Data from Italy suggests that covid-19 deaths are being undercounted there too

Even for physicians, determining a cause of death can be challenging. A patient's medical conditions may not be known to the doctor who pronounced the patient deceased. A patient arriving at a hospital may be unable to communicate or may not be accompanied by family who can provide sufficient information. Even when a patient's medical conditions are known, it can be difficult to identify the single major cause among multiple potential contributing causes of death. In the case of an emerging disease, such as the early phase of a pandemic like covid-19, necessary diagnostic tests may not be available, leading to undercounts. In some cases, deaths may have occurred before a new illness had been recognized as a distinct entity. Once recognized, older death records may not be re-analyzed to reflect updated knowledge.

In light of this, the authors of a new study in JAMA Internal Medicine set out to determine whether the initial death counts reported in Lombardy, Italy fully reflected the mortality from covid-19. The investigators compared mortality estimates provided by Italy's National Health Authority with mortalities reported by municipalities to Italy's National Institute of Statistics. The authors report that the official count of covid-19 reported deaths in Italy as of April 30, 2020 was 27,682 but the overall increase in deaths as compared to the average number of deaths tallied by municipalities during that same time period from 2015 to 2019 was 41,329, leaving a surge of 13,647 unexplained deaths. Both data sets demonstrated higher mortality in men older than 65 than in any other age group. The authors did not report the year-to-year variation in deaths from either of the two sources. However, a visual estimation from a figure in the paper suggests a normal fluctuation of about 300 deaths per year in reports from the municipalities, far lower than the 13,647 reported during the study period of 2020.

This is a promising first step in better understanding of the death and disability wrought by covid-19. These two sources compare all deaths with deaths thought to be due to coronavirus. It would be informative to investigate what the stated causes of death in the unexplained 13,647 deaths were. Unfortunately, that information was not provided in the study. It is also important to distinguish between deaths directly due to coronavirus from deaths where coronavirus was thought to have contributed in part to the death. (The US Centers for Disease Control and Prevention reckons these as two separate statistics).

Nor is death the only outcome of concern. The long-term health effects to patients who have survived SARS-CoV-2 infection are just now beginning to be discussed by medical experts. It will be months if not years before these burdens are fully accounted for in our understanding of the impact of this disease.


CDC in the news. Three major developments

The United States Centers for Disease Control and Prevention (CDC) has been featured heavily in the news for its evolving role during the pandemic. Early on there were well-documented missteps, relating to testing errors, and inconsistent messaging. Three major recent developments are noteworthy and will be discussed here.

First, and most concerning, the White House announced last week that all data collected by hospitals related to coronavirus cases should now be sent directly to a system maintained by the US Department of Health and Human Services (HHS), bypassing the CDC. This policy has implications for data transparency that immediately worried experts. After the announcement was made last week, many state and local health entities claimed they no longer had access to aggregated data that had been made available by the CDC. There are also reports of hospitals having difficulties submitting newly acquired data to the CDC's system, run by the National Healthcare Safety Network (NHSN), making population-level health decisions and threat assessment more difficult. Back in March, Brief19 was the first media source to report on the creation of a nationwide reporting system run by the NHSN. Thousands of hospitals participated voluntarily. The system tracks case counts in hospitals as well as a number of other statistics, including the number of available hospital and ICU beds, information on the number of mechanical ventilators were in use, and data regarding emergency department overflow.

Separately, the CDC reported a delay in the release of its updated school reopening guidelines.  While previously stating that recommendations would be made available by the end of last week, new tensions between the agency and the White House's drive for full reopening in the Fall has slowed the process. The CDC has said that the guidelines will be science and evidence-based recommendations with a goal of safely opening schools. President Trump called the circulating drafts "too tough" and Vice President Pence said the report should not be used as a reason to keep schools closed.  The current timeline for the release of updated guidelines is projected for the end of the month.

Finally, in an effort to reduce the strain on limited supplies of test swabs, the CDC is finalizing recommendations on repeat testing, specifically emphasizing the avoidance of routine follow-up testing after quarantine (and before returning to work) of otherwise healthy individuals. Various.

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