Attempt to view in perspective the health
hazard posed by the COVID-19 pandemic:
Mortality between February and the end of May 2020 in Spain
and January and the end of April in Germany
compared to the general death rate in both countries
Notes
1: "The National Center of Epidemiology
clarifies to eldiario.es that, indeed, 'today we have made an important
update resulting from the work we have been doing with the Ministry of
Justice'. The objective is to 'recover those deaths that had not entered
the MoMo System due to delays in notification during the previous three
months'. (...) The Instituto de Salud Carlos III provides in its graphs
the estimated average time in delay of notifications, and for these days
in which the 12,032 deaths have been added, the delay is 35 days. (...)
The minimum personnel services due to the state of alarm and the
increase in deaths due to the coronavirus led to a situation of collapse
in several civil registries and morgues, especially the one in Barcelona
and the morgue of the City of Justice of the Catalan capital. In a
report from early April, the time of the peak, the Generalitat's
(Catalan government's, R.W.) sub-directorate general for planning the
administration of Justice revealed that the death section of the
Barcelona civil registry had not been carrying out death registrations
since March 17 as its minimum services are focused on issuing family
books and burial licenses due to the 'high workload.'"
("Desde el Centro Nacional de Epidemiología aclaran a eldiario.es que,
efectivamente, 'hoy hemos hecho una actualización importante resultante
del trabajo que venimos realizando con el Ministerio de Justicia'. El
objetivo es 'recuperar aquellas defunciones que no habían entrado en el
Sistema MoMo por retraso en la notificación durante los tres meses
anteriores'. (…) El Instituto de Salud Carlos III aporta en sus gráficas
el tiempo medio estimado en retraso de notificaciones, y para estos días
en en los que se han sumado las 12.032 muertes, el retraso es de 35
días. (…)
Los servicios mínimos de personal debido al estado de alarma y el
aumento de muertes por el coronavirus llevaron a una situación de
colapso en varios registros civiles y depósitos de cadáveres, que sufrió
especialmente el de Barcelona y el depósito de cadáveres de la Ciudad de
la Justicia de la capital catalana. En un informe de principios de
abril, momento del pico, la subdirección general de planificación de la
administración de Justicia de la Generalitat revelaba que la sección de
defunciones del registro civil de Barcelona no estaba practicando
inscripciones de defunciones desde el 17 de marzo ya que sus servicios
mínimos se centran en expedir libros de familia y licencias de
enterramiento debido a la 'elevada carga de trabajo'."
https://m.eldiario.es/sociedad/MoMo-registro-muertes_0_1031697065.html?_ga=2.195763883.607369215.1590683111-795171950.1590683111,
27/05/2020, last accessed 05/06/2020.
2: "The excess mortality observed, according
to Amparo Larrauri, epidemiologist and head of the MoMo team and
scientist at the National Epidemiology Centre, 'May be due to cases with
confirmed COVID-19, to cases with unconfirmed COVID-19 that surveillance
systems do not identify, and to the pandemic indirectly. The latter is
very important. We have experienced a change in the social and
health structure, and this has meant that many people with underlying
pathologies have not gone to the doctor for a multitude of reasons,
such as fear of contagion or that their consultations did not work as
they usually did. And a host of reasons that are not medical, but
social. Many studies suggest that the fact that a vulnerable, older
person has been isolated and in confinement affects their health and
evolution more than younger people. Unfortunately, we can all see such
cases around us. These are deaths that are not COVID-19, but are
related to this whole process.'" (Emphasis by R.W.)
("El exceso de mortalidad constatado, según Amparo Larrauri,
epidemióloga y responsable del equipo MoMo y científica del Centro
Nacional de Epidemiología, 'Puede deberse a casos con COVID-19
confirmada, a casos con COVID-19 sin confirmar y que los sistemas de
vigilancia no identifican, y a la pandemia de manera indirecta. Esto
último es muy importante. Hemos vivido un cambio de estructura
social y sanitaria, y eso ha provocado que muchas personas con
patologías de base no se hayan acercado al médico por multitud de
razones, como que temían el contagio o que sus consultas no
funcionaban como lo hacían habitualmente. Y un montón de razones que
no son médicas, sino sociales. Muchos estudios sugieren que el hecho
de que una persona vulnerable, mayor, haya estado aislada y en
confinamiento, infiere en su salud y evolución, afecta más que a
personas jóvenes. Desgraciadamente, todos podemos ver casos así a
nuestro alrededor. Son muertes que no son por COVID-19, pero están
relacionadas con todo este proceso.'“) (Emphasis by R.W.)
https://www.eldiario.es/sociedad/llegaremos-cuantas-muertes-directamente-COVID-19_0_1033797562.html?_ga=2.257052940.607369215.1590683111-795171950.1590683111,
02/06/2020, last accessed 05/06/2020.
The diagrams are taken from the European
Mortality Monitoring Bulletin
https://www.euromomo.eu/graphs-and-maps/,
week 20/2020, last accessed 15/05/2020.
3: Instituto Nacional de Estadística (INE), https://www.ine.es/consul/serie.do?s=MNP89585&c=2&nult=50 , last accessed 30/04/2020.
4: INE data on monthly deaths in Spain from
01/2019 until 06/2019 are provisional:
https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736177008&idp=1254735573002&menu=resultados#!tabs-1254736195546
, last accessed 22/04/2020,
published 11/12/2019. The final data for the first half of 2020 will be
published in December 2020.
5: https://momo.isciii.es/public/momo/dashboard/momo_dashboard.html, updated and corrected daily. The shaded area is the normal range, as in EuroMoMo, https://www.euromomo.eu/, determined from long-term values, and only when it is exceeded does one speak of excess mortality.
"What exactly are we talking about when we
say that there is an 'excess' in Spain of almost 43,000 deaths during
the months of the pandemic, if the Health Ministry reports 28,000? These
43,000 deaths are the results of the daily all-cause mortality
surveillance of the MoMo system, and mean the difference between the
deaths we observe for a period, and the expected mortality from the
historical series in Spain over the last ten years. The latter, the
expected mortality, is derived from data from the National Institute of
Statistics (INE), with a mathematical model of moving averages adjusted
for trend and seasonality. The daily observed mortality comes from data
from the Ministry of Justice from the computerised civil registers of
almost 4,000 Spanish municipalities, including all the provincial
capitals, which correspond to 93% of the Spanish population. This is a
very important amount of information.
Using the MoMo system, we have estimated an excess of deaths from all
causes during the first pandemic wave of COVID-19. It is very logical to
assume that part of the excess mortality corresponds directly to
COVID-19. It is also logical to think that the actual deaths due to
COVID-19 have been higher than the number provided by the Ministry of
Health, since these are official figures from the autonomous communities
that cannot cover the totality, only the microbiologically confirmed
deaths. And they are all within these excesses estimated by the MoMo.
This is neither abnormal nor contradictory: they are studies that do not
contradict each other but complement each other in order to establish
the true impact of the pandemic. The abnormal thing would be for them to
be the same. Health provides the confirmed deaths by COVID-19; MoMo provides the deaths from all causes,
many of them attributable to COVID-19. And it will still be some time
before we definitively consolidate the true mortality of these months".
Amparo Larrauri, epidemiologist and head of the MoMo team and scientist
at the National Epidemiology Centre,
https://www.eldiario.es/sociedad/llegaremos-cuantas-muertes-directamente-COVID-19_0_1033797562.html?_ga=2.257052940.607369215.1590683111-795171950.1590683111,
02/06/2020, last accessed 05/06/2020.
(„¿De qué hablamos exactamente cuando decimos que hay un 'exceso' en
España de casi 43.000 muertes durante los meses de la pandemia, si
Sanidad reporta 28.000? Esas 43.000 muertes son los resultados de la
vigilancia de la mortalidad diaria por todas las causas del sistema
MoMo, y significan la diferencia entre las defunciones que observamos
para un periodo, y la mortalidad esperada a partir de las series
históricas en España de los últimos diez años. A esta última, la
mortalidad esperada, llegamos a partir de datos del Instituto Nacional
de Estadística (INE), con un modelo matemático de medias móviles que se
ajustan por la tendencia y por la estacionalidad. La mortalidad
observada diaria procede de datos del Ministerio de Justicia a partir de
los registros civiles informatizados de casi 4.000 municipios españoles,
entre ellos todas las capitales de provincias, que corresponden al 93%
de la población española. Una cantidad de información muy importante.
Mediante el sistema MoMo hemos estimado un exceso de las muertes por
todas las causas durante la primera ola pandémica de COVID-19. Es muy
lógico suponer que parte de la mortalidad en exceso corresponde
directamente a la COVID-19. También es lógico pensar que las defunciones
reales por COVID-19 han sido un número mayor del que proporciona el
Ministerio de Sanidad, puesto que son cifras oficiales procedentes de
las comunidades autónomas que no pueden cubrir la totalidad, solo las
defunciones confirmadas microbiológicamente. Y todas están dentro de
estos excesos estimados por los MoMo. No es nada anormal, ni
contradictorio: son estudios que no se contraponen sino que se
complementan para establecer cuál ha sido el verdadero impacto de la
pandemia. Lo anormal sería que fueran iguales. Sanidad da las
defunciones confirmadas por COVID-19; el MoMo, las defunciones por todas
las causas, muchas de ellas atribuibles a COVID-19. Y aún tendrá que
pasar un tiempo para que consolidemos definitivamente la verdadera
mortalidad de estos meses.“
Amparo Larrauri, epidemióloga y responsable del equipo MoMo y científica
del Centro Nacional de Epidemiología.)
6: https://momo.isciii.es/public/momo/dashboard/momo_dashboard.html#datos, last accessed 04/06/2020.
7: Accessed 03/04., 01/05., 27/05., 02/06. and 04/06/2020.
8: https://www.euromomo.eu/graphs-and-maps/, updated
every Thursday; these are the charts for Spain and Germany respectively
from the Bulletin of week 20/2020, accessed 15/05/2020.
9: A maximum of 2,466 deaths occurred on
31/03/2020. In comparison, in 2018, the last year for which the
Instituto Nacional de Estadística provides definitive figures (https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736177008&menu=ultiDatos&idp=1254735573002
), an average of 1,172 people died every day.
I was unable to establish the daily maxima during the past flu
epidemics, so I concentrate on the more easily comparable monthly
values, especially since the contemplation of temporally as well as
geographically very small sections tends to focus on extreme values.
10: Instituto Nacional de Estadística,
https://www.ine.es/dynt3/inebase/index.htm?padre=1132&capsel=1134
, accessed 22/04/2020.
11: Centro Nacional de Epidemiología, Monitorización de la Mortalidad diaria (MoMo), https://momo.isciii.es/public/momo/dashboard/momo_dashboard.html, accessed 04/06/2020.
12: https://momo.isciii.es/public/momo/dashboard/momo_dashboard.html#nacional, accessed 04/06/2020.
13: Own calculation.
14: Excess mortality is, according to Amparo Larrauri, epidemiologist and head of the MoMo team and scientist at the National Epidemiology Centre, "... the difference between the deaths we observe for a period, and the expected mortality from the historical series in Spain over the last ten years. The latter, the expected mortality, is derived from data from the National Institute of Statistics (INE), with a mathematical model of moving averages adjusted for trend and seasonality." https://www.eldiario.es/sociedad/llegaremos-cuantas-muertes-directamente-COVID-19_0_1033797562.html?_ga=2.257052940.607369215.1590683111-795171950.1590683111, 02/06/2020, accessed 05/06/2020.
15: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Sterbefaelle-Lebenserwartung/Tabellen/sonderauswertung-sterbefaelle.html?nn=209016, accessed and downloaded 05/06/2020.
16: "When looking at the course of the year
in the death statistics, the typical fluctuations during the flu season
from around mid-December to mid-April should be noted. This becomes
clear when looking at the figures from previous years: in March 2019,
for example, around 86,400 people died; in March 2018, i.e. in a year
when the flu epidemic was particularly severe, the figure was 107,100. Even
without a Corona pandemic, the death figures can therefore fluctuate
greatly during the typical flu season. These fluctuations particularly
affect the number of deaths in the age group 65 and older.
According to the preliminary death figures, the impact of the flu wave
in 2020 was very low compared to previous years. In January 2020,
about 85 200 people died according to the preliminary count. In
February 2020, there were 79 600 deaths. Also in March 2020, with a
total of at least 86 800 deaths, no noticeable increase compared to
previous years is discernible when viewed on a month-by-month basis.
In April, however, with at least 82 600 cases, the number of deaths
was clearly above the average of previous years.
Looking at the trend by calendar week, there have been increased death
case numbers since the last week of March (23 to 29 March) compared to
the 2016 to 2019 average. This upward deviation was greatest in the
15th calendar week (6 to 12 April). From the 16th calendar week (13 to
19 April) onwards, the number of deaths fell again significantly. In
the 19th calendar week (4 to 10 May), according to the preliminary
count, the number of deaths was no longer above the average of
previous years. The findings on temporary excess mortality, when
looking at the absolute numbers, are approximately in line with the
data on confirmed COVID-19 deaths reported to the Robert Koch
Institute (RKI)." (Emphasis by R.W.)
(„Bei der Betrachtung des Jahresverlaufes in der Sterbefallstatistik
sind die typischen Schwankungen während der Grippezeit von ungefähr
Mitte Dezember bis Mitte April zu beachten. Dies wird beim Blick auf die
Zahlen aus den Vorjahren deutlich: Im März 2019 starben beispielsweise
etwa 86.400 Menschen, im März 2018, also in einem Jahr, als die
Grippewelle besonders heftig ausfiel, waren es 107.100. Auch
ohne Corona-Pandemie können die Sterbefallzahlen demnach in der
typischen Grippezeit stark schwanken. Von diesen Schwankungen sind
insbesondere die Sterbefallzahlen in der Altersgruppe ab 65 Jahren
betroffen.
Die Auswirkungen der Grippewelle im Jahr 2020 waren den vorläufigen
Sterbefallzahlen zufolge im Vergleich zu den Vorjahren sehr gering
ausgeprägt. Im Januar 2020 starben nach der vorläufigen Auszählung
etwa 85 200 Menschen. Im Februar 2020 waren es 79 600
Personen. Auch im März 2020 mit insgesamt mindestens 86 800
Sterbefällen ist bei einer monatsweisen Betrachtung kein auffälliger
Anstieg der Sterbefallzahlen im Vergleich zu den Vorjahren erkennbar.
Im April lag die Zahl der Gestorbenen allerdings mit mindestens
82 600 Fällen deutlich über dem Durchschnitt der Vorjahre.
Betrachtet man die Entwicklung nach Kalenderwochen, dann haben sich
seit der letzten Märzwoche (23. bis 29. März) erhöhte Sterbefallzahlen
im Vergleich zum Durchschnitt der Jahre 2016 bis 2019 gezeigt. Diese
Abweichung nach oben war in der 15. Kalenderwoche (6. bis 12. April)
am größten. Ab der 16. Kalenderwoche (13. bis 19. April) sind die
Sterbefallzahlen wieder deutlich gefallen. In der
19. Kalenderwoche (4. bis 10. Mai) lagen die
Sterbefallzahlen nach der vorläufigen Auszählung dann nicht mehr über
dem Durchschnitt der Vorjahre. Die Befunde zu einer zeitweisen
Übersterblichkeit decken sich bei Betrachtung der absoluten Zahlen
annhähernd mit den Daten zu bestätigten COVID-19-Todesfällen, die beim
Robert Koch-Institut (RKI) gemeldet werden.“
(Emphasis by R.W.)
(https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Sterbefaelle-Lebenserwartung/sterbefallzahlen.html,
accessed 05/06/2020)
17: https://www.destatis.de/DE/Presse/Pressemitteilungen/2020/06/PD20_203_12621.html?nn=209016, accessed 06/05/2020.
18: Instituto Nacional de Estadística: https://www.ine.es/, accessed 29/04/2020. https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736177008&menu=ultiDatos&idp=1254735573002
19: https://covid19.isciii.es/, accessed 03/05/2020
20: https://www.ine.es/jaxiT3/Tabla.htm?t=14819
21: Regarding hospital germ infections in
Spain, Informe global de España, Resumen, Análisis EPINE-EPPS 2017
(313 hospitales y 61.673 pacientes), 9 Noviembre 2017, concludes
that between 7 and 9% of patients become infected within the hospital. (http://hws.vhebron.net/epine/Global/EPINE-EPPS%202017%20Informe%20Global%20de%20Espa%C3%B1a%20Resumen.pdf)
(Note 08/05/2021: The document can no longer be accessed. It can be
viewed under "Materials"
and the title EPINE-EPPS 2017 Informe Global de España Resumen.pdf.)
The number of resulting deaths is not shown.
"According to the experts gathered at the conference, between 5%
and 15% of patients admitted to hospital end up suffering from a
nosocomial infection. The World Health Organisation (WHO) reminds that
in Europe there are 4.5 million HCAIs (Healthcare Associated
Infections, R.W.) per year, a figure that translates into 37,000
deaths and 16 million additional hospital stays." (Emphasis
mine.)
("Según
han puesto de manifiesto los expertos reunidos en la jornada,
entre un 5% y un 15% de los pacientes ingresados en un hospital
acaba padeciendo una infección nosocomial. La Organización
Mundial de la Salud (OMS) recuerda que en Europa se producen 4,5
millones de IRAS (Infecciones Relacionadas
con la Asistencia Sanitaria,
R.W.) al año, cifra que se traduce en 37.000 muertes y 16
millones de estancias hospitalarias adicionales." (Emphasis mine.) (Las
infecciones nosocomiales más frecuentes en España son urinarias,
respiratorias y del lecho quirúrgico, Article dated 28/04/2016 in
https://www.immedicohospitalario.es/noticia/8349/las-infecciones-nosocomiales-mas-frecuentes-en-espana-son-urinarias-respiratorias-y-del-lecho-quirurgico).
22: Here I take data without own
verification from Ellis Huber, The Virus, People and Life. The
Corona Pandemic and Everyday Health Care, (Das Virus, die
Menschen und das Leben. Die Corona Pandemie und die alltägliche
Gesundheitsversorgung, https://www.praeventologe.de/hauptbeitraege-nicht-loeschen/1380-informationen-zu-corona,
last accessed 24/04/2020, frequently updated, .
I have asked Mr Huber, former chairman of the Berlin Medical Association
and current chairman of the Association of Preventologists, for sources
regarding the "background"-mortality of the current pandemic in Germany,
but he has not answered me and has not expanded his internet
presentation accordingly, which I regret. (Note 08/05/2021: Now there is
a detailed list of sources at the site mentioned). Because of the
relatively clear situation in Germany, which does not go beyond the
norm, and in order to save time, I have refrained from checking the
factual assertions he has made.
23: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Fallzahlen.html, last accessed 03/05/2020.
24: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Bevoelkerungsstand/_inhalt.html, last accessed 03/05/2020.
25: SARS-CoV-2 Factsheet on
Coronavirus-Desease-2019 [Steckbrief zur Coronavirus-Krankheit-2019
(COVID-19)], Status: 29/5/2020, https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Steckbrief.html,
last accessed 11/06/2020.
"7. incubation period and serial interval
The incubation period indicates the time from infection to the onset of
the disease. It is on average (median) 5-6 days (range 1 to 14 days)
(54, 137)."
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Steckbrief.html#doc13776792bodyText7
(“7. Inkubationszeit und serielles Intervall
Die Inkubationszeit gibt die Zeit von der Ansteckung bis zum Beginn der
Erkrankung an. Sie liegt im Mittel (Median) bei 5–6 Tagen (Spannweite 1
bis 14 Tage) (54, 137).”
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Steckbrief.html#doc13776792bodyText7)
"12. Time from onset of disease to pneumonia
In one publication (Chinese case series [n = 1,099]), this time range
was four days [IQR]: 2-7 days) (23)."
"13. Time from onset to hospitalisation": 4 - 8 days.
"14. time from onset to acute respiratory distress syndrome (ARDS)": 8-9
days
"15. time from onset of illness to ICU" (intensive care unit): 5 - 10
days
"16. Time from hospitalisation to ICU
In a Chinese case series (see 13.), this time range was on average
(median) one day (IQR: 0-3 days) (130)."
"22. Proportion of deceased among ICU patients".
(...) On median, deceased patients were hospitalised for nine days
(49)."
(“12. Zeit von Erkrankungsbeginn bis
Pneumonie
In einer Veröffentlichung (chinesische Fallserie [n = 1.099]) betrug
diese Zeitspanne vier Tage [IQR]: 2–7 Tage) (23).”
“13. Zeit von Erkrankungsbeginn bis Hospitalisierung”: 4 - 8 Tage"
“14. Zeit von Erkrankungsbeginn bis zum Akuten Lungenversagen (Acute
Respiratory Distress Syndrome, ARDS)”: 8 - 9 Tage
“15. Zeit von Erkrankungsbeginn bis ITS” (Intensivtherapiestation): 5 –
10 Tage
“16. Zeit von Hospitalisierung bis ITS
In einer chinesischen Fallserie (siehe 13.) betrug diese Zeitspanne im
Mittel (Median) einen Tag (IQR: 0–3 Tage) (130).“
“22. Anteil Verstorbener unter den ITS-Patienten
(…) Im Median waren die Verstorbenen Patienten neun Tage hospitalisiert
(49).“)
My calculation of the period from
infection to death:
Incubation min 1 - max 14 days
Onset of illness to hospitalisation min 4 - max 8 days
Onset of illness to ICU min 5 - max 10 days
Hospitalisation to death average 9 days
Period from infection to death: MINIMUM: 14 days MAXIMUM: 31 days
26: Tagesspiegel, 29/05/2020: "'Without the
test, this would have been detected 'only a month' later, 'when the
deaths would have accumulated as in Italy, Spain and Great Britain'.
That's how long it takes from infection to death in intensive care, the
virologist continued. 'And that's the month we - and by that I mean my
lab - put in as a lead for Germany.'"
("'Ohne den Test sei dies ‚erst einen Monat‘ später festgestellt worden,
‚wenn sich wie in Italien, Spanien und Großbritannien die Toten gehäuft
hätten‘. So lange dauere es von der Infektion bis zum Tod auf der
Intensivstation, so der Virologe weiter. 'Und diesen Monat haben wir –
und damit meine ich mein Labor - für Deutschland als Vorsprung
eingespielt.‘“)
https://m.tagesspiegel.de/wissen/mein-labor-hat-deutschland-vorsprung-eingespielt-virologe-drosten-reklamiert-rettung-von-bis-zu-100-000-leben-fuer-sein-team/25871954.html??,
last accessed 11/06/2020.
27: Robert-Koch-Institut, Estimate of the current development of the SARS-CoV-2 epidemic in Germany (Schätzung der aktuellen Entwicklung der SARS-CoV-2-Epidemie in Deutschland) – Nowcasting, Epidemiologisches Bulletin 17-2020, 23. April 2020, p. 14. https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2020/Ausgaben/17_20.pdf?__blob=publicationFilehttps://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2020/Ausgaben/17_20.pdf?__blob=publicationFile, downloaded 10/06/2020.
28: I am not complaining, because I was privileged: Secure income, health, little house with a garden, pleasant climate...... But I was constantly aware of what this means for people who live in a big city, possibly with children, in a floor flat and have to worry about their income.
29: https://euromomo.eu/graphs-and-maps/, accessed and downloaded 16/05/2021.
30: Naomi Klein, The Shock Doctrine: The Rise of Disaster Capitalism, Metropolitan Books, Henry Holt and Company, 2007, p. 290-291.
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