New Data Emerging from Italy May Explain High COVID19 CFR’s
Examining Italy’s CFR and their data as new figures are released
Italy has been the outlier in the COVID19 pandemic. Fatalities from the virus were extremely high, worryingly so and many felt that there were other factors at play that influenced their CFR (Case Fatality Rate)
Over the last few days, new data have emerged to support this. Here is what we know so far and a lens through which the data should be viewed. A few key factors first regarding Italy’s demographics.
- Italy has the second oldest population in the world, after Japan. People over the age of 65 make up a whopping 24% of their population.
- Italy has the unpleasant distinction of leading Europe in deaths related to antibiotic-resistant infections. This directly impacts doctors abilities to effectively treat pneumonia in many elderly patients.
- Italians smoke, nearly 24% of the population. A factor known to aggravate symptoms in those testing positive for COVID19
This is how data have unfolded over the last few days. For those of you who are interested in how these figures are arrived at, here is an excellent article to help you understand data in meta-analyses.
Italy has been reporting an alarming CFR of around 9.5-%. Far higher than most countries, by a large margin.
20th of March
Professor Walter Ricciardi, who is the scientific adviser to Roberto Speranza, Italy’s minister of health, suggests Italy’s mortality rate is far higher because of demographics (elderly population) and the manner in which hospitals record the deaths. Prof Ricciardi says,
“The age of our patients in hospitals is substantially older – the median is 67, while in China it was 46,”
A study released this week in the Journal of the American Medical Association found that almost 40% of infections and 87% of deaths in Italy have been in patients aged over 70. According to modelling, the majority of this age group are likely to need critical hospital care, including 80% of 80+ individuals.
Italy’s death rate may also appear higher because of how doctors record fatalities. Prof Ricciardi has this to say.
“The way in which we code deaths in our country is very generous in the sense that all the people who die in hospitals with the coronavirus are deemed to be dying of the coronavirus.”
He continues to explain this with the following statement.
“On re-evaluation by the National Institute of Health, only 12 per cent of death certificates have shown a direct causality from coronavirus, while 88 per cent of patients who have died have at least one pre-morbidity – many had two or three.”
What does that mean exactly and why does it matter? These people contracted COVID19 and died. Unfortunately, it’s not that simple. Let me try and explain this through an example.
A man is involved in a car crash. He is hospitalised with severe injuries. Over the course of a few days, he develops sepsis as a result of a pre-existing condition, diabetes, and dies. The car crash was incidental to his death. Although it caused the initial injuries, it didn’t kill him. Sepsis did, resulting from his diabetes and will be recorded as the cause of death .
This is a hugely important distinction. Italy has been writing car-crash on all the death certificates.
Recording the numbers of those who die with Coronavirus will inflate the CFR as opposed to those that died from Coronavirus, which will reduce the CFR.
Case Specific Data
On the 17th March 2020, a report from the Italian National Institute of Health analysed 355 fatalities and found only three patients (0.8%) had no prior medical conditions whilst 99% who died had one pre-existing health condition.
- 49% had three or more health conditions
- 26% had two other conditions
- 25% had one
The most common problems amongst the 355 who died were
- 76% high blood pressure
- 36% diabetes
- 33% ischemic heart disease
Also the following data, stressing age.
- The average age of deceased and COVID19 positive patients was 79.5 years (median 80.5, range 31–103, InterQuartile – IQR 74.3–85.9).
- The median age of the patients who died was 15 years higher than that of patients who contracted the infection (median age: patients who died 80.5 years – patients with infection 63 years).
- Women who died after contracting COVID-19 infection were older than men (median ages: women 83.7 – men 79.5).
What does this mean in terms of Italy’s figures? Before we look at that, let’s examine one last instance of death associated with the COVID19 virus.
Cardio Vascular Disease
Why is cardiovascular disease (CVD) so prevalent in those who die with COVID-19?
Most acute viral infections have three short-term effects on the cardiovascular system:
- They increase the risk of acute coronary syndromes due to an inflammatory response
- Depression of the myocardium leads to worsening heart failure.
- The inflammatory process can expose heart arrhythmias
Seasonal flu has been shown to contribute to a significant increase in CVD related deaths. Community-level rises in Influenza-like illness. (ILI) are associated with and predictive of CVD mortality.
Clearly, association and causation matter when recording figures. A car crash or sepsis. What the Italian figures have shown is that it can be dangerous extrapolating data early on when we cannot account for variables.
In Italy’s case, we have been fortunate enough to have these variables emerge over the last few days, clarifying the data.
They explain the outlier, the high CFR figure and whilst Italy’s true CFR is indeed much lower than previously thought, that should in no way influence our global response or indicate reduced risk.
If you flood the health care system with elderly COVID19 patients who almost all require Intensive Care, it will take days, rather than weeks, for the healthcare system to be overwhelmed. To prevent this we need to slow the rate of infection, particularly in the most at-risk groups.
The virus is clearly deadly to those aged 75 and over. Whilst it may not be recorded as the eventual cause of death, it is the car crash waiting to happen.
What Italy’s figures do reveal with terrible clarity is just how deadly the virus can be to the elderly and at risk geoups. We need to protect them at all costs and ensure they are not unnecessarily exposed.
We need to all do our bit to buy our frontline staff the time they need to deal with new cases and ensure everyone has the benefit of treatment. It’s important to remember that high risk factors such as diabetes and high blood pressure affect not only the aged.
Stay indoors and stay safe.
For a detailed breakdown of risk factors and why men are more susceptible to COVID19 refers to this article.