Ask Dr. Halverson: Changing demographics, better treatments and care improve mortality rates

web 4 17 Halverson photo
By Dr. Jim Halverson
Healthcare workers are now seeing unprecedented increases in COVID-19 diagnoses and hospitalizations.
However, there has not been a similar rise in mortality rates even as case counts set records. In fact, the COVID-19 mortality rate in the United States has fallen since the start of the pandemic. That decline has no single, clear explanation. Experts have pointed to a host of contributing factors, including a higher proportion of cases among the young, better therapies, increased knowledge of how to treat COVID patients and less overcrowding in hospitals.


1. Changing demographics
Currently, 25- to 44-year-olds have the highest incidence of COVID-19 in the United States. This is well illustrated by the statistics in Ventura County. Of the 18,394 reported cases of COVID-19, 6,550 (35.6%) have occurred in this age group. This is a shift from the start of the pandemic, when it was older adults who experienced the highest number of infections. The Centers for Disease Control reported that the median age of infected patients dropped from 46 in May to 38 in August.
Some experts believe that this shift in infections, toward younger people, is the primary explanation for the drop in mortality. Recent data indicate that the age-specific infection fatality rate was extremely low among children and young adults, measuring 0.002% at age 10 and 0.01% at age 25. However, the rate progressively increased with age, growing from 0.4% at age 55 to around 15% at age 85.
“When you compare the fatality rate among people in their 20s and 30s to those in their 70s and 80s, it is truly an order of magnitude difference,” said Jeremy Faust, M.D., and emergency physician at Brigham and Women’s Hospital in Boston. “Small changes in the demographics can make huge differences in mortality.”


2. Better treatments
Studies show that mortality has decreased among older patients, too. In a cohort of more than 5,000 hospitalized COVID-19 patients at New York University, researchers found that mortality rates dropped 18 percentage points from the start of the pandemic, falling from 26% in March to 8% in August.
Christopher Petrilli, M.D., a hospitalist at NYU Langone stated that even after adjusting for age differences, there was a considerable reduction in COVID deaths. “When we ran our statistical models, it was very clear that mortality declined over time and pretty significantly, even when you controlled for demographic data, chronic conditions and how patients presented initially based on vital signs and laboratory values.”
Lower death rates in older groups exemplify how much better doctors have gotten at treating COVID-19. Mangala Narashim, D.O., a critical care specialist from Northwell Health in New York, said that more knowledge about how to treat these patients is a critical reason why the death rates have decreased within her health system. “We have a standardized approach to these patients now. When patients are admitted to the hospital, it is easier to decide when to start them on steroids or administer remdesivir, as opposed to the beginning of the pandemic when doctors had to make educated guesses about what treatments might have some benefit.”
Steroids, in particular, have become much more widely used when clinical trial results showed that they slashed deaths by a third in patients on mechanical ventilation, and by a fifth for those on supplemental oxygen.


3. Better care
New medications may have helped, but probably aren’t the main drivers in the increase in survival rates. Physicians understand COVID-19 better now. Dr. Patrick E. Jackson, an infectious disease and international health specialist at University of Virginia Health, said he thinks the drop in mortality has been more due to supportive therapies rather than specific treatments. This includes using masks and high-flow oxygen to provide patients with higher concentrations of oxygen and using nonmechanical ventilation instead of putting them on a ventilator. “We can provide them with ventilation without putting a tube in their throat, by putting a mask over the nose and mouth.” In addition, lying patients in the prone position has also helped keep them from being put on a ventilator.
“COVID-19 patients in the hospital often get sick very rapidly,” said Jackson. “So just the clinical familiarity with the disease has allowed us to intervene more rapidly and know when patients are going to do OK and know when they need more aggressive intervention.”


4. Difficult months ahead
As cases continue to rise across the country, experts worry that the pandemic will still result in high absolute death tolls among all age groups.
Although age-specific mortality rate for young people is relatively low, they still suffered many excess deaths this year. Faust, the emergency physician from Boston, and colleagues authored a study showing that COVID-19 was likely the leading cause of death so far this year in people between the ages of 25 and 44. 
“You certainly want to protect the elderly because they are at such higher risk,” Faust said. “But the alternative is not to let the virus roam free among the young, because that’s when you see this huge increase in deaths that we didn’t expect.”
Petrilli said it is correct to say that certain patients are at higher risk than others, including the elderly, those with chronic medical conditions and pregnant women. “But that doesn’t mean that the patients who are not in those categories are at low risk. It just means that they are not at as high a risk.”
Until the majority of the U.S. population has access to a vaccine, Petrilli said it is essential to continue social-distancing and mask-wearing. In addition to lessening your chance of catching the coronavirus, these measures reduce the viral inoculum that an individual may receive, and thus illnesses may be less severe. “This virus didn’t change,” Petrilli said, warning that it is still “incredibly contagious,” and COVID-19 has a much worse death rate than the flu. 
“It’s going to be a long road,” Petrilli added. “While it’s good news that the mortality rate is down, the reason that it is down is because everyone is doing a good job with mask-wearing and distancing. We just need to keep it up.”
We continue to do well in the Ojai Valley thanks to all of you. A vaccine will be approved this month and should be available to all by late spring. We all need to continue the preventative guidelines. Stay committed, stay well informed, stay positive, stay safe, and stay well.


— Dr. Jim Halverson is a longtime Ojai physician who writes a weekly column on COVID-19 for the Ojai Valley News.


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