How Bad is COVID-19 Really?
COVID-19 is significantly worse than you probably think it is. To understand how seriously we need to take COVID-19, let’s compare it to some other major disease events like the worst flu season on record and the worst pandemic in US history.
COVID-19 vs The Flu
To compare the same time frame of a year of the flu vs a year of COVID-19, COVID-19 totals have been doubled for the sake of simplicity. I consider this a conservative estimate given new cases are reaching an all-time high and are likely to continue above levels reached in the first half of the year.
| Average Flu Season | Worst Flu Season 2017-2018 | COVID-19 – extrapolated for 1 year in the US | |
| Deaths | 36,500 | 61,000 | ~300,000 – Note 1 |
| Infection fatality rate | .1% | .1% | 1% – Note 3 |
| Case fatality rate | .1% | .1% | 5% |
| Hospitalizations | 450,000 | 810,000 | 3,000,000 |
| Hospitalization rate | .7% | 1.8% | 10% |
| Long term complications | Minimal | Minimal | Significant |
| Infections | 28,000,000 | 45,000,000 | 30,000,000 – Note 2 |
Note 1: includes excess death counts
Note 2: CDC estimates 15M people or 5% of the US population have been infected based on antibody testing.
Note 3: The infection fatality rate is the number who have died over the total number of infections. The case fatality rate is the number who have died over the total number of confirmed cases. In diseases like the flu, they are almost identical, for COVID there is a large divergence because of the number of asymptomatic cases.
Examining the chart above you’ll see COVID-19 is 14x more deadly than the flu, and could claim more than ~8x more lives in a year than in the average flu season, and ~5x the worst flu season on record. This estimated number of fatalities is after significant intervention and lockdowns to control the disease. Scientists estimate 14x more cases had these steps not been taken.
Long Haulers
A lot of COVID-19’s destruction gets lost if we only look at the death rate. There are numerous lesser-known and longer-term effects of the disease that have significant impact.
Preliminary studies show that almost 90% of patients report at least 1 lingering symptom 2 months post-recovery. The most common symptoms are fatigue, difficulty breathing, joint pain, chest pain, coughing, and the loss of smell. Patients are also experiencing permanent heart damage that increases their chance of heart attacks, permanent lung damage sometimes requiring lung transplants, permanent kidney damage requiring long term dialysis, permanent liver damage, and permanent brain damage. Other symptoms include blood clots, PTSD, depression, and long-lasting cognitive impairment.
| % of hospital patients | |
| Heart Damage | 19%-78% |
| Lung Damage | 61%-77% |
| Neurological Damage | 36%-55% |
Note: Based on preliminary limited studies.
For those patients who are admitted to the ICU, the results are even worse. ICU patients that are intubated, sedated, and isolated in a hospital bed, often experience a terrifying delirium that lasts days. During this time they are unable to tell the difference between hallucinations and reality.
Theodore Iwashyna, an ICU physician-scientist at the University of Michigan and VA Ann Arbor goes on to explain “about half of people have some substantial new disability, and half will never get back to work. Maybe a third of people will have some degree of cognitive impairment. And a third have emotional problems.”
Other patients, called long haulers, are still systematic and are testing positive months later.
Michael Peluso, a clinical fellow in infectious diseases at the University of California San Francisco says, “It’s not necessarily just the sickest patients who experience long-term symptoms, but often people who weren’t even initially hospitalized.” Some people are asymptomatic and are still found to have sustained lung damage.
One child born with COVID-19 has shown signs of systemic inflammation and neurological injury.
Many of the long term effects are just now being studied and it will take some time before we understand how prevalent and persistent they are. Studies on the long term effects of SARS patients, taken 2 years post disease, showed 50% of patients had reduced exercise capacity. Only 78% were able to return to full-time work 1-year post-infection. Another 40% developed chronic fatigue and 27% had chronic fatigue syndrome, a debilitating disease that can last years or decades, with no known cure or treatment protocol.
Comparing Pandemics: COVID-19 vs the Flu of 1918
Let’s compare the final result of the 1918 Flu Pandemic vs what it would take to reach herd immunity for COVID-19, absent any development of a robust drug treatment protocol or vaccine. It is projected that 60-80% of a population would have to be infected to reach herd immunity. Additionally, based on the above data, we can assume from 25-50% of hospital patients will require long term care. The best-case scenario is infection of 60% of the populations to reach herd immunity with 25% hospitalizations requiring long term care, and the worst-case scenario is 80% to reach herd immunity at 50% hospitalizations requiring long term care. The 1918 Flu Pandemic has also been adjusted to today’s population levels to have an appropriate comparison.
| Flu Pandemic of 1918 | Flu Pandemic Adjusted (3.2x) | COVID-19 Best Case | COVID-19 Worst Case | |
| Deaths | 500,000-850,000 | 1.6M – 2.7M | 2,000,000 | 2,650,000 |
| Hospitalizations | Insufficient data | Insufficient data | 20,000,000 | 25,000,000 |
| Fatality Rate | 2% | 2% | 1% | 1% |
| Infections | 25,000,000 | 80,000,000 | 198,000,000 | 264,000,000 |
| Long Term Care | none | none | 5,000,000 | 12,500,000 |
Note: based on the best available current information and subject to change as new evidence emerges.
Until scientists successfully develop a vaccine or robust drug protocol, we must acknowledge that this path is the current trajectory. This chart should make clear that three problems need to be addressed:
Deaths
If left unchecked the coronavirus pandemic will kill as many people as the worst pandemic in US history. Utilizing masks and hygiene standards, drug development, and a vaccine would prevent this scenario from happening, while cases surging and overwhelmed hospital capacity will make it more likely.
Hospitalizations
There are about 1,000,000 hospital beds spread across the US, with 68% occupied for normal operations, which leaves about 300,000 beds available to accommodate new COVID-19 patients, which could reach 20-25M. Cases surge in different geographical areas, but those hospital beds are static across the country. Hospitals in Texas and Florida have maxed out their ICU and bed capacity and have had to turn patients away, leading to some deaths. One hospital in Texas is so overwhelmed they are deciding which patients are unlikely to survive and are sending them home to die. Many have rented refrigerated trucks to handle the overflow of bodies from their overfilled morgues. Transfer patients and elective surgeries have stopped in some counties that are already nearing capacity or merely anticipating a coming surge.
Preparedness
The military prepares for combat situations by developing readiness, which includes readying not only the supplies necessary for combat, but also the mental and physical condition of its soldiers. The pandemic has created a situation of diminished healthcare readiness.
Supplies
As demand increases, so does the demand for Personal Protective Equipment (PPE), ventilators, test kits, and drugs. In Arizona, as hospitals reach capacity medical care rationing is becoming a possibility, with patients either sharing a ventilator or not getting one at all. Additional patients will also consume the hospital’s limited supply of drugs and PPE. According to Labcorp CEO Adam Schechter, the virus is spreading faster than their ability to expand testing capacity which causes long delays in receiving results. While we don’t have the same shortages of PPE as we did in March, a lack of supplies has started to arise in some areas like Corpus Cristi, Texas where limits have been placed on mask and gown use. The number of new cases are now double what they were in April of this year, which could easily create a situation where demand outstrips supply.
Physical and Mental Fitness
It is unrealistic to expect healthcare workers to be at peak performance after working 12-18hrs shifts 6 days a week and being isolated away from one’s family on the 7th day. Healthcare workers’ mental and emotional well being is also being assaulted at a level never before seen outside of the battlefield. Having a patient die is stressful, losing historic levels of patients day in day out is more stressful. Losing a coworker is virtually unheard of, and fearing you’ll be next is emotionally and physically exhausting. In the military, there are mandated rest and recovery periods to rotate soldiers out and bring in reinforcements. In these hospitals, there are no recovery periods and states have little capacity to send in reinforcements. Eventually, healthcare professionals will walk away if they feel abandoned by their country and company as seen in New York City. In April, 60% of healthcare workers said they were planning to quit if they couldn’t get the PPE they need. A study published in JAMA found patients in overburdened hospitals are 300% more likely to die than adequately staffed and provisioned hospitals.
Failing to maintain hospital capacity is a self-reinforcing cascade that diminishes our ability to fight the disease and could result in exponential increases in all-cause mortality.
Long Term Care
For every person who dies another five could have life long complications and require long term health care. Dr. Zijian Chen, medical director at Mount Sinai’s Center for Post-COVID Care says, “If you look at the total cases, even if a small percentage have these post-COVID problems, we’re going to be in a lot of trouble. That would be an immense number of patients. Our health system cannot take care of that many people.”
There will be a crisis in ensuring patients can receive the physical and mental healthcare they need. This is occurring at a time when 5.4M people lost their health insurance, a 40% increase over any annual loss ever recorded.
It Doesn’t Have To Be This Way
If you get sick, you have a 50% chance of being asymptomatic and infecting others, a 35% of having significant symptoms lasting weeks to months, a 10% chance of becoming hospitalized, a 5% chance of developing long term to permanent health problems, and a 1% chance of dying in the next 30 days. But, we have the ability to keep that from ever happening.
The CDC announced that if everyone wore a mask, COVID-19 would be under control in 4-8 weeks. In one simulation, scientists predicted that 80% of a population wearing masks would do more to prevent COVID-19 spread than a strict lockdown alone. A new study published in JAMA found mask-wearing not only decreases the spread of the virus but also decreases the disease severity of those who do get sick. In at least one outbreak, the data suggests that the use of masks increased the incidence of asymptomatic infections to 95%. While infections were not eliminated, their impact was diminished. We’ve seen this strategy work in places like Japan and Hong Kong who, which are next door to the disease epicenter yet have seen less than 1,000 and ~10 deaths respectively. Universal mask coverage is the single biggest and minimally intrusive lever we can pull to contain the spread of COVID-19. So please, wear a mask anytime you think you might come into contact with others, it isn’t worth the risk.
