Comparison of Estimated Excess Deaths in New York City During the COVID-19 and 1918 Influenza Pandemics | Infectious Diseases | JAMA Network Open | JAMA Network
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Figure.  Deaths in New York City During the 1918 H1N1 Influenza Pandemic and the Coronavirus Disease 2019 (COVID-19) Pandemic and During the Preceding Years of Both Pandemics
Deaths in New York City During the 1918 H1N1 Influenza Pandemic and the Coronavirus Disease 2019 (COVID-19) Pandemic and During the Preceding Years of Both Pandemics
1.
Centers for Disease Control and Prevention. Excess deaths associated with COVID-19. Published July 1, 2020. Accessed July 7, 2020. https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm
2.
Centers for Disease Control and Prevention. Products—vital statistics of the US 1890-1938. Published June 6, 2019. Accessed July 7, 2020. https://www.cdc.gov/nchs/products/vsus/vsus_1890_1938.htm
3.
NYC Health. COVID-19: data summary. Accessed July 7, 2020. https://www1.nyc.gov/site/doh/covid/covid-19-data.page
4.
Centers for Disease Control and Prevention. National Center for Health Statistics Mortality Surveillance System. Accessed July 7, 2020. https://gis.cdc.gov/grasp/fluview/mortality.html
5.
US Census Bureau.2017 National population projections tables: main series. Accessed July 15, 2020. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html
6.
Pew Research Center. US politics & policy. Published April 16, 2020. Accessed July 7, 2020. https://www.pewresearch.org/politics/2020/04/16/most-americans-say-trump-was-too-slow-in-initial-response-to-coronavirus-threat/
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    4 Comments for this article
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    COVID-19 and 1918 Death Rate NYC Comments.
    Gary Ordog, MD, DABEM, DABMT | County of Los Angeles, Department of Health Services, (retired)
    Thank you for your interesting article. My writing here is precipitated by the fact that COVID-19 is not over yet. Yes, so far, COVID-19 appears to be following the death curve of 1918, and we in the Americas are on the upslope of Phase Two of Three, as happened in 1918. Even the Reopening Trough One of COVID-19 was similar to that of 1918, with protests and rioting. In 1918 Phase Two was worse than Phase One, we shall possibly witness similar figures in the next few months. With no valid cure as yet, we are dependent on the administration of a 'good' vaccine to put an end to this. Hopefully, it will be in time to prevent the Trough Two, followed by more public insurrection and finally, Phase Three. The 1918 flu had no cure or vaccine, but we now have the hope of a 'good' vaccine which should prevent the decimation that COVID-19 would have projected for the next two years. Thank you and stay safe until then.
    CONFLICT OF INTEREST: None Reported
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    Discrepancies in Data for 1918 H1N1 influenza outbreak in NYC
    Israel Kochin, MD | NY Presbyterian Brooklyn Methodist Hospital
    If one compares other available published data on death rates/age group in NYC from just 3 months of 1918 - in no single demographic group was the rate lower than 9/1000, and mostly it was about 2-3 times that in most demographic groups for just 3 months of Spanish Flu  [source: "City of New York, Death rates from influenza, September to November 1918. Monthly Bulletin of the Department of Health, December 1918. NYC Municipal Library" available at https://www.nytimes.com/2020/04/02/nyregion/spanish-flu-nyc-virus.html ]. However, this study reports that NYC emerged with a mortality rate of about "287.17 deaths per 100,000" (less than 3/1000) in NYC, according to Faust's research as described in https://www.nytimes.com/2020/08/13/health/coronavirus-flu-new-york.html. Could this discrepancy result from NYC public officials a 100 years ago falsifying data, and yet fail to falsify all the data which accounts for the demographically adjusted numbers being several times worse? Comparing to other, even less crowded US cities, it looks more like the demographically adjusted NYC graph  ["City of New York, Death rates from influenza, September to November 1918. Monthly Bulletin of the Department of Health, December 1918. NYC Municipal Library" available at https://www.nytimes.com/2020/04/02/nyregion/spanish-flu-nyc-virus.html ], than the official total death rate for NYC: "...the City fared much better than most counterparts with a rate of 3.9 deaths per thousand residents" [https://www.archives.nyc/blog/2018/3/1/the-flu-epidemic-of-1918]. As we know in other cities in the USA and around the world the mortality rate from influenza was more than 10x worse, or about 5%, which should reflect about 275,000 deaths for NYC alone (based on a population of 5.5 million) and would reflect our historical sense of the Spanish Flu epidemic as being severe.
    CONFLICT OF INTEREST: None Reported
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    Response
    Jeremy Faust, MD, MS | Brigham and Women's Hospital, Harvard Medical School
    Correction: the Y axis in the figure should read "person-months" instead of "person-weeks." All other information remains the same (the bar graphs and integers provided in the text are correct).

    The 1914-1918 data we obtained was from the US Bureau of Labor and Statistics, and is housed by the US Centers for Disease Control and Prevention online. To clarify, we compared the incident rates for all-cause deaths in the first 61 days in which deaths occurred in New York City in 2020 due to COVID-19 to the 61 days of October and November of 1918. The incident rates and
    ratios reported reflect these time periods alone, and can not be extrapolated. They do, we feel, provide an important insight into the scale of the COVID-19 outbreak in New York City during the early pandemic periods.
    CONFLICT OF INTEREST: None Reported
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    Years of life lost per death by COVID-19 versus the 1918 Spanish Flu
    David Keller, MS, MD | Independent Internal Medicine Physician
    Comparing the mortality associated with the COVID-19 pandemic to the mortality observed during the 1918 H1N1 influenza pandemic does not account for the larger number of years of life lost per death due to the 1918 pandemic, even after accounting for shorter life expectancy at every age in 1918 compared with today.

    For example, the CDC reports the median age of death due to COVID-19 in the U.S. is over age 75, and about 80% of COVID-19 deaths occur in patients over the age of 65. The life expectancy for a 75 year old man at present is
    about 11 years.

    The CDC also states that the median age of death due to the 1918 influenza pandemic was 28 years of age. A 28 year old man had a life expectancy of approximately 65 years in that era, so this median patient lost about 37 years of life due to the 1918 flu pandemic.

    So, for a patient who succumbed to the 1918 Spanish Flu pandemic at its median age of death lost 37 years of expected life, while a patient who succumbed to the COVID-19 pandemic at its median age of death lost 11 years of expected life. These figures illustrate that one death is not equivalent to another when comparing the devastation on families and society caused by deaths during these two pandemics.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    Public Health
    August 13, 2020

    Comparison of Estimated Excess Deaths in New York City During the COVID-19 and 1918 Influenza Pandemics

    Author Affiliations
    • 1Brigham and Women’s Hospital, Division of Health Policy and Public Health, Department of Emergency Medicine, Harvard Medical School, Boston Massachusetts
    • 2Yale New Haven Hospital, Center for Outcomes Research and Evaluation, New Haven, Connecticut
    • 3Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
    • 4Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, Georgia
    JAMA Netw Open. 2020;3(8):e2017527. doi:10.1001/jamanetworkopen.2020.17527
    Introduction

    During the 1918 H1N1 influenza pandemic, there were approximately 50 million influenza-related deaths worldwide, including 675 000 in the US. Few persons in the US have a frame of reference for the historic levels of excess mortality currently being observed during the coronavirus disease 2019 (COVID-19) pandemic.1 In this study, excess deaths in New York City during the peak of the 1918 H1N1 influenza pandemic were compared with those during the initial period of the COVID-19 outbreak.

    Methods

    This cohort study compared the incident rates of all-cause mortality in New York City during the peak of the 1918 H1N1 influenza pandemic and the early COVID-19 outbreak in 2020 using public data from the Centers for Disease Control and Prevention (1914-1918), The New York City Department of Health and Mental Hygiene (2020), and the US Census Bureau (2017-2020).2-5 This study was deemed to be exempt from institutional review approval because it used publicly availably data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Analyses were performed using SAS, version 9.4 (SAS Institute). Incidence rate per person-months and corresponding 95% CIs were calculated for October and November (61 days) from 1914 through 1918, and for March 11, 2020, through May 11, 2020 (61 days), separately. Sixty-one day incident rates were divided by 2 to obtain person-month units. To compare the all-cause mortality between 2020 and 2019, an incidence rate ratio and its corresponding 95% CI was calculated.

    Results

    During the peak of the 1918 H1N1 influenza outbreak in New York City, a total of 31 589 all-cause deaths occurred among 5 500 000 residents, yielding an incident rate of 287.17 deaths per 100 000 person-months (95% CI, 282.71-291.69 deaths per 100 000 person-months) (Figure, A). The incident rate ratio for all-cause mortality during the H1N1 influenza pandemic compared with corresponding periods from 1914 to 1917 was 2.80 (95% CI, 2.74-2.86). During the early period of the COVID-19 outbreak in New York City, 33 465 all-cause deaths occurred among 8 280 000 residents, yielding an incident rate of 202.08 deaths per 100 000 person-months (95% CI, 199.03-205.17 deaths per 100 000 person-months) (Figure, B). The incident rate ratio for all-cause mortality during the study period of 2020 compared with corresponding periods from 2017 through 2019 was 4.15 (95% CI, 4.05-4.24). The incident rate ratio for all-cause mortality during the peak of the 1918 H1N1 influenza pandemic and the early 2020 COVID-19 outbreak was 0.70 (95% CI, 0.69-0.72).

    Discussion

    This cohort study found that the absolute increase in deaths over baseline (ie, excess mortality) observed during the peak of 1918 H1N1 influenza pandemic was higher than but comparable to that observed during the first 2 months of the COVID-19 outbreak in New York City.

    However, because baseline mortality rates from 2017 to 2019 were less than half that observed from 1914 to 1917 (owing to improvements in hygiene and modern achievements in medicine, public health, and safety), the relative increase during early COVID-19 period was substantially greater than during the peak of the 1918 H1N1 influenza pandemic.

    One limitation of this study is that a direct comparison of the native virulence of the 1918 H1N1 influenza strain and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not possible. It is unknown how many deaths due to SARS-CoV-2 infection have been prevented because of modern interventions not widely available a century ago, including standard resuscitation, supplemental oxygen, mechanical ventilation, kidney replacement therapy, and extracorporeal membrane oxygenation. If insufficiently treated, SARS-CoV-2 infection may have comparable or greater mortality than 1918 H1N1 influenza virus infection.

    These findings suggest that the mortality associated with COVID-19 during the early phase of the New York City outbreak was comparable to the peak mortality observed during the 1918 H1N1 influenza pandemic. Recent polling indicates that a majority of individuals in the US believe that some states lifted COVID-19 restrictions too quickly.6 Specifically, shutdowns did not adequately lower caseloads in many areas, meaning that subsequent spikes in new cases during the summer stretched US hospital resources in many areas. We believe that our findings may help officials and the public contextualize the unusual magnitude of the COVID-19 pandemic, leading to more prudent policies that may help to decrease transmission by decreasing the effective reproduction number of SARS-CoV-2 and prevent the exhaustion of essential supplies of life-saving resources in the coming weeks and beyond.

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    Article Information

    Accepted for Publication: July 9, 2020.

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Faust JS et al. JAMA Network Open.

    Published: August 13, 2020. doi:10.1001/jamanetworkopen.2020.17527

    Correction: This article was corrected on September 9, 2020, to fix the y-axis labels in the Figure.

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

    Author Contributions: Dr. Faust had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Faust, del Rio.

    Acquisition, analysis, or interpretation of data: Faust, Lin.

    Drafting of the manuscript: Faust, del Rio.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Faust, Lin.

    Administrative, technical, or material support: del Rio.

    Supervision: Faust.

    Conflict of Interest Disclosures: Dr Lin reported working under contract with the Centers for Medicare & Medicaid Services. Dr del Rio reported receiving grants from the National Institute of Allergy and Infectious Diseases, National Institutes of Health during the conduct of the study. No other disclosures were reported.

    References
    1.
    Centers for Disease Control and Prevention. Excess deaths associated with COVID-19. Published July 1, 2020. Accessed July 7, 2020. https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm
    2.
    Centers for Disease Control and Prevention. Products—vital statistics of the US 1890-1938. Published June 6, 2019. Accessed July 7, 2020. https://www.cdc.gov/nchs/products/vsus/vsus_1890_1938.htm
    3.
    NYC Health. COVID-19: data summary. Accessed July 7, 2020. https://www1.nyc.gov/site/doh/covid/covid-19-data.page
    4.
    Centers for Disease Control and Prevention. National Center for Health Statistics Mortality Surveillance System. Accessed July 7, 2020. https://gis.cdc.gov/grasp/fluview/mortality.html
    5.
    US Census Bureau.2017 National population projections tables: main series. Accessed July 15, 2020. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html
    6.
    Pew Research Center. US politics & policy. Published April 16, 2020. Accessed July 7, 2020. https://www.pewresearch.org/politics/2020/04/16/most-americans-say-trump-was-too-slow-in-initial-response-to-coronavirus-threat/
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