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CMAAO Coronavirus Facts and Myth Buster 101 Why Do Countries COVID-19 Death Rates Vary So Much? |
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CMAAO Coronavirus Facts and Myth Buster 101 Why Do Countries COVID-19 Death Rates Vary So Much?

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Why Do Countries COVID-19 Death Rates Vary So Much?

European countries have the highest infection and death rates, while Asian countries have considerably lower rates, and Canada falls between Asia and the U.S.

Infected people in the U.S. are 500 times more likely to die in comparison with Singapore; the data is too serious to be ignored.

Death rates as on 8th May: World: 6.9%; Europe: 9.6%; North America: 6 %; Asia 3.4%; South America: 5.1%; Africa: 3.8%; Oceania: 1.4% and deaths per Million Population: USA: 232; Spain: 558; World: 34; India: 2

On 15th may: Case fatality: USA 6%; Switzerland 6%; Sweden 12.4%; Belgium 16.3%; Spain 11.8%; France 15%; Germany 4.4%; Italy 13.9%; Netherland 12.8%; Canada 6.9%; UK 14.7%; Hong Kong 0.4%; Singapore 0.1%; South Korea 2.4%; Taiwan 1.4%; China 5.6% and Japan 3.8%.

What really explains these stark differences?

Multiple factors are at play: testing capacity, case definitions, age distribution, preparedness

  1. The extent of testing:Since the outbreak in January this year, testing has been widely available in Asia. Germany, the country with the lowest mortality rate, also initiated early testing. A lack of testing would lead to underestimation of cases and deaths, but countries that have been better able to control the outbreak ensured wide access to testing. It does not appear that extensive testing makes the epidemic look worse by finding more people with minor or no symptoms. Infection rates are low in Asian countries and high in the U.S. and Spain where testing was less available. However, in India with testing only of symptomatic and high-risk cases, the case fatality remains < 3.5%.
  2. Countries define and report COVID-19-related deaths differently, and the methods have changed over time. In the early phases of the epidemic in China, the initial few versions of case definition stated that up to six criteria needed to be fulfilled, which possibly led to an underestimation of cases by five-fold. As of April 14, 2020, the new CDC guidelines include counting both confirmed and probable cases, depending on doctors judgment based on symptoms and contact history. Additionally, attributing cause of death to COVID-19 seems to vary by country, especially since most of these deaths occur in people with chronic illnesses. Some countries are not including deaths due to MI, embolism, etc., as COVID deaths.  However, this can make a difference of only 5% as evident by cases on 12 Febraury when China included the clinical CT diagnosed criteria.
  3. Demographics: In Hong Kong, 60% of cases were attributed to incoming travelers, primarily constituting returning students and expatriates. In Singapore, outbreaks in foreign worker dormitories amount to 80% of cases, while community cases only account for 10%. These younger populations are relatively healthy and may contribute to overall lower mortality rates. In European countries such as France and Italy, and in the U.S., community outbreaks in nursing homes and long-term care facilities have contributed to higher infection and mortality rates among the elderly. It does not explain; however, why in Japan with very high elderly population, the morality remains 3.8%.
  4. Density of population: India: In states with average population density of 1185/sq km, the average number of cases were 2048. On the contrary, in states with population density of 909/sq km, the number of cases were 56. When Chandigarh and Pondicherry were taken out from this group, the Average Density of other states were 217 and the average number of cases were 35. [HCFI]
  5. BCG vaccination: Countries that do not have a BCG vaccination policy in place seem to have ten times greater incidence of and mortality from COVID-19, compared to the countries that have the policy in place, as per a forthcoming study from medical researchers in the US and UK, analyzing data from 178 countries. The study assessed COVID-19 instances and mortality for 15 days from 9 to 24 March across 178 countries and concluded that the incidence of COVID-19 was 38.4 per million in countries with BCG vaccination compared to 358.4 per million in countries without such a program. The death rate was 4.28/million in countries with BCG programs compared to 40/million in countries without such a program. Among the 178 countries studied, 21 had no vaccination program, while the status was unclear in 26 countries. 
  6. A report titled MMR Vaccine Appears to Confer Strong Protection from COVID-19: Few Deaths from SARS-CoV-2 in Highly Vaccinated Populationshas underscored how children and most adults below 50 are likely protected from COVID-19 because of the rubella component of common MMR vaccinations. Some young children with a rare condition - Kawasaki disease - are; however, facing severe COVID-19 complications which could be related to a relationship between MMR vaccines and COVID-19.

There is a large amount of data suggesting that the rubella component of MMR vaccines protects most children from COVID-19. However, if a child has a genetic predisposition to Kawasaki disease, they may not be protected since Kawasaki disease is known to decrease the responsiveness of MMR vaccinations.

  1. Countries also differ in the capacity of their healthcare systems to handle a rapidly spreading epidemic.When a spike in the number of patients overwhelms the healthcare systems capacity, mortality rates are bound to shoot up. Countries with best of the ICU care will have lower mortality rates. But as on today, there are only 2% of the patients who are serious, and this would only make 0.3% difference in the case fatality rate. And also, the case fatality in Europe and North America with very high level of intensive care is the highest.
  2. Robust preparedness and response strategies: Death rates were lower in countries and regions with standing plans for containing the infection. For instance, Singapore, Hong Kong, China, and Canada had fought the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003. That led them to develop national strategies to build capacity, preparedness, coordination, and communication in preparation for the next outbreak. The SARS experience also gave way to a higher level of public acceptance and adherence to masking and social distancing measures. Amongst CMAAO countries, India has done worse as it had never faced SARS-like illness before.
  3. Negative isolation rooms and timely RT PCR report: A negative-pressure AII room is meant to isolate a patient who is suspected of, or has been diagnosed with, an airborne infectious disease. The aim is to help prevent the spread of a disease from an infected patient to others in the hospital.

Negative-pressure isolation rooms should have minimum 12 air changes of exhaust per hour and must maintain a minimum 0.01-inch WC negative-pressure differential to the adjacent corridor, irrespective of the usage of an anteroom. A setpoint close to minus 0.03-inch WC is employed. When an infectious patient is not there, the room may be occupied by non-infectious patients. The negative-pressure relationship to the corridor must be upheld; however, it is not necessary to be maintained at the minimum of minus 0.01-inch WC.   

All SARS and MERS affected countries had enough and mandatory AII rooms in their hospitals. All the patients in the triage room are in kept in the ER AII room. The RT PCR report is available in three hours and then the patient is shifted to a COVID or NON COVID facility accordingly. South Korea this time expanded their AII room numbers in five days.

  1. Culture:Most Asian countries - Japan, India, China, South Korea, etc. - have a culture of Namaste or bowing. This might have been the protective factor in human to human transmission. The burka, nakab wearing in Islam may be protective in Arabian countries. In cult communities, the mortality and number of cases would have been half if the cultural practices of South Korean Church and JAMATIS in India would have cooperated in the virus spreading management. These communities do not believe in masking, isolation and treatment. Also, culture of not putting elderly in the nursing homes in the Asian countries has also helped. In US and Europe, nursing home inhabitants had high mortality rates.
  2. The virus behaves in seven different ways and these responses may differ from country to country with variable mortalities.
  3. It’s a viral self-limiting disease
  4. It caused immune inflammation (high ESR, CRP and ferritin)
  5. It causes bacteria like activity (responds to antibiotics and severe cases have high procalcitonin levels)
  6. It causes thrombi inflammation (high D Dimer with high fibrinogen levels).
  7. It causes cytokine storm like influenza.
  8. It has HIV like activity, attacks CD4 and T cells and causes low lymphocytes counts.
  9. Walking dead: with severe silent hypoxia without damage to the lungs and retained consciousness levels. 

For example, severe inflammatory disease among infants who are arriving in hospital with high fevers and swollen arteries.

(Excerpts from: Medpage Today; Economic Times; GlobeNewswire)

Total cases and deaths across the world 

 #

Country,

Other

Total

Cases

New

Cases

Total

Deaths

New

Deaths

Total

Recovered

Active

Cases

Serious,

Critical

Tot Cases/

1M pop

Deaths/

1M pop

Total

Tests

Tests/

1M pop

Population

 

Asia

778,081

+20,157

24,302

+339

445,644

308,135

4,941

     

3

India

90,648

+4,864

2,871

+118

34,224

53,553

 

66

2

2,134,277

1,548

1,378,307,692

4

China

82,941

+8

4,633

 

78,219

89

11

58

3

  

1,439,323,776

6

Pakistan

38,799

+1,581

834

+31

10,880

27,085

111

176

4

359,264

1,631

220,333,311

8

Singapore

27,356

+465

22

+1

8,342

18,992

16

4,681

4

224,262

38,371

5,844,637

10

Bangladesh

20,995

+930

314

+16

4,117

16,564

1

128

2

167,114

1,016

164,484,082

11

Indonesia

17,025

+529

1,089

+13

3,911

12,025

 

62

4

182,818

669

273,160,748

13

Japan

16,237

+34

725

+12

10,338

5,174

232

128

6

240,368

1,900

126,522,222

15

Philippines

12,305

+214

817

+11

2,561

8,927

79

112

7

215,060

1,966

109,395,919

16

S. Korea

11,037

+19

262

+2

9,851

924

55

215

5

741,145

14,457

51,263,879

17

Malaysia

6,872

+17

113

+1

5,512

1,247

13

213

3

434,136

13,435

32,313,467

25

Thailand

3,025

 

56

 

2,855

114

61

43

0.8

286,008

4,099

69,778,764

30

Hong Kong

1,053

 

4

 

1,022

27

1

141

0.5

168,291

22,470

7,489,431

31

Sri Lanka

957

+22

9

 

520

428

1

45

0.4

42,056

1,965

21,402,294

36

Taiwan

440

 

7

 

389

44

 

18

0.3

68,988

2,897

23,811,570

38

Vietnam

318

+4

  

260

58

2

3

 

275,000

2,828

97,229,451

39

Nepal

281

+14

1

+1

36

244

 

10

0.03

92,440

3,180

29,068,924

40

Myanmar

182

+1

6

 

96

80

 

3

0.1

13,634

251

54,364,802

44

Cambodia

122

   

122

0

 

7

 

14,684

880

16,689,523

 

#

Country,

Other

Total

Cases

New

Cases

Total

Deaths

New

Deaths

Total

Recovered

Active

Cases

Serious,

Critical

Tot Cases/

1M pop

Deaths/

1M pop

Total

Tests

Tests/

1M pop

Population

 

Europe

1,761,355

+20,226

161,672

+1,190

755,525

844,158

11,757

     

1

Spain

276,505

+2,138

27,563

+104

192,253

56,689

1,208

5,914

590

3,037,840

64,977

46,752,605

2

Russia

272,043

+9,200

2,537

+119

63,166

206,340

2,300

1,864

17

6,656,340

45,614

145,926,952

3

UK

240,161

+3,450

34,466

+468

N/A

N/A

1,559

3,540

508

2,489,563

36,696

67,842,296

4

Italy

224,760

+875

31,763

+153

122,810

70,187

775

3,717

525

2,944,859

48,698

60,472,408

5

France

179,365

 

27,625

+96

61,066

90,674

2,132

2,749

423

1,384,633

21,218

65,256,039

6

Germany

176,247

+548

8,027

+26

152,600

15,620

1,203

2,104

96

3,147,771

37,585

83,751,395

7

Belgium

54,989

+345

9,005

+46

14,460

31,524

364

4,747

777

663,755

57,302

11,583,464

8

Netherlands

43,870

+189

5,670

+27

N/A

N/A

346

2,561

331

287,943

16,809

17,130,286

9

Switzerland

30,572

+58

1,879

+1

27,400

1,293

69

3,536

217

339,364

39,247

8,646,793

10

Sweden

29,677

+470

3,674

+28

4,971

21,032

278

2,941

364

177,500

17,589

10,091,512

11

Portugal

28,810

+227

1,203

+13

3,822

23,785

115

2,824

118

600,061

58,828

10,200,225

 

Total:

1,761,355

+20,226

161,672

+1,190

755,525

844,158

11,757

     

 

#

Country,

Other

Total

Cases

New

Cases

Total

Deaths

New

Deaths

Total

Recovered

Active

Cases

Serious,

Critical

Tot Cases/

1M pop

Deaths/

1M pop

Total

Tests

Tests/

1M pop

Population

 

North America

1,660,308

+28,140

101,662

+1,641

421,214

1,137,432

17,398

     

1

USA

1,507,773

+23,488

90,113

+1,218

339,232

1,078,428

16,248

4,558

272

11,949,625

36,127

330,764,077

2

Canada

75,864

+1,251

5,679

+117

37,819

32,366

502

2,012

151

1,265,502

33,567

37,700,962

 

Dr KK Aggarwal

 President CMAAO, HCFI, Past National President IMA, Chief Editor Medtalks

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