Why have so many coronavirus patients died in Italy? | Hacker News Reader

Why have so many coronavirus patients died in Italy?

telegraph.co.uk

39 pointsAngeloAnolin58 comments

"But there are other factors that may have contributed to Italy’s fatality rates, experts say. This includes a high rate of smoking and pollution - the majority of deaths have been in the northern region Lombardy region, which is notorious for poor air quality."

This was also the case in china, but the age structure is different:

"A study in JAMA this week found that almost 40 per cent of infections and 87 per cent of deaths in the country have been in patients over 70 years old."

"An older population skew within the infected population explains most of the disparity in fatality rates between high and low countries. According to a study of the fatalities of COVID-19 cases in Italy, 99% of all deaths had an underlying pathology. Only 0.8% had no underlying condition."

Seems like a perfect storm for the elderly in italy who smoke a lot and most of them having an underlying condition like cardiovascular disease or diabetes II.

Couldn't worse air and more smoking in Wuhan lead to the same numbers? Worse conditions in Wuhan: more people needing hospitalization (young and old) the young recover, and get counted as recovered. Meanwhile in Italy, better air means only the very weak show severe symptoms, are tested, counted as infected, and their prospects are worse.

Age is an independent risk factor, and richer countries' populations skew older. More old people means more deaths. Assuming similar environmental conditions and infection rates, Italy will see more critical cases purely as a function of population age.

Lots of people over 40 have at last some mild health issues, over 60 almost everyone. Even younger people often enough have conditions they're not even aware of. So just wanted to say, don't get overly relaxed by these stats.

> Even younger people often enough have conditions they're not even aware of.

True and more complicated than that sounds. I was diagnosed with asthma at 28. A year and a half ago, at age 39, a pulmonary specialist rated my lung capacity at 115% compared to other males of my age and height likely due to exercising through unmedicated asthma. Undiagnosed underlying conditions shouldn’t prevent intentional efforts to be continuously healthy.

Also lots of people in Italy living together with children and grandchildren might have aggravated the problem.

When we talk about underlying conditions, note that a pretty significant percentage of the population qualifies.

Elevated blood pressure, childhood asthma, obesity, diabetes

High blood pressure alone captures 1/3rd of the public, and it qualifies as a underlying condition. 1/2 of the public has "cardiovascular disease". It goes on and on.

It just seems like at this point people are just trying to comfort themselves. A 51 year old gentleman near me passed very quickly from COVID-19 and the report claimed he had a pre-existing condition. Later the wife was interviewed and she described him as completely healthy...but he had bronchitis when he was a child.

That’s a good point. I imagine many populations have large numbers of people with these ‘underlying conditions’, minor or not. Many folks are at high risk of severe reactions.

I still think it’s important for people to understand that the other conditions do appear the be strongly correlated to severe cases. I don’t think it’s just a false comfort. There is so much misunderstanding out there. Many friends and family I talk to seem to have a distorted view of the realty of what the disease actually is.

https://www.bloomberg.com/news/articles/2020-03-18/99-of-tho...

There is no doubt that the other conditions make people more vulnerable to this disease, and others. That correlation is incredibly real.

What is the false comfort is people's belief that noting this ensures their own safety. My comment was that underlying conditions afflict the vast majority of us, yet people are taking the news as if it means these people all had stage 4 cancer or something and were already on death's door.

Yeah that makes sense.

It does drive me crazy though, when I hear friends that have let themselves be consumed by fear or misunderstanding. It can unnecessarily affect their live in very negative ways.

For example, my co-worker had a falling accident a couple days ago and severely hurt his shoulder. He is afraid he tore his rotator cuff. He is early 30s, a very smart person, but has been consumed with panic about the disease. He refuses to go see a doctor in fear of catching covid-19. It’s like he thinks it’s some sort of death sentence. He lives in a relatively rural county in SC, where according to the state health department there is 1 confirmed case.

No, no, no, the main factor that they do not speak about is testing, simple as that.

If you do proper testing, like in South Korea, you detect everybody or almost everybody that has coronavirus, even when they don't have symptoms of the illness. That is 7 to 10 times more people detected(and controlled), that can actually transmit the virus.

In a country like UK, Portugal or Germany they had copied lots of things that worked in Taiwan, South Korea, Singapur or Japan.

Germany could have as many detected cases as Spain, but that will make only 1/10 of the real illnesses cases of Spain.

In a country like Spain or Italy people in charge are so incompetent that they have only reacted when it was too late.

That at the same time forces the entire's population to follow quarantine, because without tests you are blind to the people that has the virus without symptoms.

Spain's Government is today promising a million test kits(broken promises is the seal of Mr Sanchez), in the future, but as of now there are not enough test just for testing all people with symptoms, unless you are a politician or family member of a politician of course.

That is the result of not getting preventive stocks early on. They simply could not imagine(and hence prepare) what has happened and just took zero anticipative actions like buying face masks.

Those politicians have zero scientific or technical preparation, so they could not understand something as simple as an exponential function.

In the case of Spain, they have very well prepared people down the command chain. But the people that takes the decisions are just scientific illiterate.

This. It is highly irritating to me that all the popular maps and comparison sites don't use metrics like "coronavirus deaths per 1M population" (or similar) that are more comparable across areas.

For that information see this:

https://ourworldindata.org/coronavirus

and they have very good information about testing in each country.

Reasonably chosen metrics, and explanatory context too. Thank you.

> In a country like UK, Portugal or Germany they had copied lots of things that worked in Taiwan, South Korea, Singapur or Japan.

Can you explain further? The responses in these countries have been quite different from each other.

Could you comment more about the UK?

> “The way in which we code deaths in our country is very generous in the sense that all the people who die in hospitals with the coronavirus are deemed to be dying of the coronavirus.

How else could deaths be recorded? It would seem negligent to not record someone who died with coronavirus as dying of coronavirus.

I think they're pointing out that some people who got afflicted with Corona virus cannot be completely attributed to the virus alone. There may be underlying conditions which contributed more that caused the demise of the person.

https://www.bloomberg.com/news/articles/2020-03-18/99-of-tho...

Not ‘may’ have underlying problems. No less than 99% have other health problems. Around half of the deaths had 3 underlying problems. But we still credit the virus? Not the fact many of these folks have serious health issues?

”As of March 17, 17 people under 50 had died from the disease. All of Italy’s victims under 40 have been males with serious existing medical conditions.”

I have an eyebrow raised.

It seems to mean that if someone with coronavirus goes on to have a fatal heart attack, they'd still be recorded as dying "of" coronavirus. (Silly example, of course.)

I'm not sure how much of a blanket rule that is, or to what extent it's masking true numbers, or how it compares with other countries.

That’s exactly how first death in Russia was recorded. That patient died from preexisting condition and her lungs were not affected by corona.

the first death in Romania from coronavirus happened today and was a patient with terminal cancer, taken off chemo weeks ago before infection.

it is still counted as a coronavirus death, but somehow it doesn't seem right...

What’s the most likely place to catch coronavirus? I would posit it’s probably hospitals. If an elderly person needs to go to a hospital for any reason these days, I would guess they get taken to one full of other elderly people with coronavirus. I wonder what effect this might have on the results.

In italy hospitals are right now divided in two parts. One is for covid positives only and the other for covid negatives only. The staff which works in one part does not work in the other and has no contact with any member of the other one. Even ambulances are separated and with independent staff.

Are they testing the negatives? If not, asymptomatic transmission will contaminate the negatives-ward.

This is the most important case for extensive testing.

There is a great podcast from an Italian doctor summarizing the best practices for hospitals dealing with COVID-19 https://www.stemlynsblog.org/covid-19-podcast-from-italy-wit...

The first point being "Divide your department into resp patients and non-resp patients."

Do they code for covid19 even if someone got hit by a car and just dies in a covid19-treating hospital?

He has to be covid-19 positive to be recorded as such. However, yes, he could die of internal bleeding, but have covid and he will be recorded as a covid-19 death. The article states that 88% of the dead had other pre-morbidity, sometimes two or three.

I think the fact that the hospitals are overwhelmed is killing people a lot quicker than they would've taken.

If 5000 people die a day in average before the virus and 6000 people die a day on average after the virus would you say that the death toll is 1000/day or would you test all 5000 and say that any who had the virus were included in the virus death toll?

Do we have these numbers to compare? How much has the overall death rate increased by?

Some countries might publish sooner, but the most comprehensive database (WHO Mortality Database) has about a three year delay (2016 as the most recent year for many countries).

There is an official European organisation trying to track mortality:

https://www.euromomo.eu/

So far nothing suspicious, but they are always a few weeks behind.

Also note that you can look at subpopulations, e.g. people in Italy of age >= 65

https://www.euromomo.eu/outputs/zscore_country65.html

I think for the purpose of reporting it should be 5000, but those who calculate death rate should have more details. It's just reporting everyone with the virus is the only common way we can use to compare between countries.

Coding for death is something that statisticians do all the time. They have established, well used, processes to assign death to a particular cause.

Covid-19 causes a range of severity of illness.

If someone is hospitalised for covid-19 they are very unwell -- this is because hospitals are overwhelmed by the number of patients and are only admitting those who are very ill, and also because hospitals want infectious people to stay at home out of hospital as long as possible to reduce the amount of infection being spread.

So, when someone with covid-19 dies in hospital it's almost certain that it's the covid-19 that killed them, even if they would have died later that year of something else.

It depends on your reason for counting.

For a hospital that needs to handle the diseased person, recording the most contagious disease makes sense, and acting as relevantly.

For an actuary looking at deaths after the fact, trying to analyse the lethality of diseases, attributing all deaths to the most contagious disease is less sensible.

I read a story about a guy in Italy, he lost both parents, only his father died in the hospital so his mother was not counted in statistics as having died of coronavirus.

What if they were dying anyway? Seems hard to decide how to count that.

But this leads to double (and n-) counting. And that way we don't measure the death rate, but rather the spread of infection in the general population. If that is the case I would expect the death rate nowhere at no point to be much higher than normal or during a heavy flu season. The next weeks will show if the numbers are actually increased.

> If that is the case I would expect the death rate nowhere at no point to be much higher than normal or during a heavy flu season.

In Bergamo, obituaries in the newspaper went from little more than 1 page per day to about 10 [1] (sorry, link in Italian), so yes, it is much higher than normal. And this was about ten days ago, now I guess it is even worse.

[1] https://www.youtube.com/watch?v=iQaQBqH0txs

Yeah I know, and I did some numbers on that particular town. At least for that, the numbers are actually massively higher now, as implied by the video. But even if you look at Lombardy, they are just somewhat higher. And the farther away you look, the more it's just noise. Which is expected of course. But whether this is all worth the consequences we're imposing on ourselves - I'm having doubts.

How about reporting ”number of life years lost”?

A death of healthy new born would mean 80 years lost. Death of elderly person maybe 5. You could simple stats by comparing to general life expectancy and more detailed by considering the health condition of the person.

Or report "number of years of experience lost"? I'm disinclined to dismiss the lives of older folk as valueless, as so many are doing these days.

> Of the 47,000 people confirmed coronavirus patients in Italy, 4,032 so far have died - with a record increase of 627 in the last 24 hours. By contrast China has almost twice as many cases, 81,250, but 3,253 fatalities.

One major problem with this is China's reporting and actual figures.

How about the differences with Germany?

Could you formulate your question in a more precise fashion?

Here are some stats for Germany [1] as of yesterday:

  cases         deaths
  16,662(+19%)  47(+52%)

I have a contact high up in a Gesundheitsamt. While I can not give out any information I was asked not to divulge, I am happy to answer any questions. Please note that top level decisions are decided in small rooms and acted upon very quickly (Federal->Land, 2 hours lead time), so no way I can know anything time critical before everyone knows it.

[1] https://en.wikipedia.org/wiki/2020_coronavirus_pandemic_in_G...

The RKI statistics are not complete because the electronic submission is not done by everybody (allegedly NRW is particularly bad and has high numbers). I guess the system is new and the federal organizations are too busy to use it properly?

This is sad because RKI is the official authority.

The efforts to compile good numbers are a difficult task indeed. This is, after all, the first pandemic that hits the country for a long time. Not sure what happens at the interface RKI/Bunderland, but it seems the problem does not start with electronic submission, but from the intelligence generating and patient tracking in the field. While doctors in the 'Gesundheitsaemter' (federal and local public health organisation of the goverment) are on the phone the whole day, tracking and advising people (testing, quarantine protocols) that had contact with Corona patients, the foreign office (Auswaertiges Amt) allows 30000+ people come in from vacation destinations like Egypt without any testing or quarantine, mixing people in planes, and just letting them spread in Germany - effectively sabotaging the the entire process. Moreover, it seems that it is difficult to track infection cascades in high contact places such as hospitals (especially with staff): It is not clear how and when infections are taking place.

As far as I know, they were on the limit of tracking existing cascades in southern Germany last week, and word was that they realized that it was out of hand. Carneval, public gatherings, and failing personal hygiene and isolation, plus our tourists from Tirol and Egypt made tracking measures obsolete. Before that, so my source said, they had a very good overview of the number of infected (minus those without symptoms).

Taiwan and Singapur seem to have learned their lessons from SARS-CoV-1 but it did not hit us enough to act back then.

Also: The degree of testing, and time of testing e.g. the false negative rate of Corona is quite high (forgot how much, need to look it up) in Germany due to the nature of the RNA based test.

It is the level of testing isn't it?

Death pr. infected goes from 0.4% (Germany) to 1% (Diamond Princess) to 7.8% (Iran) to 9% (Italy).

If you have plenty of resources and you do contact tracing you are going to find many cases and the denominator will be high. If you are pressed on ressources and only test people admitted to hospitals with obvious symptions then the denominator will be low.

Demographics, overall population health, polution explains some of it but not a difference of factor 20.

Although an important thing to consider, I'm not sure how much it contributes. Look at:

https://www.worldometers.info/coronavirus/#countries

Italy has one of the highest rate of cases per capita and the highest CFR.

> with a record increase of 627 in the last 24 hours.

Worth pointing out that the record increase in 630 deaths was the number of two days ago... Yesterday, the increase in deaths was even bigger: 790 (from 4035 to 4825 total casualties).

Source: https://github.com/pcm-dpc/COVID-19

It depends how a country classifies casualties outside those confirmed cases. Autopsy usually would not be viable given the scarcity of health care staff.

I find this article disingenuous and misleading to readers. Yes, there are cultural and demographic differences between Italy, China and Germany, but the subtitle claims a level of certainty that the experts interviewed in the piece do not support.

> "The country's high death toll is due to an ageing population, overstretched health system and the way fatalities are reported"

This can be read with a level certainty that minimizes the seriousness of this virus for English speaking readers that may be faced with making life saving choices over the next week.

Further, the Italian expert interviewed __in the article__ underlines the importance of not searching for explanations, because right now it is hard to be certain.

> “It’s too early to make a comparison across Europe,” he says. “We do not have detailed sero-surveillance of the population and we do not know how many asymptomatic people are spreading it.”

Unfortunately the author chooses to make exactly such a comparison in the fourth paragraph!

> In very crude terms, this means that around eight per cent of confirmed coronavirus patients have died in Italy, compared to four per cent in China. By this measure Germany, which has so far identified 13,000 cases and 42 deaths, has a fatality rate of just 0.3 per cent.

This is a moment where we need very concise and accurate information. Even if this article comes from a reputable source, I find it misses that mark.

I find significantly more enlightening the ISS's (Istituto di Sanità Superiore) info-graphics which are prepared quasi-daily. [1] They are translated into english. [2]

Stay safe out there.

[1]: https://www.epicentro.iss.it/coronavirus/sars-cov-2-sorvegli... [2]: https://www.epicentro.iss.it/coronavirus/bollettino/Infograf...

It is very hard not to think that also the number of deaths (not only that of cases) is under-reported. For instance, the Major of Bergamo, one of the few not entirely rotten politicians, claims that actual deaths in the Province in the last days have been 4 times the reported deaths. He verified the figures with the other majors. Who died at home, and there have been many, has not been tested.

Here the interview:

https://www.huffingtonpost.it/entry/giorgio-gori-chiudete-tu...

And it is very hard not to think that the most plausible explanation for the anomaly is shortage in ICUs.

> The way in which we code deaths in our country is very generous in the sense that all the people who die in hospitals with the coronavirus are deemed to be dying of the coronavirus.

But people who died without a diagnose for the Coronavirus are deemed to be dead not because of it.

From https://www.reuters.com/article/us-health-coronavirus-italy-...

> in the city of Bergamo, there were 108 more deaths in the first 15 days of March this year compared to 2019 (164 deaths in 2020 vs. 56 deaths in 2019) according to the mayor of the city Giorgio Gori. During this period, 31 deaths were attributed to the coronavirus (less than 30% of the additional deaths this year)

> "There are significant numbers of people who have died but whose death hasn't been attributed to the coronavirus because they died at home or in a nursing home and so they weren't swabbed," said the mayor

Granted, the sample and time interval is small to draw conclusions. But we'll know (perhaps when it's too late) what's the real death-toll of the coronavirus is.

tl;dr: The death count is not generous; probably the other way around. By, perhaps, a very big margin.

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