June 2020 - News Granularity

Although it is appropriate that almost all the news about Covid 19 is about new cases, and the second wave, there is not much said about how the covid 19 policies that limit medical treatment are effecting the population. The short answer is that there is likely to be a very large consequence for not going to the doctor for checkups, diagnostics and elective surgeries. It is estimated that, between March and June, more than 80,000 cases of the five most common cancers in the US will not be diagnosed because of covid 19 disruptions in elective treatments. Screenings or breast, prostate, colorectal, cervical and lung cancer were down 39-90% during the week ending on April 10. The delay in diagnosis and treatment can result in as many as 34,000 excess deaths due to cancer in the US.

Additionally, the number of admissions to oncology outpatient clinical have decreased up to 50%. It is expected that the majority of the cancers not diagnosed will be breast cancers.

Cancer screenings generally take place in a doctor’s office or at diagnostic centers run by larger health systems. However, there has been great variability system to system, state to state on how these facilities have responded to cancer screenings due to covid 19. Some have simply closed, while others open for ‘emergencies’ only.

Cancer patients may be longer term, and somewhat hidden consequence of covid 19. This is a lot of people not getting cancer diagnoses.

In a more general sense, it is estimated that there will be 28 million who will have had their surgeries cancelled because of covid 19. The long term health consequences of delaying these surgeries is yet to be determined. This corresponds to over 70% of all elective surgeries being cancelled. Of these surgeries, an estimated 2 million will be cancer related surgeries. Elective surgeries have an extraordinary influence on hospital revenues. In many large hospitals, elective surgeries account for nearly 50% of the revenue. The loss of elective surgeries deprives hospitals of their largest source of income.

In the UK, it is estimate that over 40,000 surgeries are cancelled each week elective surgeries are not allowed. It could take well over a year to catch up on the backlog of surgeries.

It is estimated that there has been up to a 70% decrease in patient visits to doctors from February through April. In the past month, this has rebounded to the level where there are 30% fewer visits to the doctor than in February.

The moratorium on elective procedures jeopardizes the financial integrity of health care systems that are disproportionately reliant on elective procedures as a revenue source. In response, the U.S. Congress passed the Coronavirus Aid, Relief, and Economic Security Act (CARES), a $2.2 trillion bill with $100 billion designated to hospitals and $350 billion designated to small businesses including private orthopedic practices . Although these relief programs may alleviate some of the economic burden, the legislation is not comprehensive, and it will not resolve all financial losses accrued by health care systems and orthopedic practices. Without the revenue from elective procedures, many orthopedic practices have had to furlough employees and withhold surgeon salaries. Mayo Clinic has announced a projected $900 million shortfall, with employee pay adjustments and furloughs .

There are so many things happening around the country that covid 19 has almost gotten lost in the news. This is the latest update on the statistics.

The news headlines may be somewhat misleading. There are many headlines that reporting an increase number of covid 19 cases. However, the question is, how do we interpret these numbers? What numbers are indications of trouble to come and what numbers suggest that we are on the road to recovery?

The main headline has been that on Jun 12, 21 states reported an increase in the number of covid 19 cases. However, a more granular look at the data provides some better insight.

Recall that the main reasons for a lockdown and stay-at-home orders were to minimize deaths and not to overflow hospital capacity. The purpose was never to simply reduce the number of cases.

A reminder that at the peak of the Covid 19 infections in April, there were no hospitals that were overly full. In fact, extra hospital beds provided by the USN Comfort in NY, USN Mercy in Los Angeles and thousands of temporary hospital beds in New York, New Orleans and other cities were not utilized.

Further, in March and April that were predictions that said that we would be short on ventilators and that several thousand more would be needed. These predictions turned out to be untrue. There was never a ventilator shortage anywhere.

Not everyone will get infected.

A seldom reported experience is that some people appear to be immune to the covid 19. This is seen on people who have been isolated on cruise ships and military carriers. It appears on the cruise ships between 50-70% of the people get infected, the rest do not. On a French aircraft carrier, 60% of the sailors got infected. However, there were no deaths and only of the 1074 infected sailors required hospital type care. https://Berenson, Alex. Unreported Truths about COVID-19 and Lockdowns: Part 1: Introduction and Death Counts and Estimates . Kindle Edition.

Who is dying from covid 19?

In a previous blog, it was reported that 42% of all covid 19 deaths occurred in nursing homes. However, deaths can also be analyzed as function of age. World wide, median age of people who died from covid 19 is 81 years old. That is, half of the people who died who died from covid were 81 years old or older.42% of covid 19 deaths were in nursing homes and assisted living facilities

In New York, as of May 28, almost 40 percent of the 23,700 reported deaths occurred in people over 80. (https://covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=n)

In Minnesota, the median age of the 1,000 COVID deaths is almost 84. More people over 100 have died than under 50.http://(https://www.health.state.mn.us/diseases/coronavirus/stats/covidweekly22.pdf)

The flip side of the risk to the elderly is that younger adults and especially teenagers and children are at extremely low risk from SARS-COV-2. In Italy, a total of 17 people under 30 have died of the coronavirus. In the United Kingdom, four people under 15 have died. In New York, 14 under 20 and 102 under 30. Worldwide, it is almost certain that more people over the age of 100 than under 30 have died of SARS-COV-2. Many more children die of influenza than coronavirus; in the 2019-20 flu season, the Centers for Disease Control received about 180 reports of pediatric flu deaths. It has received 19 reports of coronavirus deaths in children under 15 so far.

How to interpret increasing number of cases.

There were no patients that were denied access to medical care or ventilators due to overcrowding.

It is difficult to interpret reports simply on the number of covid cases. This is because each area has a different and changing number of tests being run. In general, there are more tests being run each day than the day before. This alone could account for the increase in the number of cases. For this reason, a better assessment of our ability to cope with covid 19 cases are the hospitalizations (number of people sick enough to need hospital care) and the number of covid 19 caused deaths.

Questions you should ask yourselves when reading about covid 19 statistics, especially number of cases.

Where are the increases in cases occurring? In isolated, bounded areas or are they evenly distributed. Recall from earlier blogs that 42% of all covid fatalities occurred in nursing homes. Also, in each state there were just a few counties that accounted for well over half to two thirds of the number of cases is the state. Am I in area where there are lot of cases?
Who is getting infected? Especially, what age group? We now know that the vast majority of fatalities were in people over the age of 70 with pre existing conditions. The fatality rate of people under is not higher than many other diseases and causes of deaths.
It has been over a month since protests involving thousands of people that were not practicing social distancing and/or wear masks. Are any increases in cases due to this?
Are the number of hospitalizations going up so fast that the hospitals can’t handle the number of patients?
Is the fatality rate going up or down?

CONTINUE TO KEEP SOCIAL DISTANCING WHEN POSSIBLE.WEAR A MASK IF YOU ARE IN A CROWD.STAY HOME IF YOU DON’T FEEL WELL.

The headlines are that on Jun 12, 21 states reported increases in covid 19 deaths, but only 9 of these reported increased hospitalizations. Further, in general the number of total US deaths is decreasing. As seen in the chart below:

It is also important to note that it has been over 2 weeks since the first protests involving thousands of people who were not social distancing and many were not wearing masks masks. To date, there has been no increase in hospitalizations or deaths in any areas where these protests took place (Minneapolis, New York, DC etc.) This is yet another indication that covid infctions are depending on location, age and other factors – stay-at-home and lockdowns effectiveness is being questioned more and more.

I have provided from three states for discussion, California, Texas and Florida.

From the chart below, it appears that the number of cases has increase in past week.

CALIFORNIA

However, the following chart shows that the number of deaths has NOT increased during this same time period and remained more or less unchanged for weeks. The number of hospitalizations has NOT increased with the increasing number of new cases.

It is also reminded that the cases in Calfirornia are very location dependent. Of the 150,267 cases reported in Ca, 72,023 have occurred in Los Angeles (48%). Of the 5062 covid 19 fatalities in Ca, 2890 have occurred in Los Angeles (57%). The county with the second number of fatalities is Riverside with 383 deaths. It very much makes a difference where you live.

NEW YORK. New York has received the most attention throughout the covid 19 crisis because it leads the nation as the state with the most cases and the most deaths. However, the following charts show that there has been a dramatic decreases in both cases and deaths for New York.

TEXAS. Similar to Ca, the number of cases in Texas has increased but the number of deaths has not. There has been an increase in hospitalizations for Texas, but they are well under their maximum number of beds available. There were over 2000 covid 19 hospitalizations in the past 2 weeks but there are over 31,000 hospital beds in the states. There is substantial hospital space in Texas so time will tell if the number of serious cases continues to rise. It is a very good sign that the number of deaths has not increased during this same time period.

Similarly, Florida reported the highest single day number of new cases, 2500. However, the number of deaths did not increase correspondingly, More importantly, there was not a signficant increase in hospitalizations.