COVID-19 then and now: 4 reasons why death rates are improving
SAN JOSE — The sickest coronavirus patients can live for weeks with a gripping headache, profound nausea, burning lungs, malaise, cough and waves of pain in their bones. They may be tethered to a breathing machine.
But eight months into the pandemic, fewer are dying.
New data reveals that while patients are still being rushed to intensive care units, a greater proportion are coming out alive. Since the pandemic began, the cumulative death rate for Californians with COVID-19 has fallen by more than half in the past three months. In early June, it was 5.87%; by Sept. 13, it was down to 2.14%. What’s going on? Some of the decline simply reflects a shift in testing, as infections in younger and healthier people are diagnosed. But that doesn’t explain all of it. There also have been fundamental improvements in how we prepare and care for the sickest patients, according to interviews with top medical experts.
“These declines in the case fatality ratios are striking,” said Dr. George Lemp, an epidemiologist and former director of the HIV/AIDS Research Program at UC’s Office of the President, who analyzed death rates using state data.
“We should applaud and appreciate the medical community for being able to find rapid ways to improve the outcome of this life-threatening illness,” he said.
Here are six major reasons why the death rate is falling:
More testing, younger patients
When the pandemic first hit, only people with severe symptoms were tested. Now expanded testing is detecting milder and earlier cases, so the prognosis is better, said UCSF epidemiologist Dr. George Rutherford.
We’re also diagnosing more infections in younger people, who fare better. Early on, we focused a lot of testing on outbreaks in nursing care facilities, where the sick and elderly face slimmer odds of survival. Now, fewer of this vulnerable population is getting sick.
As the patient mix has changed, so has the math, explained Rutherford. The denominator — the total number of cases — has grown faster than the numerator — total deaths. So the overall mortality rate is falling.
The declines have occurred across all age groups, during the fourmonth period between May and August 2020, according to Lemp’s analysis. This means everyone is doing better.
The phenomenon is driven by more than statistics, said Rutherford. “As we gain greater experience with novel infections, mortality goes down.”
Preparation
Hospitals cite “the four S’s” needed for effective “surge” planning: staff, supplies, space and systems. Managing a patient on a ventilator, in particular, is a labor-intensive and delicate task.
During a surge of cases, hospitals in Southern California fell short on all four of these metrics, nearly hitting capacity. Some patients were intubated in emergency rooms instead of the intensive care units. Hospitals were forced to use older equipment, as well as doctors and nurses from outside hospitals who were less familiar with procedures and life-saving devices.
In the San Francisco Bay Area, hospitals were better prepared. And this planning has improved, over time.
The death rates of the regions are a study in contrast. For example, Los Angeles reports 57 deaths per 100,000 residents, while San Francisco has only one-tenth as many, with about 6 deaths per 100,000 residents, according to data presented at UCSF’s Grand Rounds last week.
Improved use of ventilators
Doctors now have a better understanding of how to manage breathing in severely ill patients, said Dr. Andra Blomkalns, chair of the Department of Emergency Medicine at Stanford Medicine.
Initially seen as a lastditch measure — and a sign of impending death — doctors now recognize the value of putting people on mechanical ventilation early, if needed, she said.
“We used to say ‘someone doesn’t quite need it yet, let’s see how they do in the hospital.’ That hasn’t worked well,” she said. “We’ve resolved that if they have to be on it, it’s better to put them on it earlier rather than wait until too late.”
We’ve also gotten better at fine-tuning ventilation, understanding the optimal amount of oxygen, pressure and time between breaths, she said. We’ve learned to be very gentle on the lungs.
Sharing of information
Clinicians aren’t waiting to get their news through formal channels; instead, they’re talking to each other, in hospital Grand Rounds and other forums. There’s more communication and collaboration, said Stanford’s Blomkalns.
“Initially, everything was rumor,” said El Camino’s Chausow. “Now we’re practicing more evidence-based medicine.”
“It’s a tough, tough disease, which nobody thinks will go away. It will be a part of our lives, long term,” he said. “So getting answers will really involve good data.”
The best way to reduce death, he said, is to prevent infection altogether, through mask-wearing and social distancing.
“The goal is to not get sick in the first place,” he said. “We save more lives by keeping people out of the ICU.”