Tueday, 31 March 2020, marked exactly three months since the World Health Organization, the Chinese office, was notified of incidences of pneumonia from an unknown cause. According to specialists from the Robert Koch Institute in Germany, we have not yet reached the peak of the pandemic in Europe. We hear about mild and asymptomatic cases, but also about many deaths globally.
We all wonder about our risk of getting infected with the new coronavirus, but especially about the risk of dying from this infection. There is much discussion and literature in the media about mortality, particularly with reference to a marker called “case fatality rate”, which represents the ratio between the number of deaths and the total number of diagnosed individuals.
What do the statistics say?
At the time I write this article, according to statistics provided by Johns Hopkins University in the USA, the worldwide case fatality rate for COVID-19 is 5.04%, with large differences between nations. But this measure has many shortcomings.
First, it is not a specific biological constant of the virus, but rather a reflection of the severity of a disease in a certain context, in a certain area, at a certain time and in a certain population. There may be weeks from the first symptoms of a patient to their death. Therefore, from a statistical point of view, the case fatality rate may easily be underestimated.
Second, the marker is most likely overestimated. The main explanation lies in the fact that many countries do not test patients for COVID-19 except under certain strict conditions and the testing differs from one country to another. This is why many asymptomatic or mild cases do not appear in the statistics, which leads to an overestimated fatality rate.
Third, the probability that a patient infected with COVID-19 will die depends on the medical services they can benefit from and the individual’s ability to survive the disease.
Therefore, at this time we should not rely on the case fatality rate, except for comparisons between countries, this marker being rather relevant at the end of the pandemic and where testing has been widely available. Any statistical comparison at this time with other pandemics or epidemics is premature and leads to the wrong conclusions.
Who is more at risk?
The data we have from China and Europe suggest that the elderly population – those over 65 and especially over 80, more so where comorbidities are present – has no higher risk of infection than the rest of the population, but has a higher risk developing a severe case of the disease once infected.
Epidemiological studies conducted in Italy after the first approximately 6,800 deaths, out of over 13,000 at the time of writing this article, show that the average age of deceased persons is 78 years, with a net differentiation between men and women from 70% to 30%.
The World Health Organization issues a warning through the voice of Director General Tedros Adhanom Ghebreyesus. “I have a message for young people: You are not invincible! The virus can hospitalize you for weeks or can even kill you.”
The associated pathologies (comorbidities) present in the deceased, in their frequency order, were: high blood pressure (73%), diabetes, ischemic heart disease, atrial fibrillation, chronic renal failure, active cancer during the last 5 years, chronic obstructive pulmonary disease, dementia and history of stroke.
Another extremely important thing is that 50.7% of the deceased had 3 or more pre-existing conditions, 25.9% had 2 conditions and 21.3% a single pathology.
A statistic that takes into account the age of the deceased shows that up to the age of 60, the fatality rate is at maximum of 1.3%, with no deaths under the age of 10.
COVID-19 in young people
Even if the deaths among young people or adults in general are much lower, the World Health Organization issues a warning through the voice of Director General Tedros Adhanom Ghebreyesus. “I have a message for young people: You are not invincible! The virus can hospitalize you for weeks or can even kill you.”
This is due to the fact that the disease pathology manifested in elderly patients tends show more and more among young people too, due to risk factors such as smoking. Currently, in Romania, the youngest deceased patient is a woman aged 27, with decompensated type I diabetes.
Other possible risk factors
In recent weeks, various assumptions have been made regarding drugs that may increase the risk of worsening the COVID-19 infection, such as non-steroidal anti-inflammatory drugs and antihypertensive drugs in the class of conversion enzyme inhibitors and sartans. Although these assumptions have been refuted on account of lack of sufficient data, it is well known that the use of non-steroidal anti-inflammatory drugs is not recommended without the advice of a doctor for cold or flu symptoms. For flu or cold symptoms, paracetamol is considered suitable.
There are studies that sound an alarm about vitamin D deficiency, immune status and severity of respiratory manifestations, particularly acute respiratory distress syndrome. Vitamin D supplementation thus becomes necessary for people with proven deficiency, all the more since most people are quarantined, with limited sun exposure.
In the end, it is good to remember that the risk of becoming infected with COVID-19 grows the more we expose ourselves to the infection during this time. Personal hygiene and social distancing remain essential. The risk of developing a severe case is strongly linked to individual risk factors (such as age, sex, associated pathologies).
Bogdan Popa, MD, is an Internal Medicine and Gastroenterology Medical Specialist.