And why masks still matter
CLINICAL MATTERS
With the All-Souls Day celebration last week, it seems like as good a time as any to examine how many people we have lost during the pandemic. The official global death toll due to Covid-19 stands at about 6.6 million. That is most definitely a gross underestimate. Not everyone who died was tested for one reason or another. Whether it is a lack of tests, a refusal to test, or Covid-19 was not considered as a possible cause of death, there are many uncounted Covid-19 deaths from each country. In addition, indirect deaths in which Covid-19 contributed to the demise are harder to count, not to mention downstream effects on the healthcare system that affected care of people with non- Covid-19 ailments.
The easiest way to estimate the impact of Covid-19 deaths, whether direct or indirect, is to look at excess mortality. This involves examining historical averages of death from the last few years and comparing these with the current year. This data is imperfect since there can be substantial delays in reporting mortalities. Excess deaths will not just capture the untested Covid-19 deaths but will also include excess deaths from other causes, and these may be difficult to distinguish. For instance, the delayed screening and detection of certain cancers brought about by the closure of physician clinics during the early phase of the pandemic will translate to higher rates of cancer mortality later. This also does not consider the effects of long Covid-19 on those with cancer who survive their coronavirus infection.
The most comprehensive study looking at excess deaths was done by the World Health Organization (WHO) last May (https://www.who.int/news/item/05-05-2022-14.9-million-excess-deaths-were-associated-with-the-covid-19-pandemic-in-2020-and-2021). Using multiple data sources and epidemiologic modeling, researchers generated yearly estimates of excess death during the first two (2020 and 2021) pandemic years. The WHO report reveals that the full death toll associated directly or indirectly with the pandemic between Jan. 1 2020 and Dec. 31, 2021 was approximately 14.9 million. Confirmed cumulative Covid-19 deaths within that time frame is 5.47 million, which means that nearly 10 million additional deaths could have been caused by undetected Covid-19 or from its indirect effects. This only captures actual deaths from Covid-19 and does not even begin to hint at the economic devastation or chronic effects on health from the pandemic.
Looking at country-level data, the US reported a total of 825,614 confirmed Covid-19 deaths up to December 2021. The excess deaths calculated by WHO for those two years is about 930,000. This suggests that a little over 100,000 deaths, whether directly or indirectly from Covid-19, were missed. Given the high testing rate in the US and relatively mild lockdowns, this data seems to be consistent with what we see on the ground. Currently the US has nearly 1.1 million confirmed Covid-19 deaths, and so Covid-19 continues to kill many Americans, especially those who still refuse to be vaccinated.
For India where cases peaked at 400,000 cases a day, the disparities are much larger. This is likely due to their overwhelmed testing capacity on top of other factors. The actual Covid-19 deaths for the study time frame in India are 481,486. The WHO calculations show an excess death count of 4.7 million. Whether a large part of those excess deaths is due to actual Covid-19 or from indirect effects is difficult to ascertain but early deaths are more likely from undetected Covid-19 as there would not be enough time for exacerbation of chronic illnesses. In the interest of fairness, India disputes these calculations and argues that the numbers should be much smaller. It does seem plausible, however, that the true death rate is indeed 10 times higher than the official report given early shortages in testing capacity and the harshness of their instant lockdowns, which did not even allow people to go home to their provinces.
The Philippines situation is more complicated. At the end of Dec. 31, 2021, the Philippines had 51,504 confirmed Covid-19 deaths. During the first year of reporting (2020), the estimated excess deaths is negative, i.e., it shows 40,545 fewer deaths than expected compared to other years. This is consistent with the early lockdown shutting down exponential virus spread. At the end of 2020, we only had 9,244 confirmed Covid-19 deaths and a lot less recorded deaths from the usual causes. This may be because the lockdowns and mask mandates also prevented a whole host of infectious diseases like tuberculosis from spreading. Compared to Mexico, which locked down only 10 days after the Philippines and had 314,545 excess deaths in the first year, the early lockdown is acknowledged to have saved at least 350,000 Filipino lives in the first year of the pandemic.
Unfortunately, lockdowns are not sustainable and we saw many excess deaths in the second year of the pandemic. This was also the year the Delta variant hit, and we were only beginning to vaccinate at that time. The combination of a severe lockdown and a bad variant resulted in 225,425 excess deaths in 2021, at least some of which were undetected Covid-19 cases. Many more of these excess deaths, however, were due to undetected and unmanaged chronic diseases. In fact, the case fatality rate of Covid-19 continued to drop throughout the year, especially after the vaccines were rolled out along with the discovery of effective treatment. This increase in excess mortality from non- Covid-19 causes was the reason we advised the government to gradually shift to more granular lockdowns.
While the strict mobility restrictions preserved and saved many lives in the first year of the pandemic, it was starting have an adverse effect on other diseases. Adding the initial decrease in deaths from 2020 to the excess deaths in 2021, the actual number of excess deaths from the two-year pandemic (January 2020 to December 2021) is about 180,000. This is about three and a half times higher than the actual confirmed Covid-19 death toll for the same time period. All things considered, this is still more than four times less than that of the projected excess Covid-19 deaths of the US, and about 24 times less than that of India.
Another major issue with death counts in the Philippines is the delay in reporting especially from far-flung provinces, which have not updated their systems and are still doing their reporting manually. Looking at the weekly DOH bulletins, over half of the reported deaths each week are from at least one year ago. When looking at new deaths reported, it is very important to look at the breakdown in time (actual date of death) since this can artificially inflate the mortality rate, especially with daily cases being so low currently. For instance, the average daily deaths from May to July 2022 is one death per day, and all other deaths reported during those days were backlogs. This went up to about four deaths per day in August 2022 and is now going down again. This is clear evidence that the Covid-19 vaccines continue to protect against severe disease.
As the pandemic starts to wind down, we are starting to get a better picture of its toll on our society. The number of deaths from Covid-19 is much more than the official counts. It is a shame that some of the lessons of the pandemic are being lost because people just want to move on.
As other potentially deadly respiratory diseases like influenza and respiratory syncytial virus (RSV) start to mix in with SARS-CoV-2 this flu season, it is unfortunate that mask mandates are being set aside just because the Covid-19 situation seems to be getting better.
Masks aren’t just useful for Covid-19, they also prevent transmission of other respiratory pathogens. The responsibility is now on us to protect ourselves and our fellow Filipinos by continuing to use the tools that saved many lives from Covid-19.
Masks can save lives against other infectious diseases, but only if we use them and keep wearing them.