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May 14, 2020

Assessment of Deaths From COVID-19 and From Seasonal Influenza

Author Affiliations
  • 1Harvard Medical School, Brigham and Women’s Hospital, Division of Health Policy and Public Health, Department of Emergency Medicine, Boston, Massachusetts
  • 2Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
  • 3Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, Georgia
JAMA Intern Med. 2020;180(8):1045-1046. doi:10.1001/jamainternmed.2020.2306

As of early May 2020, approximately 65 000 people in the US had died of coronavirus disease 2019 (COVID-19),1 the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This number appears to be similar to the estimated number of seasonal influenza deaths reported annually by the Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm).

This apparent equivalence of deaths from COVID-19 and seasonal influenza does not match frontline clinical conditions, especially in some hot zones of the pandemic where ventilators have been in short supply and many hospitals have been stretched beyond their limits. The demand on hospital resources during the COVID-19 crisis has not occurred before in the US, even during the worst of influenza seasons. Yet public officials continue to draw comparisons between seasonal influenza and SARS-CoV-2 mortality, often in an attempt to minimize the effects of the unfolding pandemic.

The root of such incorrect comparisons may be a knowledge gap regarding how seasonal influenza and COVID-19 data are publicly reported. The CDC, like many similar disease control agencies around the world, presents seasonal influenza morbidity and mortality not as raw counts but as calculated estimates based on submitted International Classification of Diseases codes.2 Between 2013-2014 and 2018-2019, the reported yearly estimated influenza deaths ranged from 23 000 to 61 000.3 Over that same time period, however, the number of counted influenza deaths was between 3448 and 15 620 yearly.4 On average, the CDC estimates of deaths attributed to influenza were nearly 6 times greater than its reported counted numbers. Conversely, COVID-19 fatalities are at present being counted and reported directly, not estimated. As a result, the more valid comparison would be to compare weekly counts of COVID-19 deaths to weekly counts of seasonal influenza deaths.

During the week ending April 21, 2020, 15 455 COVID-19 counted deaths were reported in the US.5 The reported number of counted deaths from the previous week, ending April 14, was 14 478. By contrast, according to the CDC, counted deaths during the peak week of the influenza seasons from 2013-2014 to 2019-2020 ranged from 351 (2015-2016, week 11 of 2016) to 1626 (2017-2018, week 3 of 2018).6 The mean number of counted deaths during the peak week of influenza seasons from 2013-2020 was 752.4 (95% CI, 558.8-946.1).7 These statistics on counted deaths suggest that the number of COVID-19 deaths for the week ending April 21 was 9.5-fold to 44.1-fold greater than the peak week of counted influenza deaths during the past 7 influenza seasons in the US, with a 20.5-fold mean increase (95% CI, 16.3-27.7).5,6

The CDC also publishes provisional counts of COVID-19 deaths but acknowledges that its reporting lags behind other public data sources.7 For the week ending April 11, 2020, data indicate that the number of provisionally reported COVID-19 deaths was 14.4-fold greater than influenza deaths during the apparent peak week of the current season (week ending February 29, 2020), consistent with the ranges based on CDC statistics.6 As the CDC continues to revise its COVID-19 counts to account for delays in reporting, the ratio of counted COVID-19 deaths to influenza deaths is likely to increase.

The ratios we present are more clinically consistent with frontline conditions than ratios that compare COVID-19 fatality counts and estimated seasonal influenza deaths. Based on the figure of approximately 60 000 COVID-19 deaths in the US as of the end of April 2020, this ratio suggests only a 1.0-fold to 2.6-fold change from the CDC-estimated seasonal influenza deaths calculated during the previous 7 full seasons.3 From our analysis, we infer that either the CDC’s annual estimates substantially overstate the actual number of deaths caused by influenza or that the current number of COVID-19 counted deaths substantially understates the actual number of deaths caused by SARS-CoV-2, or both.

There are a number of considerations. Deaths from COVID-19 may be undercounted owing to ongoing limitations of test capacity or false-negative test results. When patients present late in the course of illness, upper respiratory tract samples are less likely to yield positive test results. Conversely, influenza counts may be less reliable because adult influenza deaths are not reportable to public health authorities, as is the case for COVID-19 deaths. Moreover, because adult influenza deaths are not reportable, epidemiologists must rely on surveillance mechanisms that attempt to account for potential underreporting.8 Similarly, some cities, such as New York City, are beginning to report cases of both probable and confirmed COVID-19 deaths. The inclusion of both probable and confirmed deaths has led to revised mortality figures that, in effect, straddle the line between counting and estimating the number of COVID-19 deaths. It is also possible that some deaths that have been labeled as having been caused by COVID-19 are not due to COVID-19. For example, in areas where there is high-level community spread, such as New York City, if a patient is brought to an emergency department in cardiac arrest and has a known positive real-time reverse transcriptase polymerase chain reaction test result for SARS-CoV-2, and dies, that would be considered a COVID-19 death in local death counts. Whether that death may have occurred anyway is impossible to say. Eventually, a fuller reckoning of the burden of disease that focuses on excess mortality, including both direct and indirect COVID-19–related deaths, will be helpful. That analysis will be most complete if it also considers the possibility of excess deaths owing to deferred care during the peak of the epidemic and the lack of capacity for care of patients without COVID-19 at overwhelmed hospitals.

Case fatality rates are another topic of confusion. Comparisons of the case fatality rates of SARS-CoV-2 and influenza are premature. Estimates of case fatality rates for COVID-19 range from less than 1% in some nations to approximately 15% in others. This wide range reflects limitations in calculating case fatality rates. These include failure to account for scarcity in testing (thereby falsely decreasing the denominator) and incomplete follow-up information for people who were critically ill but still alive when last assessed (thereby decreasing the numerator). Eventually, results from serologic studies will help to determine a more accurate denominator for the case fatality rate of SARS-CoV-2.

At present, the Diamond Princess cruise ship outbreak is one of the few situations for which complete data are available. For this outbreak, the case fatality rate as of late April 2020 was 1.8% (13 deaths out of 712 cases); age adjusted to reflect the general population, the figure would have been closer to 0.5%.1,9 A case fatality rate of 0.5% would still be 5 times the commonly cited case fatality rate of adult seasonal influenza.3,10

Directly comparing data for 2 different diseases when mortality statistics are obtained by different methods provides inaccurate information. Moreover, the repeated failure of government officials and others in society to consider these statistical distinctions threatens public health. Government officials may rely on such comparisons, thus misinterpreting the CDC’s data, when they seek to reopen the economy and de-escalate mitigation strategies. Although officials may say that SARS-CoV-2 is “just another flu,” this is not true.

In summary, our analysis suggests that comparisons between SARS-CoV-2 mortality and seasonal influenza mortality must be made using an apples-to-apples comparison, not an apples-to-oranges comparison. Doing so better demonstrates the true threat to public health from COVID-19.

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Article Information

Corresponding Author: Jeremy Samuel Faust, MD, MS, Harvard Medical School, Brigham and Women’s Hospital, Division of Health Policy and Public Health, Department of Emergency Medicine, 10 Vining St, Boston, MA 02115 (jsfaust@gmail.com).

Published Online: May 14, 2020. doi:10.1001/jamainternmed.2020.2306

Conflict of Interest Disclosures: None reported.

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16 Comments for this article
Daniel Goyal, MRCP, PhD | Gibraltar Health Authority
I welcome this clear and succinct account of reality. A useful reminder too, that simply increasing the denominator will not lower the total number of deaths.
Many thanks
PETER DAMIANIDIS, B.S. | Navy Marine Corps Public Health Center Virginia
Dr. Deborah Birx stated during a White House press conference that all deaths with COVID are counted as a COVID deaths. How is this factored into the conclusions of the article? If someone presents to a medical center with heart disease, stroke, car accident, or drowning and die, and they test positive, how are they counted? If these deaths are considered COVID deaths, thereby inflating the numerator, doesn't that seem somewhat disingenuous?
Valid Comparisons of Deaths from COVID-19 and the Seasonal Flu
Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
The invaluable and informative Viewpoint by two experts compares the officially documented weekly counts of COVID-19 deaths with the estimated weekly counts of seasonal influenza deaths, with an emphasis on the serious threat to public health.

Although the numbers of reported cases and deaths arising from COVID-19 vary daily, as of 15 May 2020, the number of confirmed cases was approaching 1.5 million, with the number of reported deaths at 87,000 (Worldometer, https://www.worldometers.info/coronavirus/).

Despite the marked disparity in the numbers of official deaths from COVID-19 and the estimated number from the seasonal flu, political considerations, consciously or otherwise,
have led to inappropriate comparisons between the two viral infections.

Seasonal flu patterns have been monitored for over sixty years since the first safe and effective monovalent flu vaccine was invented in 1938.

In comparison, COVID-19 cases have been monitored for less than four months.

A minimum of one year is essential to be able to detect a seasonal pattern in any set of data, so it is still too early to infer any seasonal patterns in COVID-19 due to a lack of data availability and frequency.

If COVID-19 does not disappear "magically" in the foreseeable future, as is likely, seasonal patterns will be observed, with higher infection rates during the colder months.

As a statement of fact, the worst is yet to come.
Public Health reporting needs to improve: will it?
B Magee, MD, MS |
This article makes important points regarding the failure of our data sources to provide accurate, actionable information. The CDC data needs to be more timely, data collection needs to either be standardized with other diseases or the differences made apparant and explained.

Politicians will never be up to the task of nuancing data and will always put the spin on that suits them, as do the flood of experts competing for attention. Nothing new here.

Meanwhile, this pandemic has exposed a multitude of opportunities to improve our public health system data collection and reporting from the
localities up to the CDC. Improvement, however, may require more than developing new processes. The organizations have been underperfoming for decades and the culture may be imbedded. Don't look for any miracles with an administration change.
Advance Care Planning in Nursing Facilities using Covid-19 data
Robert Houston, Associate Professor | Spartanburg Family Practice Program. Spartanburg, SC.
I am a board certified Family Physician in an educational program in Spartanburg, SC. I have added qualifications in Geriatrics and Hospice & Palliative Care. The current CDC policy response on the Covid-19 pandemic discussed in this article has focused on mortality with Covid-19 and influenza. The data presented in the literature is population based and not patient based. It is data being used and argued with health care planners, funding, etc. I am trying to educate our physicians about how to present this data to "individual patients" that are currently in "lock down" at our local nursing facilities.

Currently their patients are in "lock down" with the national emergency response. The Covid-19 data presented in this article and multiple other articles shows that the Geriatric population is at the highest risk for dying with Covid-19 but as a practicing Palliative Care physician, Quality of Life is frequently more important than Quantity of Life. Mortality data may be useful to health care planners but we need to give our "locked down" elderly a choice and use good "science."

Social distancing and masks are types of "treatments." What is the "number needed to treat" to save one life and which life will it save? Are these "treatments" based on "expert opinion" or evidence based medicine. Should the Geriatrician recommend DNR to Long Term Care patients if they get Covid-19? I think we have and ethical obligation to give these patient's choice and "informed consent".

R Houston
Is that the real question?
Joseph DeRose, OD, MS |
Thank you for the article. The article is interesting but the discussion is academic.

Shouldn't the real question be are we doing this the correct way given the immense collateral damage? Of course there will be more reported deaths of Covid-19 - no one until now has immunity nor has been vaccinated as is the case with influenza. And the shutdown may be preventing the important herd immunity that helps limit pandemic damage.

Where are the other facts though? What is the medical profile of the people dying from Covid-19. What per-existing conditions and comorbidities existed in the
patients on the cruise ship? Surely they would have been easily obtained. How many were very obese, smokers, have existing lung disease, etc? Why is medicine not releasing these data?

If in fact the majority of deaths are in older people with significant comorbidities, why keep young healthy people from going to work? I admire your answer but I think you asked the wrong question. Thank you.
Believe we are far from any Apples to Apples comparison
Tom Kocsis, BSME, MSTelecom | Engineer - IT Professional
Interesting article but filled with assumptions and speculation in my opinion. The same criticisms of the way Influenza cases are reported can be made against the way that Covid-19 cases are being counted. I have yet to see the data showing how many of the reported Covid-19 deaths had a confirmed test associated with them versus an medical diagnosis without a test. If it exists, would like to see that data. Further, how many Covid-19 patients are also being tested for Influenza? It would be very interesting to know whether any of these patients that died had both infections. Further, the counting of Covid-19 cases, based on the guidance I've read at CDC appears to give medical professionals very broad discretion in declaring a case "probable" outside of an actual test to confirm the existence of a Covid-19 infection. There are still many unanswered questions and the discovery will be ongoing for years. While I appreciate the article for its benefit in generating discussion and providing a viewpoint, I would also say the methodology and assumptions made to arrive at this very speculative assessment conclusion of Covid-19 being 20x more deadly than Influenza is open to many questions and critique. As Dr Fauci likes to say, the models are only as good as the assumptions put into them. I believe it will be years before any accurate and reliable "apples to apples" comparison can be made between Covid-19 and Influenza when we hopefully will have more complete, accurate and vetted data to use in this kind of comparison. Thanks.
This does not add up
Daniel Rebich, Construction Management | Confused Citizen
The data from CDC's FluInteractive seasonal flu P&I Mortality (deaths from Flu & Pneumonia) is as follows:

2019/2020 136k deaths (up to week 18)
2018/2019 176k deaths
2017/2018 195k deaths
and so on.

How is it that, when comparing Covid-19 deaths to the seasonal flu, you only compare it to deaths directly from the seasonal flu and not include pneumonia deaths from the seasonal flu?
And if you were to make the comparison, wouldn't you want to make the comparison equal? Why include
"presumed" deaths with Covid-19. Or "heart attack" deaths but counted as Covid-19?

The data from Flu Interactive P&I Mortality is the CDC's data, not mine. You may be using a totally different set of data from the CDC in regards to the seasonal flu. I don't know, but in my view this comparison is not an equal comparison at all and  the Covid-19 deaths are in truth much lower.

A very interesting side note. When you chart the CDC Flu P&I Mortality for this season, there is an incredible spike in P&I deaths right after week 12, the week that we were all put on self quarantine, stay at home, etc. Week 12 (4717 deaths), week 15 (10,879 deaths highest ever), but by week 18 (1637 deaths, lowest ever). Does this show that sheltering in place was a horrible idea? And does it also show that Covid-19 "cured" the seasonal flu by week 18? Or did those deaths in week 18 (which is normally very similar year to year) get counted as Covid-19 deaths.

Perhaps this is all a misunderstanding for those of us that are not medically trained, but numbers are numbers and facts are facts. If it is not a misunderstanding, and is being deliberately hyped to deceive, that would be wrong.
With vs From
Rickard Gardell, Bachelor of science | Corporate
I am not a medical doctor but my medical friends always told me from the beginning of the covid outbreak that flu deaths are very narrowly counted(from) vs Covid that is very broadly counted (with). To be consistent with a covid comparison one would have to record every death that had a presence of influenza A or B. This flu number would obviously be much larger than the authors use and would be an intellectually honest comparison. I must say that I am surprised that “experts” fail to make that observation.
Best data to look for is number of
total deaths between January-December for 2020 and compare that to a year(or a twelve months period) for a bad influenza year( in the US it would be the 2017/18 season. This should give you a true sense of the relative difference in morbidity.
Beyond fuzzy picture of mortality outcome
Simo Du, MBBS, MHS | Healthcore, Inc.
Being a researcher in health outcome research fields, I do understand that mortality can be the most important while tricky and difficult to ascertain health outcome, especially when we talk about cause specific deaths: The complex chain of death related events, unclear immediate,sequential and underlying cause of death, different reporting standards and incompleteness of the death certificates... all contribute to this fuzzy picture. Not to mention the undertested cases of COVID-19 and the death occurred outside of hospitals for both covid and influenza cases.Instead of waiting for the data to be complete and accurate to make apple-to-apple comparison, I think we have to live with the fact that the pictures of mortality outcome may never get clear, all we can do is to understand the data limitation and move forward to get a comprehensive pictures from combined knowledge from different fields and perspectives.

For example,we may need to understand how different the demographic and comorbidity profiles of patients being infected with influenza vs COVID-19 look like, what does it mean for a recent finding in Italy reporting Kawasaki like cases in children infected with COVID-19 [1], which nearly never occured in influenza. Similarly, it's not uncommon for patients infected with COVID-19 to present and even die from myocardial injuries [2], especially YOUNG ADULTS, which could be attributed to cytokine storm while it's a different story for influenza. Moreover, the increased D-dimer values in COVID patients, the common cause of death due to pulmonary embolism(PE) in COVID patients confirmed by autopsy all pointed to some different direction than influenza.

None of these discoveries are definite and although most people are uncomfortable with uncertainty,the only thing we are certain is the uncertainty of COVID-19. However, understanding these differences between two viruses, the distinct disease mechanisms, natural history of disease and prognosis, transmission pathway etc. , we may be able to connect the dots and piece the puzzles together using these fuzzy pictures and clues.

For officials and reporters, instead of using data with so many limitations to draw dangerous conclusion and influence the public, maybe they should "show, but don't tell" by presenting the evidence and mentioning about the caveats behind the fuzzy pictures;

[1] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31129-6/fulltext

lies, danmed lies and statistics
Jeff Truman, M.A.Sc | Independant engineering consultant
Good article and study. A step towards better understanding of statistics in medicine would be a great benefit.

Since flu deaths are not required to be counted, and pneumonia is a direct effect of the flu and those deaths are also not fully tested, are flu deaths not even higher?

Is it possible that the number COVID-19 deaths is greater because flu is impacting people as well? Which is the one causing lung failure, if flu can lead to it as well?

Ignoring science
Kenneth Murphy, MD | The Murphy Clinic
This report illustrates a vital fact that medical researchers, physicians and medical leaders have failed to tell the public and our leaders at all levels. At this critical point in time science is being ignored. We should all take every opportunity to inform anyone who will listen that it is imperative that we heed the recognized medical leaders of this fight against pandemic, Not the politicians, the talking heads and the self-proclaimed experts that have popped up like whack-a-moles. We all should teach others that there are recognized ways to conduct medical research, that science cannot be rushed and that one must look at results with a critical eye (one not focused on dollars). We as physicians should be leading this charge.
Harnessing science for spatiotemporal models for public health actions in pandemic - precision in medicine and public health
Evelyne Bischof, MD | Shanghai University of Medicine and Health Sciences
While the Viewpoint induces a variety of collateral aspects and debates, it is worth mentioning that the current pandemic leads to an explosive harnessing of novel technologies in order to accelerate a medical response (e.g. drug discovery and repurposing, vaccine development, invasive approaches etc.). However, despite intensive efforts of various groups and global consortia to develop models of social measures against COVID-19, these were not adequately used for the public health response. Surely, considering solely the current mortality statistics is by far not sufficient to make statements at the policy level, especially considering the extremely complex interrelation and distinct character of influenza and Covid-19.

Prompt but elaborated use of organizational and operational multidisciplinary teams are incumbent to develop approaches against the existing, but also future pandemics. Joining forces of public health, policymakers, and multidisciplinary scientific groups in regard to expertise is crucial to harness navigating pillars of patient care, avoiding rushed decisions, and popularism.
Comparing a Mean to a Peak?
Brian McIntyre, MS | Media
I’m not suggesting that there is an equivalency between the two, but I am concerned about the approach of comparing the peak weeks of Covid with the average week of Influenza. The article correctly states that the CDC only estimates flu deaths. Isn’t it possible those underestimate the impact? We know that if a person that has comorbidity issues and dies with Covid, the cause of death is being logged as Covid. However, if a person with comorbidity issues dies while also having the flu, is the cause of death being logged as influenza?

Hawthorne effect, local rules, and image
Paul Kivela |
First of all, I appreciate your attempt to look at this and compare apples to apples. The issue here is can we use this to educate our patients, politicians and our colleagues. Without adequate and accurate testing we really don't know how many people have been exposed to COVID-19, whether asymptomatic or even mildly people mount an antibody response, whether viral load is a factor, and the politics of local officials not wanting to test people because they don't want to alarm their communities or shut down local economies. Everybody on the front lines at least early on saw patients that now clearly had COVID-19 but the tests were negative. We all have seen people that have pulse ox of 70% and look pretty damn good. In my humble opinion, we need to know a lot more before we can make an accurate estimate of mortality. This is all without direct mention of the social disparities in health which unfortunately clearly is also part of our challenge.
compare adjusted death counts between Covid-19 and influenza
Bruce Nelson, Doctorate in Biology | National Institute for Amazon Research
Authors state "the more valid comparison would be to compare weekly counts of COVID-19 deaths to weekly counts of seasonal influenza deaths."
The more valid comparison would be between the adjusted numbers, not the counts. Excess deaths in the USA from all causes during the Covid pandemic were only 28% above counted COVID deaths (Weinberger et al. 2020, JAMA). Multiply flu counts by about six (CDC correction) and multiply COVID-19 counts by 1.28 and then compare.