are we so wasteful and what do we get for all this money. If you look at longevity as the overall measure of success for healthcare, we are not doing very well, as described in a recent article in the NY Times:

The above graph shows life expectancy over time compared to similar developed nations.

This shows life expectancy as a function of health spending per person.

So what are the proposed causes for this dramatic inefficiency? The authors propose many factors to explain the sudden up tick in health care spending around 1980. For example:

“suppliers marketed very costly technological innovations with gusto,”and they “found ready customers in hospitals, medical practices and other entities eager to keep up with rivals in the medical arms race.” The last third of the 20th century or so, was a fertile time for expensive health care innovation: Coronary artery bypass grafting, innovative drug treatments for H.I.V. for cancer and expensive NICU care for premature babies.

But innovation does not necessarily translate in to better outcomes. Almost no matter how it’s measured, longevity in the United States has not kept pace with that of other nations.

Another study, published in JAMA, found that even accounting for motor vehicle traffic crashes, firearm-related injuries and drug poisonings, the United States has higher mortality rates than comparably wealthy countries.

So here is the presumed bottom line.

“The lack of universal health coverage and less safety net support for low-income populations could have something to do with it. The most efficient way to improve population health is to focus on those at the bottom,” says Ms Glied from Columbia Univ. “But we don’t do as much for them as other countries.”

The effectiveness of focusing on low-income populations is evident from large expansions of public health insurance for pregnant women and children in the 1980s. There were large reductions in child mortality associated with these expansions. “Those reductions were much larger for poor children than for richer children,” Ms. Currie said.

In 1980 the United States spent 11 percent of its G.D.P. on social programs, excluding health care, while members of the European Union spent an average of about 15 percent. In 2011 the gap had widened to 16 percent versus 22 percent.

Slow income growth could play a role because poorer health is associated with lower incomes. “It’s notable that, apart from the richest Americans, income growth stagnated starting in the late 1970s,” Cutler said. “Social underfunding probably has more long-term implications than underinvestment in medical care.”

Read more here about how social programs can lead to increased longevity: Are better health outcomes related to social expenditure?

It has been known for some time that low income/wealth is associated with much decreased longevity:

as the income gap increases in the US, so does the disparity in life spans between rich and poor as reported in the NY Times
in the U.S., the richest 1 percent of men lives 14.6 years longer on average than the poorest 1 percent of men, while among women in those wealth percentiles, the difference is 10.1 years on average.
This eye-opening gap is also growing rapidly: Over roughly the last 15 years, life expectancy increased by 2.34 years for men and 2.91 years for women who are among the top 5 percent of income earners in America, but by just 0.32 and 0.04 years for men and women in the bottom 5 percent of the income tables.
U.S. tax and spending policy does relatively little, compared with its peers in the developed world, to reduce inequality and with the new tax policies enacted by our current government this will worsen.

In the NY Times (2014) Leonhardt and Quealy note that “The American Middle Class Is No Longer the World’s Richest”. The following interactive graph shows who many developped countries like Norway, Canada, Germany, Sweden, Netherlands are making gains for the lower 20th percentile of wage earners surpassing American incomes for this bracket. American incomes are losing their edge, except at the top:

It is this same bracket (the lower 20th percentile) that have such poor life expectancy dragging down the overall life expectancy for the entire country.

Finally, this study shows an interesting shift: since about 2004 the lowest quintile income group in the US is spending much less on healthcare on a per capita basis, than the highest income quintile. One of the authors remarks that “co-payments and deductibles have bent the cost curve. But it’s come at the expense of poor people and middle-income people.”

My conclusions:

efforts by the GOP to slash medicare will make things worse
the new tax law will make things worse by aggravating income disparity
advances in medicine benefit the health care industry and affluent Americans who have access to the newest treatments, but on average the population does not benefit as measured by life expectancy, for example.
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