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COVID-19 Clinical Outcomes

COVID-19 in Italy: Why is the Case Fatality Rate So High?

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BACKGROUND AND PURPOSE:

  • Number of COVID-19 cases in Italy grew exponentially
    • Beginning of February: 3 cases | Related to international travel
    • February 20: Severe case in Lombardy not tied to travel
    • Within 14 days, multiple cases, many critical
  • SARS-CoV-2 likely circulating in Italy undetected since January
  • Onder et al. (JAMA, 2020) provide a review on the Italian experience with the COVID-19 pandemic

METHODS:

  • Review (through March 17)
  • Setting: Italy
  • Surveillance of COVID-19 cases
    • The Italian National Institute of Health (ISS) : Data From all 19 regions and 2 autonomous provinces
    • COVID-19 identification: real-time RT-PCR
    • Fatality rate was calculated as the number of deaths/number of cases

RESULTS:

  • Overall COVID-19 fatality rate: 7.2%
    • Total fatalities: 1625
    • Total cases: 22,512
  • The fatality rate in Italy is higher than other countries
    • Italy’s case fatality rate: 7.2%
    • China’s case fatality rate: 2.3%

Possible Factors Contributing to Italy’s High Fatality Rate

Age of Population

  • 23% of the Italian population is ≥65 years
  • Stratified by age: The case-fatality rate in Italy and China are
    • Similar for age groups age groups 0 to 69 years
    • Higher in Italy for those in age groups ≥70 years
  • Cases skewed toward people >70 years in Italy
    • Italy: 37.6%
    • China: 11.9%
  • Age >90 years
    • Italy: 687 cases with 22.7% fatality
    • China: No cases reported

Case Definition of COVID-19 Death

  • Presently, no standardized definition for COVID-19 fatality
  • Italy: Fatality defined as anyone who died with a positive test for SARS-CoV-2
    • May overestimate death rate
  • Researchers conducted a chart review of Italian subsample (335 patients) identified as a COVID-19 fatality
    • Mean age: 79.5 years | 30.0% women
    • Pre-existing conditions
      • Ischemic heart disease: 30% (117 patients)
      • Diabetes: 35.5% (126 patients)
      • Active cancer: 20.3% (72 patients)
      • Atrial fibrillation: 24.5% (87 patients)
      • Dementia: 6.8% (24 patients)
      • History of stroke: 9.6% (34 patients)
    • Number of conditions
      • No disease history: 0.8% (3 patients)
      • Single disease: 25.1% (89 patients)
      • 2 diseases: 25.6% (91 patients)
      • 3 or more diseases: 48.5% (172 patients)
  • Comorbidities themselves may independently drive mortality risk

Different Testing Approaches

  • Initial testing strategy: Symptomatic individuals and their contacts
    • Abandoned due to increasing spread and healthcare system burden
  • Subsequent prioritization strategy: Severe cases that need hospitalization
    • Prioritization strategy drives increase in positive test rate (19.3%)
    • Fatality rate will be calculated based on a denominator with more severe cases
      • Case fatality rate with initial strategy (February): 3.1%
      • Case fatality with prioritization strategy (March) 7.2%
  • South Korea uses a very broad testing strategy and therefore denominator will include les severe COVID-19 cases
    • Italy’s case fatality rate: 7.2%
    • South Korea’s case fatality rate: 1.0%

CONCLUSION:

  • Italy’s high case-fatality rate could be explained by
    • Older population
    • Any fatality with a positive SARS-CoV-2 result is reported as a COVID-19 fatality; however, cause of death may be related to underlying co-morbidity
    • Current testing strategies prioritize sicker patients which will alter the fatality rate
  • The authors stress that to get a more complete picture of case fatalities in different countries there needs to be
    • Clear reporting on age, sex, comorbidities, and testing strategies
    • Clear definitions of COVID-19 fatalities

Learn More – Primary Sources:

Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy

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Related ObG Topics:

COVID-19: Category Definitions, Symptoms and Those at Increased Risk
Washington State’s First COVID-19 Cases: Outcomes and Characteristics of 21 Critically Ill Patients
MMWR Reports on Initial US COVID-19 Experience: Demographics, Mortality and Outcomes 

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