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How deadly is COVID-19? A biostatistician explores the question
The latest statistics, as of July 10, show COVID-19-related deaths in U.S. are just under 1,000 per day nationally, which is down from a peak average of about 2,000 deaths per day in April. However, cases are once again rising very substantially, which is worrisome as it may indicate that substantial increases in COVID-19 deaths could follow. How do these numbers compare to deaths of other causes? Ron Fricker, statistician and disease surveillance expert from Virginia Tech, explains how to understand the magnitude of deaths from COVID-19.
As a disease surveillance expert, what are some of the tools you have to understand the deaths caused by a disease?
Disease surveillance is the process by which we try to understand the incidence and prevalence of diseases across the country, often with the particular goal of looking for increases in disease incidence. The challenge is separating signal from noise, by which I mean trying to discern an increase in disease incidence (the signal) from the day-to-day fluctuations in that disease (the noise). The hope is to identify any increase as quickly as possible so that medical and public health professionals can intervene and try to mitigate the disease’s effects on the population.
A critical tool in this effort is data. Often disease data is collected and aggregated by local and state public health departments and the Centers for Disease Control and Prevention from data that is reported by doctors and medical facilities. Surveillance systems then use this data and a variety of algorithms to attempt to find a signal amidst the noise.
Early on, many people pointed out that the flu has tens of thousands of deaths a year, and so COVID-19 didn’t seem so bad. What’s wrong with that comparison?
The CDC estimates the average number of flu-related deaths since 2010-11 is around 36,000 per year. This varies from a low of 12,000 deaths in 2011-12 to a high of 61,000 deaths in 2017-18. Thus, the number of COVID-19 deaths to date is three to four times greater than the annual average number of flu-related deaths over the past decade; it is 10 times larger when compared to the 2010-11 flu season but only about twice as large compared to 2017-18.
To make this a fair comparison, note that seasonal influenza mostly occurs over a few months, usually in late fall or early winter. So, the time periods are roughly comparable, with most of the COVID-19-related deaths occurring since late March. However, COVID-19 does not appear to be seasonal, and fatalities are a lagging measure because the time from infection to death is weeks if not months in duration, so the multiples in the previous paragraph will be greater by the end of the year.
Furthermore, while death rates have been coming down from a peak of more than 2,700 on April 21, 2020, the United States is now averaging just under 1,000 deaths per day as of July 10, and given the dramatic increase in cases of late, we should expect the fatality rate to further rise. For example, the University of Washington’s IHME model currently predicts slightly more than 208,000 COVID-19-related deaths by November 1.
So, by any comparison, the COVID-19 death rate is significantly higher than the seasonal influenza death rate.
What are some comparisons that could provide some context in understanding the scale of deaths caused by COVID-19?
As of this writing, more than 130,000 people have died of COVID-19, and that total could grow to 200,000 or more by fall. Those numbers are so big, they’re hard to grasp.
Michigan Stadium in Ann Arbor is the largest football stadium in the United States. It holds 107,420 people, so no football stadium in the country is large enough to hold everyone who has died from COVID-19 thus far. By the time bowl season comes along, assuming we have a football season this year, the number of COVID-19 fatalities will likely exceed the capacity of the Rose and Cotton bowl stadiums combined.
The state of Wyoming has a population of slightly less than 600,000 people, so it’s the equivalent of one out of every five people in that state dying in the last four months. By this fall, the COVID-19 death total will be the equivalent of fully one-third of the people in Wyoming dying.
The populations of Grand Rapids, Michigan; Huntsville, Alabama; and Salt Lake City, Utah are each just over 200,000 people. Imagine if everyone in one of those cities died over the course of six months. That’s what COVID-19 may look like by fall.
How do COVID-19 deaths compare to chronic diseases like cancer or heart disease?
Today, COVID-19 ranks as the sixth leading cause of death in the United States, following heart disease, cancer, accidents, lower chronic respiratory diseases and stroke. Heart disease is the leading cause, with just over 647,000 Americans dying from it each year. Alzheimer’s disease, formerly the sixth largest cause of death, kills just over 121,000 people per year. If the University of Washington IHME model’s current prediction of COVID-19-related deaths comes to pass, COVID-19 will be the third leading cause of death in the United States by the end of the year.
The American Cancer Society estimates that in 2020 there will be an estimated 1.8 million new cancer cases diagnosed and 606,520 cancer deaths in the United States. Lung cancer is estimated to kill about 135,000 people in the US in 2020, so the number of COVID-19 deaths is currently equivalent and will exceed it soon. Of course, it is important to note that the COVID-19 deaths have occurred in about the past four months while the number of lung cancer deaths is for a year. So, COVID-19 deaths are occurring at roughly three times the rate of lung cancer deaths.
What are some historical comparisons that you think are useful in understanding the scale of deaths from COVID-19?
The 1918 influenza pandemic was similar in some ways to the current pandemic and different in other ways. One key difference is the age distribution of deaths, where COVID-19 is concentrated among older adults while the the 1918 pandemic affected all ages. In my state of Virginia, only 8% of the people who died in the 1918 pandemic were more than 50 years old, compared to more than 97% for COVID-19.
The CDC estimates that the 1918 pandemic resulted in about 675,000 deaths in the United States, so slightly more than five times the current number of COVID-19 deaths. In October of 1918, the worst month for the influenza pandemic, about 195,000 people died – well more than all who have died so far from COVID-19.
As with any historical comparison, there are important qualifiers. In this case, the influenza pandemic started in early 1918 and continued well into 1919, whereas COVID-19 deaths are for about one-third of a year (March through June). However, today the United States’ population is about three times the size of the population in 1918. These two factors roughly “cancel out,” and so it is reasonable to think about the 1918 epidemic being about five times worse than COVID-19, at least thus far.
In comparison to past wars, the U.S. has now had more deaths from COVID-19 than all the combat-related deaths in all the wars since the Korean War, including the Vietnam War and Operations Desert Shield and Desert Storm. In World War II there were 291,557 combat casualties. So the number of people who have died from COVID-19 thus far is about 45% of the WWII combat casualties. By the fall, it could be more than 70%.
Finally, note that the number of confirmed and probable deaths from COVID-19 in New York City (23,247 on July 10, 2020) is more than eight times the number who died in the 9/11 attack (2,753).
Mask resistance during a pandemic isn’t new – in 1918 many Americans were ‘slackers
We have all seen the alarming headlines: Coronavirus cases are surging in 40 states, with new cases and hospitalization rates climbing at an alarming rate. Health officials have warned that the U.S. must act quickly to halt the spread – or we risk losing control over the pandemic.
There’s a clear consensus that Americans should wear masks in public and continue to practice proper social distancing. While a majority of Americans support wearing masks, widespread and consistent compliance has proven difficult to maintain in communities across the country. Demonstrators gathered outside city halls in Scottsdale, Arizona; Austin, Texas; and other cities to protest local mask mandates. Several Washington state and North Carolina sheriffs have announced they will not enforce their state’s mask order.
I’ve researched the history of the 1918 pandemic extensively. At that time, with no effective vaccine or drug therapies, communities across the country instituted a host of public health measures to slow the spread of a deadly influenza epidemic: They closed schools and businesses, banned public gatherings and isolated and quarantined those who were infected. Many communities recommended or required that citizens wear face masks in public – and this, not the onerous lockdowns, drew the most ire.
In mid-October of 1918, amidst a raging epidemic in the Northeast and rapidly growing outbreaks nationwide, the United States Public Health Service circulated leaflets recommending that all citizens wear a mask. The Red Cross took out newspaper ads encouraging their use and offered instructions on how to construct masks at home using gauze and cotton string. Some state health departments launched their own initiatives, most notably California, Utah and Washington.
Nationwide, posters presented mask-wearing as a civic duty – social responsibility had been embedded into the social fabric by a massive wartime federal propaganda campaign launched in early 1917 when the U.S. entered the Great War. San Francisco Mayor James Rolph announced that “conscience, patriotism and self-protection demand immediate and rigid compliance” with mask wearing. In nearby Oakland, Mayor John Davie stated that “it is sensible and patriotic, no matter what our personal beliefs may be, to safeguard our fellow citizens by joining in this practice” of wearing a mask.
Health officials understood that radically changing public behavior was a difficult undertaking, especially since many found masks uncomfortable to wear. Appeals to patriotism could go only so far. As one Sacramento official noted, people “must be forced to do the things that are for their best interests.” The Red Cross bluntly stated that “the man or woman or child who will not wear a mask now is a dangerous slacker.” Numerous communities, particularly across the West, imposed mandatory ordinances. Some sentenced scofflaws to short jail terms, and fines ranged from US$5 to $200.
Passing these ordinances was frequently a contentious affair. For example, it took several attempts for Sacramento’s health officer to convince city officials to enact the order. In Los Angeles, it was scuttled. A draft resolution in Portland, Oregon led to heated city council debate, with one official declaring the measure “autocratic and unconstitutional,” adding that “under no circumstances will I be muzzled like a hydrophobic dog.” It was voted down.
Utah’s board of health considered issuing a mandatory statewide mask order but decided against it, arguing that citizens would take false security in the effectiveness of masks and relax their vigilance. As the epidemic resurged, Oakland tabled its debate over a second mask order after the mayor angrily recounted his arrest in Sacramento for not wearing a mask. A prominent physician in attendance commented that “if a cave man should appear…he would think the masked citizens all lunatics.”
In places where mask orders were successfully implemented, noncompliance and outright defiance quickly became a problem. Many businesses, unwilling to turn away shoppers, wouldn’t bar unmasked customers from their stores. Workers complained that masks were too uncomfortable to wear all day. One Denver salesperson refused because she said her “nose went to sleep” every time she put one on. Another said she believed that “an authority higher than the Denver Department of Health was looking after her well-being.” As one local newspaper put it, the order to wear masks “was almost totally ignored by the people; in fact, the order was cause of mirth.” The rule was amended to apply only to streetcar conductors – who then threatened to strike. A walkout was averted when the city watered down the order yet again. Denver endured the remainder of the epidemic without any measures protecting public health.
In Seattle, streetcar conductors refused to turn away unmasked passengers. Noncompliance was so widespread in Oakland that officials deputized 300 War Service civilian volunteers to secure the names and addresses of violators so they could be charged. When a mask order went into effect in Sacramento, the police chief instructed officers to “Go out on the streets, and whenever you see a man without a mask, bring him in or send for the wagon.” Within 20 minutes, police stations were flooded with offenders. In San Francisco, there were so many arrests that the police chief warned city officials he was running out of jail cells. Judges and officers were forced to work late nights and weekends to clear the backlog of cases.
Many who were caught without masks thought they might get away with running an errand or commuting to work without being nabbed. In San Francisco, however, initial noncompliance turned to large-scale defiance when the city enacted a second mask ordinance in January 1919 as the epidemic spiked anew.
Many decried what they viewed as an unconstitutional infringement of their civil liberties. On January 25, 1919, approximately 2,000 members of the “Anti-Mask League” packed the city’s old Dreamland Rink for a rally denouncing the mask ordinance and proposing ways to defeat it. Attendees included several prominent physicians and a member of the San Francisco Board of Supervisors.
It is difficult to ascertain the effectiveness of the masks used in 1918. Today, we have a growing body of evidence that well-constructed cloth face coverings are an effective tool in slowing the spread of COVID-19. It remains to be seen, however, whether Americans will maintain the widespread use of face masks as our current pandemic continues to unfold.
Deeply entrenched ideals of individual freedom, the lack of cohesive messaging and leadership on mask wearing, and pervasive misinformation have proven to be major hindrances thus far, precisely when the crisis demands consensus and widespread compliance.
This was certainly the case in many communities during the fall of 1918. That pandemic ultimately killed about 675,000 people in the U.S. Hopefully, history is not in the process of repeating itself today.
How the coronavirus pandemic became Florida’s perfect storm
https://theconversation.com/how-the-coronavirus-pandemic-became-floridas-perfect-storm-142333
If there’s one state in the U.S. where you don’t want a pandemic, it’s Florida. Florida is an international crossroads, a magnet for tourists and retirees, and its population is older, sicker and more likely to be exposed to COVID-19 on the job than the country as a whole.
When the coronavirus struck, the conditions there made it a perfect storm.
Florida set a single-day record for new COVID-19 cases in early July, passing 15,000 and rivaling New York’s worst day at the height of the pandemic there. The state has become an epicenter for the spread, with over 300,000 confirmed cases. Its hospital capacity is under stress, and the death toll has been rising.
Despite these strains, Disney World reopened two theme parks on July 11, and Florida Gov. Ron DeSantis announced schools would reopen in August. The governor had shut down alcohol sales in bars in late June as case numbers skyrocketed, but he hasn’t made face masks mandatory or moved to shut down other businesses where the virus can easily spread.
As public health researchers, we have been studying how states respond to the pandemic. Florida stands out, both for its absence of statewide policies that could have stemmed the spread of COVID-19 and for some unique challenges that make those policies both more necessary and more difficult to implement than in many other states.
The challenges of economic pressures
Florida is one of nine states with no income tax on wages, so its tax base relies heavily on tourism and property in its high-density coastal areas. That puts more pressure on the government to keep businesses and social venues open longer and reopen them faster after shutdowns.
If you look closely at Florida’s economy, its vulnerabilities to the pandemic become evident.
The state depends on international trade, tourism and agriculture – sectors that rely heavily on lower-wage, often seasonal, workers. These workers can’t do their jobs from home, and they face financial barriers to getting tested, unless it’s provided through their employer or government testing sites. They also struggle with health care – Florida has a higher-than-average rate of people without health insurance, and it chose not to expand Medicaid.
In the tourism industry, even young, healthy employees typically at lower risk from COVID-19 can unknowingly spread the virus to visitors or vice versa. The tourism industry also encourages crowded bar and club scenes, where the governor has blamed young people for spreading the coronavirus.
The past few weeks have been emblematic of the economic battles facing a state that depends on tourism for both jobs and state revenues.
Even as the public health risks were quickly rising, businesses continued to open their doors. Major cruise lines planned to resume their itineraries in the fall. A note on the Universal Studios website read: “Exposure to COVID-19 is an inherent risk in any public location where people are present; we cannot guarantee you will not be exposed during your visit.”
Reopening guidance has been largely ignored
The Governor’s Re-open Florida Taskforce issued guidelines in late April meant to lower the state’s coronavirus risk, but those guidelines have been largely ignored in practice.
No county in Florida has reduced cases or maintained the health care resources recommended by the task force. The data needed to fully assess progress are also questionable, given a recent scandal regarding the state data’s accuracy, availability and transparency.
Still, the coronavirus’s rapid surge in Florida is evident in the state-reported cases. Testing lines are long, and almost 1 in 5 tests have been positive for COVID-19, suggesting the prevalence of infections is still increasing.
Florida’s patchwork of local rules also makes it hard to contain the virus’s spread.
With no statewide mask rules or plans to reverse reopening, other than for bars, communities and businesses have taken their own actions to implement public health precautions. The result is varying mask ordinances and restrictions on large gatherings in some cities but not those surrounding them. Though the Florida Department of Health has issued an advisory recommending face coverings, some local areas have voted down mask mandates.
More warning signs ahead
Late summer and fall will bring new challenges for Florida in terms of the virus’s spread and the state’s response to it.
That’s when Florida’s risk of hurricanes grows, and while Floridians are well-versed in hurricane preparedness, storm shelters aren’t designed for social distancing and will need careful plans for protecting nursing home residents. Storm cleanup could mean lots of people working in close proximity while protective gear is in short supply.
If Florida’s schools reopen fully, the risk of the virus rapidly spreading to teachers, parents and children who are more vulnerable is a real concern being weighed against the costs of keeping schools closed.
Colleges that reopen to classes and sporting events also raise the risk of spreading the virus in Florida communities. And the possible return of retirees who spend their winters in Florida would increase the high-risk population by late fall. One in five Florida residents is over age 65, giving the state one of the nation’s oldest populations – a risk factor, along with chronic illnesses, for severe symptoms with COVID-19.
Florida is also a battleground state for the upcoming presidential election, and that’s likely to mean campaign rallies and more close contact. The Republican National Convention was moved to Jacksonville after President Donald Trump complained that North Carolina might not let the GOP fill a Charlotte arena to capacity due to coronavirus restrictions. Florida organizers recently said they were considering holding parts of the convention outdoors.
The high number of cases being reported in Florida will lead to even more hospitalizations and fatalities in coming weeks and months. Without clear public health messages and precautions implemented and enforced across the state, the coronavirus forecast for the Sunshine State will remain stormy.
Adapting leadership for the virtual world
https://mailchi.mp/da2dd0911f99/the-weekly-gist-july-17-2020?e=d1e747d2d8
Recently, a senior executive shared a concern with us about his leadership style during the pandemic: “I have always thought of myself as a good leader. For the first time in my career, I feel like I’m failing.”
His worry was less about making the big decisions needed in a crisis, and more about the ongoing engagement and “forward motion” of his team.
When in-person meetings transitioned to Zoom calls, he was struck by how much of leadership and team building relies on in-person interaction, whether it’s formal group sessions to drive a decision, or the hundreds of informal one-on-one interactions every week in the office. As our small firm went virtual, it’s something we noticed, too. Virtual interactions require a different structure and pace, and it takes more work to engage the full group.
And while no one enjoys an hours-long videoconference, more frequent, shorter calls can build momentum. Dedicating time to sharing personal updates builds the connections lost when we’re not physically together.
But despite the risks, one CEO shared that in a crisis like COVID-19, showing up in person matters: “You can’t always stay at home or in your office. As a leader you have to be out and talking to staff. I know it’s risky but that is really what it takes.
Being there to clearly articulate the go-forward plan.” We’d love to hear your insights about how you’re adapting your leadership approach to navigate this balance, keeping your teams engaged through this difficult and unfamiliar time.
Modeling the ominous impact of testing delays
https://mailchi.mp/da2dd0911f99/the-weekly-gist-july-17-2020?e=d1e747d2d8
With delays in getting test results growing in many areas of the country, a new analysis in the Lancet shows just how destructive increased turnaround times for COVID tests can be.
Researchers modeled the impact of the timeliness and completeness of contact tracing, finding that minimizing testing delay—shortening the time between symptom onset and a positive test result—had the greatest impact on reducing future spread of the disease.
Digging into the details, if infected individuals who develop symptoms are isolated within one day of symptom onset, the R0 (“R-naught”) can be reduced to 1—each existing infection seeds one new case—stabilizing the level of infection in a population. With contact tracing, the R0 can be reduced to 0.8, meaning the disease will decline.
And researchers found with a testing delay of three days or more, even the most efficient isolation and contact tracing is essentially futile, powerless to bend the curve of transmission rates.
Ominous findings for many states, where average test turnaround times are again approaching one week, showing just how far we are from being able to implement the basic public health strategy of “test, trace and isolate”, which has proven effective for so many countries around the world.
Anticipating a post-pandemic “Renaissance Era”
https://mailchi.mp/da2dd0911f99/the-weekly-gist-july-17-2020?e=d1e747d2d8
The primary measures we’re using to control the spread of COVID-19—masks, social distancing, isolation—have changed little from those used to mitigate the Spanish Flu in 1918, or even the bubonic plague in the Middle Ages. (In fact, the word “quarantine” comes from the Italian quaranta giorni, the forty-day period of time that arriving ships were required to anchor off the Venetian coast to prevent the spread of the Black Death.)
We were intrigued by a recent piece in the New Yorker that looks at another impact of the plague that ravaged the world in the 14th and 15th centuries: the Black Death likely ushered in an era of unprecedented social change and knowledge advancement. Devastated economies recovered to become stronger than before, with greater equality. With half of the population wiped out, workers’ wages rose, leading to the rise of a new class of artisans and innovators. With a shortage of adult men to fill jobs, women found meaningful employment in many trades.
Science and medicine moved from a spiritual and astrological orientation to a more knowledge-based approach. The “quarantine enforcers” birthed a public health infrastructure. And so the Renaissance was born. But the author also points out that great upheavals, whether caused by disease, depression or war, lead to radical social adjustments—which can be a good thing or a bad thing.
Our current pandemic offers glimpses of both possibilities. Will distrust of science, government ineptitude, and political divisiveness become further entrenched? Or will society emerge stronger, with advances in technology and medicine, a stronger economy and a renewed social system that addresses deep-rooted inequality—our own post-pandemic Renaissance? It’s up to us.
Europe’s lessons on reopening schools
https://www.axios.com/europe-lessons-reopening-schools-b713801e-26d6-4ba1-bb9e-c0b0b5809a11.html
American parents and policymakers hoping for a safe return to schools in the fall have been looking to Europe, where several countries reopened as early as April without a subsequent spike in cases.
Why it matters: There’s a growing body of evidence suggesting that schools can operate safely, at least under certain circumstances. But no country that closed schools has attempted to reopen them with outbreaks still raging as they are across much of America.
- The first countries to bring students back, as Denmark did in April, didn’t detect much spread in schools — but the virus was also under control in the broader communities.
- Harder-hit countries, like France or Belgium, contained the spread through lockdowns before bringing students back — something the U.S. has largely failed to do.
- America’s unenviable position as a global epicenter complicates matters, but the challenge is similar: adapting schools to our pandemic reality.
Social distancing: Danish class sizes were initially limited to around 12, and arrival times were staggered to avoid crowding.
- As they plan for the fall, though, countries like Belgium are dropping distancing mandates for younger students, while France is trimming its spacing requirements from 4 meters (about 12 feet) to 1 (3 feet), per the Washington Post.
- That’s due to space limitations and the difficulties of keeping children apart, as well as indications that young students are unlikely to spread the virus to one another.
Masks: Similarly, countries including Austria initially required masks but loosened those restrictions over time.
- Masks are optional for both students and teachers in Denmark, Norway, the U.K. and Sweden, per Science. Some German schools force students to wear them in the hallway, but not in class.
- Masks are required for both students and teachers in several Asian countries, including China. Some experts argue that mask requirements would make reopening safer, particularly for teachers and older students.
“Bubbles”: When the U.K. fully reopens schools in September, smaller subsets of students will spend classes, lunch and recess together — an approach several other countries have experimented with.
- If a student gets the virus, the logic goes, there are only so many people they could give it to, or who would need to self-isolate.
- Italy is asking schools to open on Saturdays to allow for lower daily attendance, and schools are encouraged to hold classes outdoors or in larger venues like cinemas, per The Local. Funding has been allocated to update schools and hire more teachers.
Hybrid learning: Several countries have resumed in-person schooling on a more limited basis, supplemented by online education. School districts across the U.S. are designing such approaches now.
- Belgian students over 12 will attend school four days a week in the fall, with an additional half-day online. If cases increase, so will the proportion of online education.
What to watch: It remains unclear how susceptible children are to the virus, though findings from a hard-hit town in France — which are consistent with other evidence — suggest it spreads significantly less easily among teens than adults, and hardly at all among young children.
The bottom line: The risks to schools remain uncertain, but will almost certainly depend on what’s happening outside their walls.
HENRY KOTULA 