Thanks to all of you who responded with help on the data question. It turns out I could probably just use weekly data in the weekly report. So I am going to try that.
I have talked about some of the characteristics of this epidemic–frontloading, bifurcation by age. Here is another phenomenon, one which would be common to any epidemic very disproportionately targeting the old. It is the pull-forward of deaths. Most of the people who have died from CV-19 were very close to the end of their lives, months, even weeks away. Something was going to get them soon. CV-19 did cause those deaths to occur earlier than they would have and we see a blip up in deaths, which has been referred to as excess deaths. But as the epidemic recedes, and it will, there will be a blip down, because the deaths that would have been occurring, already happened. You will have to look by age group because that phenomenon will be offset, perhaps completely, by lockdown deaths, but you will see it very clearly among the elderly.
I also recall having some fun at our Department of Health representatives when Wisconsin seemed to be doing so much better than we were in the spring, at least in terms of deaths and cases. But I also keep in mind the apparent rule that every location looks like it will end up at the same place. And Wisconsin’s turn has clearly come, as cases, and it appears, hospitalizations are up. It is a demonstration of the futility of attempting to suppress CV-19 that sooner or later, on an age and population health adjusted basis, every location seems like it will have similar infection and serious illness rates. Pretty remarkable, actually. Places in Europe that got praised so much for their handling of the epidemic in the spring, the Czech Republic for example, and especially for masking, are just getting hammered now. Sooner or later, everywhere. Just have to learn to live with it. So, I should learn my own lesson, and not assume that anyone is doing a better or worse job responding to this epidemic, there really just isn’t much that can be done over the longer haul.
One final note to keep in mind when looking at hospitalizations and hospitalization rates is that with increased use of remdesivir, hospitalization is required for administration, typically for five days. So even though the patient may not need to be hospitalized, they will be if remdesivir is prescribed. I believe there are also hospitalizations that are essentially for observation. Clinical uncertainty is leading to hospitalizations just as a precaution to enable closer monitoring of a patient.
I have been very curious to see more research on the impact of advance planning directives on the epidemic. With the deaths being heavily skewed toward the frail elderly, those over 80 and in nursing homes, I assumed that there was an effect from saying they didn’t want intensive treatment or even to go to the hospital. This study at Research Square is one of the first I have been able to find on the topic. (RS Research) The study was done in the UK, with hospitalized patients, and examined decisions to limit care. Advance care decisions were made for 84% of hospitalized patients with the majority opting against CPR or other intensive treatments. These decisions were made between the physicians, the patient and the family or other caregivers. Not exactly like the US system, but gives you a sense that for many of the frail elderly, who were the most likely to have treatment limited in this study, deaths are occurring almost by consent. I think it is important to identify, especially in connection with death statistics, how many of those said to have died from CV-19 did so under a limitation of care.
Another nice review of what we know about transmission and CV-19 disease. (BMJ Article) There are a couple of especially informative charts on the viral replication process and the typical progress of an infection. The authors confirm much of what seems to be known, including the more limited, but still potentially important, role of asymptomatic transmission. And the authors note the ongoing uncertainties around aerosol transmission.
This study examined a cohort of Michigan outpatients. (BMC Article) The research covered over 800 patients who were diagnosed in an ER with CV-19 but had minimal symptoms so were sent home. 19% eventually came back for a follow-up visit and of this group, 54% were admitted. 1.3% of the patients died. Even in this group of persons who came to an ER with symptoms, 80% had very mild disease for the duration and another 9% returned for follow-up but still had mild disease and did not need admission. Those patients who needed admission on follow-up were older, and had a high rate of pre-existing disease, including hypertension, diabetes and COPD. Just another study showing how non-threatening this disease is for most people who contract it.
This is an interesting piece of research that looked at what happens in a human lung cell when infected or attempted to be infected by CV-19. (Cell Article) The authors cultured lung cells in the lab and infected them and tracked the interaction and immune response. They found that as few as one virion could be sufficient to infect a cell and that viral replication usually starts within one day.