Friday, June 19, 2020

Clearer From A Distance

Since the Covid-19 lockdowns there have been many asking the question of whether it was all really necessary?

How much difference did closing the economy really have on the war against Covid-19?

The economic cost was astronomical. Was it worthwhile?

All of it was done based on models and projections.

I wrote this in March as the economic impacts of the lockdowns were becoming apparent.

If one thing is true right now it is that humanity has never wagered and spent more based on the output of a model.
Will we ever know whether the biggest wager that humanity has ever placed on a model was worth the cost?

Long after this is over we will likely still not know the real truth of whether what we have been through was worth the sacrifice and costs.

The modelers will tell us that their models saved us from the drastic effects that the virus would have had on human life.

Skeptics will argue that the virus was never as bad as advertised to begin with.

I also wrote early in the pandemic that I was not sure that the number of cases was ever going to be a reliable indicator in all of this. I pointed out more testing would invariably reveal more cases. However, that would not tell us much in the end.

We are seeing that play out right now in some states like Florida that are seeing rising case counts. However, the increased case counts in those states appear to be coming more and more from younger age groups. 

For example, look at how the median age of confirmed cases has changed in Florida over time.

Younger age groups are much more likely to be asymptomatic. The evidence also seems to suggest that those who are not symptomatic are much less likely to have heavy viral loads to pass the infection on as well as to become seriously ill themselves. 

This study from Italy indicates that symptomatic rates rises sharply with age. Nearly 70% of cases under age 60 are asymptomatic.

Therefore, cases involving younger ages generally mean fewer hospitalizations and fewer deaths. 

I suggested early on that hospitalizations due to Covid-19 rather than confirmed cases were a more reliable indicator of what our concerns should be due to limited hospital resources and ICU beds but that metric also had limitations. It seemed to me that deaths from Covid-19 would be the best data element to assess how bad all of this really was.

Of course, it quickly became apparent that determining deaths due to Covid-19 was not as straightforward as one would assume.  Yes, someone could have died and tested positive for the virus but they could have already been given two months to live with a terminal cancer or had a heart attack and tested positive for Covid-19 post-mortem. 

For that reason, I suggested on March 23 that President Trump needed better data to determine if what we were doing was justified. He could not just bet the country's future on a model. The most important number was the excess mortality that we were experiencing as a result of Covid-19. We may not be able to rely on the reasons given on a death certificate but we should be able to draw solid conclusions by looking at total deaths in the period compared to expected deaths (excess mortality).

If I was sitting in his chair I would be demanding to see the total death numbers across the United States every day and compare it to the numbers that were projected before all of this started in order to determine the excess mortality number from Covid-19 in real time.

We need better data than what I am seeing. I would also not want to get this number a year from now and find out we destroyed the economy by not having the right data when we needed it.

I don't see any other way to really assess where we are and what our next steps should be as a nation to combat the virus.

The worst thing we could have done in this situation is to not take it seriously.

What is the next worst thing? We took it way too seriously when the data later shows we vastly overreacted.

Excess mortality numbers in real time would help insure that doesn't occur.

Of course, there is no system in place to capture all deaths around the country on a real-time basis. We eventually get the data reported to the CDC with a lag that might be days, weeks or a month or two later depending on which state is doing the reporting.

European countries have similar reporting systems.

Now that a couple of months have passed the real picture is starting to come into better focus. Everything is a little clearer from a distance when looking at excess mortality data.

One thing that is indisputable about Covid-19 is that it was especially deadly to vulnerable populations. It was particularly lethal for those 80 years and older. There is no debate about that in looking at the data.

You can see the excess mortality in major European countries in the charts below for Italy, Sweden UK, Spain, France and Germany.

This data is from Euromomo which is the official mortality monitoring site for all European countries and includes mortality reports through week 24 of the year 2020 looking back to 2016.

All saw a spike in excess mortality except for Germany. Interestingly, Sweden saw the next smallest spike in excess deaths even though they did not lockdown their economy.

The excess mortality was driven in particular by deaths of those age 80+ in all these countries.


Considering the median ages of deaths in Europe could we now see a period of sub-normal deaths? 

Or could we see some additional excess mortality due to the fact that so many other medical issues went untreated over the last several months?

One interesting fact in Europe is that deaths among those under age 14 actually trended down the last couple of months. You see this particularly in France and the U.K. We know Covid-19 deaths were almost nonexistent in this age group but it seems that the lockdowns actually saved lives of the young from other causes as well. We have seen the same result in the United States. More on that below.

What about the United States?

Just as in Europe, the United States went through about a six week period from late March to mid-May where deaths spiked much above normal. 

This was driven in large part by deaths in the New York City metro area.

For example, deaths were ten times normal in New York City the week ending April 11.

However, in my home state of Ohio, deaths from all causes through May were up just 1.2% for 2020 compared to the average of the last 5 years despite the presence of Covid-19.

Source; Columbus Dispatch

71% of all deaths in Ohio have been residents of nursing homes.

53% of deaths have been age 80 or older.

There has not been one death of anyone under age 20.

Source: Ohio Department of Health, June 18,2020

The United States data is also consistent with the European mortality numbers in that total deaths from all causes of those under age 18 started dropping dramatically beginning in mid-March.

While older people in nursing homes saw substantially higher levels of excess mortality due to Covid-19 and its corollary effects (for example, will we ever know if some number of those in nursing homes just "gave up" because they could no longer see their loved ones during the lockdowns?) the lockdowns actually saved the lives of children.

Why is that?

Fewer teenagers driving?

No sports activities?

No school so less risk by staying at home?

Parents keeping a closer eye on their children?

The fact is that almost all of the "saved lives" were those under the age of 1 so none of the explanations above seems to explain it.

Amy Becker and Mark Blaxill pose another possible explanation in a white paper that asks the question, "Why Are So Many Fewer Children Dying?".

Could it be due to the fact that infant vaccinations have declined during this same period as a result of the lockdown orders? In short, no doctor visits means no vaccinations.

This graph shows how dramatic the decrease in routine pediatric vaccines between January 1 and mid-April was.

Is is just a coincidence that deaths of children under the age of 1 (who receive the most vaccine doses) started to fall just as fewer vaccinations were administered?

I don't know. 

However, it certainly seems to be a subject that should be explored more deeply that it has in the past.

Many vaccines have proven useful and saved millions of lives over the years. However, make no mistake, they also come with risks. I have written about this before.

The public health experts are very reluctant to talk about those risks because it creates a major obstacle to the simple narratives they want to use to influence public opinion.

However, if anything, Covid-19 has shown us that the public health experts don't have all the answers. 

There are a lot of things that are clearer from a distance now than they were in March.

Parents are told all the time that they should have no concerns about any adverse effects from childhood vaccines. In fact, those that have reservations about the vaccine schedule are told they are endangering their child and everyone else. 

Would it not be the ultimate irony if a pandemic actually provided a stark lesson that everything in health care involves balancing benefits and risks?

Starting with the childhood vaccination schedule.

Is any public health expert even curious about looking into  "why are so many fewer children dying?"

I think everyone would agree that is a very good thing.

Shouldn't we find out the answer to that question?

We should but you can be sure it will likely not happen. 

What are the chances the CDC or any other public health expert would want to do anything to raise questions about the safety of vaccines when they soon will want to convince everyone to be vaccinated against Covid-19?

That is clear from any distance you might want to consider it from. 

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