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Lab leak vs natural spill over is a distraction from the lack of evidence that COVID-19 is a viral pandemic originating in China.
In my previous threads I showed that the lockdown in Wuhan was too late.
I showed that all cause mortality was already well above normal and an estimated 7 million people left the city in the weeks leading up to the lockdown, including 300,000 people on the eve of the lockdown.
I showed that the vast majority of international travelers went to other Asian countries.
I showed that studies, including the Seattle Flu Study, finding a lack of early spread of the virus lack plausibility due to the absence of false positives, and I showed that there is a larger body of contradictory evidence.
In this thread, I will show that the excess mortality during the spring 2020 wave was associated with a decline in emergency department utilization, not just for low acuity visits but for high acuity visits as well.
If this is confusing due to media reporting on overwhelmed hospitals, the confusion is coming from the fact that the emergency department and intensive care unit are separate.
I will present data showing that ED utilization went down while ICU utilization went up, suggesting that patients delayed care until it was too late.
https://ourworldindata.org/grapher/excess-deaths-daily-per-100k-economist
https://www.nytimes.com/interactive/2020/03/22/world/coronavirus-spread.html
#COVID #COVID19 #epidemiology #bioinformatics #healthcareisahumanright
Collateral Impacts of the COVID-19 Pandemic: The New York City Experience
"Immediately following the first hospitalization for COVID-19 in NYC on February 29, 2020, total visits to NYC EDs dropped by approximately 50%...
...ED visits for ambulatory care–sensitive conditions also declined substantially from a monthly low of 55 343 during August 2019 to a low of 25 461 during May 2020...
...These findings align with literature from other localities and nationally that have shown a decline in care seeking for various conditions and services.
These data also suggest that forgone care among people with serious conditions may have contributed to the excess deaths not directly due to COVID-19 that were observed during the early months of the pandemic as people postponed or avoided seeking essential care due to fears of COVID-19 infection."
FIGURE 2
(A) Total Number of ED Visits per Month, NYC Syndromic Surveillance System.
(B) Total Number of ED Visits per Month for Ambulatory Care–Sensitive Conditions, NYC Syndromic Surveillance System.
(C) Percentage of ED Visits for Ambulatory Care–Sensitive Conditions Admitted per Month, NYC Syndromic Surveillance System
Davies, Emily G. AB; Gould, L. Hannah PhD; Le, Karolyn MPH; Helmy, Hannah PhD; Lall, Ramona PhD; Li, Wenhui PhD; Mathes, Robert MPH; Levanon Seligson, Amber PhD; Van Wye, Gretchen PhD; Chokshi, Dave A. MD. Collateral Impacts of the COVID-19 Pandemic: The New York City Experience. Journal of Public Health Management and Practice 29(4):p 547-555, July/August 2023. | DOI: 10.1097/PHH.0000000000001701
Variations in volume of emergency surgeries and emergency department access at a third level hospital in Milan, Lombardy, during the COVID-19 outbreak
"Since February 22, 2020, well before the Government declared a state of emergency, there was a huge reduction in the number of emergency surgeries performed at hospitals in Lombardy. A general decrease in attendance at emergency departments (EDs) was also observed."
Fig. 2
Daily ED accesses for medicine, surgery and specialist examinations in 2020, expressed as a percentage of the accesses recorded for the same time periods in 2019
Period 1 February 21–March 8
Period 2 March 9–21
Period 2 March 9–21
Period 4 April 22–May 12
Castoldi, L., Solbiati, M., Costantino, G. et al. Variations in volume of emergency surgeries and emergency department access at a third level hospital in Milan, Lombardy, during the COVID-19 outbreak. BMC Emerg Med 21, 59 (2021). https://doi.org/10.1186/s12873-021-00445-z
Here is a composite image showing that emergency department utilization in Milan started declining before deaths started going up.
https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-021-00445-z
Here is a composite image showing that during the spring 2020 wave in New York City emergency department visits for ambulatory care sensitive conditions started going down before deaths started going up.
Davies, Emily G. AB; Gould, L. Hannah PhD; Le, Karolyn MPH; Helmy, Hannah PhD; Lall, Ramona PhD; Li, Wenhui PhD; Mathes, Robert MPH; Levanon Seligson, Amber PhD; Van Wye, Gretchen PhD; Chokshi, Dave A. MD. Collateral Impacts of the COVID-19 Pandemic: The New York City Experience. Journal of Public Health Management and Practice 29(4):p 547-555, July/August 2023. | DOI: 10.1097/PHH.0000000000001701
https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm
Where Have All the Heart Attacks Gone?
"The hospitals are eerily quiet, except for Covid-19.
I have heard this sentiment from fellow doctors across the United States and in many other countries.
We are all asking: Where are all the patients with heart attacks and stroke?
They are missing from our hospitals.
Yale New Haven Hospital, where I work, has almost 300 people stricken with Covid-19, and the numbers keep rising — and yet we are not yet at capacity because of a marked decline in our usual types of patients...
...What is striking is that many of the emergencies have disappeared.
Heart attack and stroke teams, always poised to rush in and save lives, are mostly idle...
...The most concerning possible explanation is that people stay home and suffer rather than risk coming to the hospital and getting infected with coronavirus...
...We actually expected to see more heart attacks during this time. Respiratory infections typically increase the risk of heart attacks...
...Also, times of stress increase the risk of heart attacks and strokes.
Depression, anxiety and frustration, feelings that the pandemic might exacerbate, are all associated with a doubling or more of heart attack risks."
Increased Inpatient Mortality for Cardiovascular Patients During the First Wave of the COVID‐19 Epidemic in New York
"While the number of admissions for COVID‐19 surged upward, the number of admissions for critical cardiovascular illnesses such as ST‐segment–elevation myocardial infarction (STEMI) and acute strokes plummeted...
The Fire Department of New York reported that 7191 people were pronounced dead on the scene out of a total of 10 975 emergency calls for presumed cardiac arrest between March 11 and May 26 in 2020.
This represents a 2.86‐fold increase in the number of OHSD compared with the reference period the year prior...
...The Centers for Disease Control and Prevention advised patients to stay home in an effort to avoid exposure to the virus.
Similarly, on March 22, 2020, the State of New York issued a health guidance recommending that the public avoid healthcare facilities, and only seek medical attention for severe symptoms.
This likely resulted in increased anxiety and fear about seeking medical attention, especially in those at highest risk of contracting the virus, including patients with cardiovascular disease."
Mountantonakis SE, Makker P, Saleh M, et al. Increased Inpatient Mortality for Cardiovascular Patients During the First Wave of the COVID‐19 Epidemic in New York. J Am Heart Assoc. 2021;10(16):e020255. doi:10.1161/JAHA.120.020255
Here it is possible to see that during the spring 2020 wave, emergency department utilization went down.
ED utilization stayed down while intensive care unit utilization went up.
"ED overcrowding alerts initially decreased from 5% for the week ending March 13, 2020, to 1% for the week ending March 27, 2020"
Sandhu P, Shah AB, Ahmad FB, et al. Emergency Department and Intensive Care Unit Overcrowding and Ventilator Shortages in US Hospitals During the COVID-19 Pandemic, 2020-2021. Public Health Reports®. 2022;137(4):796-802. doi:10.1177/00333549221091781
"During March 29–April 25, 2020, U.S. emergency department (ED) visits declined by 42% after the declaration of a national emergency for COVID-19 on March 13, 2020."
Adjemian J, Hartnett KP, Kite Powell A, et al. Update: COVID-19 Pandemic–Associated Changes in Emergency Department Visits — United States, December 2020–January 2021. MMWR
Morb Mortal Wkly Rep 2021;70:552–556. DOI:
"Between March 11 and April 21, 2020, 42% fewer patients were admitted to VA inpatient facilities compared with the preceding 6 weeks, including for conditions generally requiring emergency treatment.
The percentage decrease in admissions for conditions generally requiring emergency treatment was greater or similar in magnitude to the decrease in admissions overall and is unlikely to be attributable to declines in elective surgeries or disease incidence related to reduced stress or lower exposure to other pathogens or pollution.
Rather, many patients may be avoiding hospitals to minimize risk of SARS-CoV-2 infection."
Baum A, Schwartz MD. Admissions to Veterans Affairs Hospitals for Emergency Conditions During the COVID-19 Pandemic. JAMA. 2020;324(1):96–99. doi:10.1001/jama.2020.9972
"On March 14, 2020 a national state of emergency was declared in Spain with a special call to house confinement in an attempt to stop the progression of the pandemic...
...The results of this study show a significant decrease of interventional cardiology procedures performed after the COVID-19 pandemic was declared in our country.
The 40% decrease in interventional procedures performed in the STEMI setting is particularly disturbing."
Rodríguez-Leor O, Cid-Álvarez B, Ojeda S, et al. Impact of COVID-19 pandemic over activity of interventional cardiology in Spain. REC Interv Cardiol. 2020.
"We retrospectively investigated the utilization of 3 hospital-based EDs in the southeast of the Netherlands, during a 60-day period starting on February 15, 2020...
...The daily ED volume in 2020 was 18% lower than during the reference period...
...When comparing a 30-day period around the modified lockdown (March 16 to April 15) with the corresponding period in 2019, the decline in ED utilization is even more pronounced.
ED visits were 29% lower in 2020 compared to 2019...
...The reduced ED utilization during the early phase of the COVID-19 pandemic has been observed in other health care systems, too, with reduction rates varying from 30 to 63%.
Likewise, ED census decreased during the initial stages of the 2003 SARS epidemic in Hong Kong...
...Although it cannot directly be concluded from the findings of our study, this observation probably reflects a complex interaction between pure lockdown effects and viral fear."
Barten DG, Latten GHP, van Osch FHM. Reduced Emergency Department Utilization During the Early Phase of the COVID-19 Pandemic: Viral Fear or Lockdown Effect? Disaster Medicine and Public Health Preparedness. 2022;16(1):36-39. doi:10.1017/dmp.2020.303
Here is a composite image showing emergency department utilization and excess mortality in the Netherlands during the spring 2020 wave.
Evidence of delays in seeking care in Paris during the spring 2020 wave:
"We retrospectively examined consecutive COVID-19 patients suffering from ARF who were treated by the Paris Fire Brigade’s basic life-support (BLS) teams in the prehospital setting.
Data were provided from primary home care providers...
...After having measured the SpO2i/RRi values in COVID-19 patients, we compared them to those of non-COVID-19 patients (i.e., patients with other causes of ARF treated by the BLS teams over the previous 3 years in the same period)...
...The median SpO2i/RRi value was significantly higher than that of patients treated in the previous 3 years"
Jouffroy, R., Jost, D. & Prunet, B. Prehospital pulse oximetry: a red flag for early detection of silent hypoxemia in COVID-19 patients. Crit Care 24, 313 (2020).
“To determine whether a decrease in PPCI is occurring in the United States in the COVID-19 era, we analyzed and quantified STEMI activations for 9 high volume (>100 PPCIs/year) cardiac catheterization laboratories in the United States from January 1, 2019, to March 31, 2020…
...Our preliminary analysis during the early phase of the COVID pandemic shows an estimated 38% reduction in U.S. cardiac catheterization laboratory STEMI activations, similar to the 40% reduction noticed in Spain…
..Potential etiologies for the decrease in STEMI PPCI activations include avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital, STEMI misdiagnosis, and increased use of pharmacological reperfusion due to COVID-19. ”
Garcia, S, Albaghdadi, M, Meraj, P. et al. Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic. JACC. 2020 Jun, 75 (22) 2871–2872.
“The first wave (FW) of COVID-19 led to a rapid reduction in total emergency department (ED) visits and hospital admissions for other diseases…
...In the city of Torino, a large northern Italian city (870,000 inhabitants), during the first wave of the pandemic, the number of daily COVID-19 diagnoses peaked in March–April 2020…
...During the first wave peak, ED visits were reduced by 66.4% compared to 2019”
Morello, F., Bima, P., Ferreri, E. et al. After the first wave and beyond lockdown: long-lasting changes in emergency department visit number, characteristics, diagnoses, and hospital admissions. Intern Emerg Med 16, 1683–1690 (2021).
"Amnesty International also received widespread complaints from care home staff and older people’s relatives concerning the serious obstacles or outright refusal to hospitalize care home residents with Covid-19 or with flu-like symptoms.
In particular, in Lombardy, the regional authorities adopted a specific policy advising that older residents aged over 75 with frailty and with COVID-19 symptoms should be cared for within care homes, de facto limiting their access to hospital.
In the absence of individualized clinical assessments aimed at identifying the best individual solution for specific patients, this resulted in a lack of protection of the rights to life, to health and to non-discrimination."
Italy: Violations of the human rights of older residents of care homes during COVID-19 pandemic. Amnesty International. December 18, 2020. Accessed August 07, 2024.
Graphs showing emergency department visits for Influenza-Like Illness (ILI) and/or COVID-19-Like Illness (CLI) as a percentage of total visits can be highly misleading.
The following CDC graph serves as a good example:
It makes it look like emergency department utilization went up when in fact it went down.
I downloaded the data table still available on the internet archive and created a more honest data visualization.
Additionally, by definition ILI is a subset of CLI, meaning that there will always be more CLI than ILI.
"ILI is defined as
fever (temperature of 100.4 degrees F [37.8 degrees C] or greater)
AND a cough
AND/OR a sore throat without a known cause."
“COVID-19 like illness is described as
new onset of subjective or measured (≥100.4F or 38.0C) fever
OR cough
OR shortness of breath
OR sore throat that cannot be attributed to an underlying or previously recognized condition. ”
CDC: Emergency Department Visits Percentage of Visits for COVID-19-Like Illness (CLI) or Influenza-like Illness (ILI)
https://web.archive.org/web/20230128084041/https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/08072020/covid-like-illness.html
Health Alert # 6
COVID-19 Updates for New York City
https://www.nyc.gov/assets/doh/downloads/pdf/han/alert/2020/covid-19-03152020.pdf
US NAVY COVID-19 STANDARDIZED OPERATIONAL GUIDANCE VERSION 3.1
https://web.archive.org/web/20201203083538/https://www.navy.mil/Resources/NAVADMINs/Message/Article/2407046/us-navy-covid-19-standardized-operational-guidance-version-31/
#COVID19 #COVID #epidemiology #bioinformatics #datascience #dataviz
For anyone wondering why there's a portion of the previously posted graph showing more ILI than CLI:
I don't know.
Without detailed information about how the CDC collects and processes this information, I can only speculate, but my first guess is that unclear and/or counter intuitive CLI and ILI definitions might have something to do with it.
#COVID19 #COVID #epidemiology #bioinformatics #datascience #dataviz
@covid19
@auscovid19
@bioinformatics
Additional evidence from New York City showing that patients delayed care during the COVID-19 spring 2020 wave:
COVID-19 doesn't cause severe symptoms on the day of infection - like any other infectious disease, it takes time for the disease to progress.
"The four clinical outcomes considered were as follows:
Dead on arrival (DOA):
if the patient arrived in cardiac arrest with high suspicion of COVID-19 and was unable to be resuscitated.
Died in ED (DED):
the patient did not survive ED resuscitation attempts.
Died as an inpatient/died in hospital (DIH).
Survived to hospital discharge...
...Sub-cohort analysis based on primary patient disposition was also considered...
...We found that within this cohort, male sex, advanced age, a history of coronary artery disease, the non-respiratory findings of lactic acidosis, elevated D-dimer, and CKD/AKI were correlated with death either in the ED or during the patient's hospital course.
Fever, hypotension, and even initial respiratory status (including our analysis of the pre and post Sp02 [the Sp02 delta]) were not strongly correlated with outcomes
(likely because of the fact that all patients were severely hypoxic on arrival)."
D'Amore J, Meigher S, Patterson E, et al. Intubation outcomes and practice trends during the initial New York SARS-COV-19 surge at an academic, level 1 trauma, urban emergency department. JACEP Open. 2021; 2:e12563.
A common explanation given for the lack of excess mortality in places like Japan is masking; however, there are many places that had low masking rates and low excess mortality rates during the spring 2020 wave.
For example, Denmark, Norway, and Australia all had low masking rates and low excess mortality rates.
Australia is particularly notable as it's a top destination for Chinese travelers.
Singapore was late to adopt masking and is also a top destination of Chinese travelers.
"For weeks after the first reports of a mysterious new virus in Wuhan, millions of people poured out of the central Chinese city, cramming onto buses, trains and planes as the first wave of China's great Lunar New Year migration broke across the nation....
...Officials finally began to seal the borders on Jan. 23. But it was too late.
Speaking to reporters a few days after the city was put under quarantine, the mayor estimated that 5 million people had already left...
...The top 10 global destinations for travelers from high-risk Chinese cities around Lunar New Year, according to their analysis, were Thailand, Japan, Hong Kong, Taiwan, South Korea, the United States, Malaysia, Singapore, Vietnam and Australia."
https://www.coviddatahub.com/engagement-with-recommended-behaviours
https://ourworldindata.org/grapher/excess-deaths-daily-per-100k-economist
https://www.nytimes.com/interactive/2020/03/22/world/coronavirus-spread.html
Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020
"The number of visits for conditions including nonspecific chest pain and acute myocardial infarction decreased, suggesting that some persons could be delaying care for conditions that might result in additional mortality if left untreated...
...The striking decline in ED visits nationwide, with the highest declines in regions where the pandemic was most severe in April 2020, suggests that the pandemic has altered the use of the ED by the public.
Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699–704. DOI: http://dx.doi.org/10.15585/mmwr.mm6923e1