In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, explains why COVID deaths are hard to count and recommends looking into an all-cause mortality framework for a more accurate picture of death rates.
Here is a transcript of his comments:
Hi, I’m Jeremy Faust, editor of MedPage Today. Thank you so much for joining us.
Today I have to speak through an article of my newsletter Inside Medicine that deals with this query that we have so much, which is: when a patient dies of COVID, did he die “of” COVID or “with” COVID?The explanation of why their deaths, was it either just because of the walk or there was a role?
Obviously, this is very complicated because, as many of us know, the death certificate only reflects people’s most productive guesses. There is no genuine way to determine whether a death was primarily caused by COVID and therefore the death certificate will need to state “underlying. “cause of death, COVID-19”, or if that user had a central attack and possibly had COVID at the same time, so possibly COVID would be a contributing or multiple cause of this death.
Then, the question that is absolutely unknowable: If they hadn’t had COVID at the time, would they have had the central attack?So you get into this very complicated game where you have to check to find out what happened. in case.
As a result, many others and I have tracked not only COVID deaths, but also what we call “excess all-cause mortality”: the concept that we don’t worry about how many other people die from COVID in a network, we simply check if more people are dying from any cause than expected and see if that follows COVID outbreaks.
At the beginning of the pandemic, if you had COVID on your death certificate, 95% of the time, it was listed as the “primary” or “underlying” cause of death. That makes sense. We know that in early 2020, we were seeing the same type of patients over and over again. We saw breathless patients with terrible pneumonia all over their lungs; They had low oxygen levels, needed oxygen assistance and mechanical ventilation.
As time goes on and vaccines have arrived and other people have herbal immunity, other people are still hospitalized with COVID, but it becomes less homogeneous. There are other types. This is a patient with a central attack with COVID. This is a patient with COPD emphysema [chronic obstructive pulmonary disease] with COVID. Who can say how much COVID is blamed for each of those deaths?
As a result, if you track, as we do, the percentage of COVID deaths that are indexed as “primary,” that number has been going down throughout the pandemic to the point where when we started, as I mentioned, 95% of COVID deaths were indexed and the idea is that they’re mostly due to COVID, The underlying cause, and is now closer to two-thirds, 60% to 65%. It’s gone down and down over time, and that’s because the types of COVID cases we’re seeing in hospitals are a little more complicated.
The appeal is that this doesn’t necessarily mean COVID deaths are genuine, it just means we’re a little less sure of what’s considered the leading cause of death. This means that business is getting complicated.
What’s also attractive is that we still see COVID tracking with excess mortality and tracking with the number of cases. So, we know that doctors and others who certify the death certificate aren’t far off, because the numbers go up and down with those outbreaks and with the end of those outbreaks. So what we’re seeing is that other people are right, apparently, to put COVID on those death certificates, but no one can tell you what percentage [was due to COVID], whether it’s one hundred percent or 0%.
Now, a question that we are asked and that I will upload here is whether it is regional or not. What’s interesting is that if you look at the four regions of the United States damaged by the census bureaus, the Northeast, the Midwest, the South, and the West, it’s actually quite attractive: there’s not a huge difference between the 4 groups. There are some diversifications in terms of how much is considered “primarily” due to COVID, how many COVID deaths are indexed as culprits for COVID. There are some differences, however, some other people are surprised to see that in the northeast, this number is rarely a little lower.
The reason for this is that in the Northeast, other people certifying those deaths are more likely to list COVID as a “contributing cause of death” than elsewhere. Therefore, the “underlying reasons for death” seem to be a bit simpler. But then what’s happening, and it’s a little regional and a little age-related, is that when they’re not sure that COVID deserves to even be on that death certificate, places like the Northeast are a little more likely to adhere to it is considered a “contributing cause of death,” whereas in the south, They are less likely to accompany you.
What it does is create an attractive artifact where it turns out that more deaths in the Northeast aren’t really COVID-like, when in fact, what it literally reflects is that more people certify deaths in the Northeast that come with COVID as a “contributing cause” when it’s not the driving cause of death. and the opposite is true in the South.
We also see an age difference. As you get older, from 18 to 49 to 50 to 64, there is also slightly more likely to be variability. We’ve noticed at times during the pandemic that the percentage of COVID deaths that is considered the “primary underlying cause” of COVID actually fell by nearly 50% in some positions and in certain age teams at certain times.
Everything to say: it becomes much harder. It’s not as undeniable as it used to be when we saw the same type of patient over and over again. Now it’s hard.
So, we want to track data at once to perceive where we are in the pandemic, because that’s what everyone needs to know. How many deaths is COVID to blame?To what extent is it the “primary cause”, the underlying cause?– Or is it a “contributing cause”? And if it’s a “contributing cause,” where does the fault go?Is it similar to 20%?Is it 80% causation? We’ll never know.
We stick to this with excess mortality from all causes and see how we cope. What we found is that when compared to past waves, we are much further away in terms of all-cause mortality. In the worst-case scenario, Omicron, for example, in the United States, we had a 37% increase in all-cause mortality in January 2022. That means we had 37% more deaths from all causes than we were intended to have. In December 2020, for example, just before vaccines arrived, nationwide, 43% more deaths from all causes than usual. Very very bad.
Now, for this summer and even this fall, we are starting to have confidence in the knowledge we have, and we can say that excess mortality is around 8 to 10%. Now we do need it to suck. And in fact, there were times in March, April, and May in various parts of the country where we had excess deaths close to 0 and, in some cases, maybe even fewer deaths than before because of the severity of Omicron.
We had a domino effect where the remaining cohort was already taken into account. In other words, other people died a few months earlier, so in March and April we had fewer deaths than expected because of this domino or harvest effect, which is a tragic thing we see in pandemics.
But overall this summer, things started to go backwards and we’re still in that 9-11% excess mortality range. This means that we are not yet in a general place. We track that, we track COVID deaths, we compare “from” as opposed to “with,” incidental or coincidental, and we put everything together and we know we’re better off than we were, but we’re not where we want to be.
So I hope that answers some of the questions that other people are asking. Are other people dying from COVID or with COVID?The answer is it’s a little bit of either, or it’s a lot of either and it’s hard to tell, and we have excess mortality and COVID surgeses to verify and put that into context.
All this is to say that we have made progress, but we still have some leeway. To be more informed, check out my article on Inside Medicine and thank you for watching MedPage Today.
Emily Hutto is an associate video editor and producer for MedPage Today. It’s in Manhattan.