TOKYO, Mar 21, 2020 - (JCN Newswire) - Consultants at Azabu Insights wanted to understand the stark differences between mortality rates in Korea (currently 1.1%) and Italy (8.3%). We felt that current explanations suggested by virologists, while making a number of valid points, have ultimately been unsatisfactory.
Azabu Insights presents the hypothesis that hospitals may have been one of the breeding grounds for virus infection in Italy and this may have been one of the causes of the high mortality rates. This is a major concern, going forward, for other countries including the United States.
Azabu Insights recommends that policy experts and hospital management carefully consider existing practices to ensure that potential carriers of coronavirus can access to testing and appropriate treatment without spreading the virus to other persons in the healthcare facility. We think that the highly contagious nature of COVID-19 suggests a need for more isolated facilities and stricter measures than have been implemented, in many cases, thus far.
We urge that the successful policies implemented to curb the early outbreaks in China and Korea, including those around hospital isolation and safe testing, should be examined and implemented when appropriate.
Exploring Macro Drivers Behind Infection and Mortality
Previous articles have noted that many of those who died in Italy were older, male, and often smokers. Experts agree that these traits are key risk factors in severe COVID-19 infections (as they are for many other respiratory diseases). It has been argued that these attributes are reflective of broader Italian society, particularly citing Italy's age profile, and by extension proving why Italy's outbreak has been so deadly. We contrasted this with Japan and Korea, which share Italy's characteristics of aging populations with high smoking rates and have also seen coronavirus outbreaks in recent weeks.
Firstly, we examined the key macro data. According to the World Bank, 23% of Italians are over the age of 65, making it the oldest nation in Europe. Note however, there are 16 European countries where at least 20% of the population is over 65, so Italy is by no means a large outlier. Compared with Italy, Korea is a little younger with 18% of its citizens over 65 however Japan is significantly older with 27% of its populace 65 or older. Digging a little further we see that in Cremona, one of the areas hit hard by the northern Italy outbreak, almost 33% of people were over the age of 60 compared with 38% over 60 in Japans Kitami, the site of Japans main outbeak. With regards to smoking, overall smoking rates are higher in Korea (24%) and Italy (22%) than in Japan (18%). However in Korea, men's smoking rates are much higher at 34% than the 27% of Japanese males and the 23% of Italian men who currently smoke.
These numbers suggest that Japan and Korea, at best, both share similar risk factors to Italy and arguably look much poorer than their European counterpart. Given this, Azabu Insights asserts there are other factors that are driving the speed and intensity of the Italian outbreak.
Partly Result of Tested Populations
Part of the effect of the disparity can be accounted for by the disparity in tested populations. Korea has tested aggressively, with over 286 thousand people (second only to China's 320 thousand) tested and 3% testing positive. They tested broadly across all age groups with 28% of test subjects 20-29 years old and 58% under the age of 50. In turn many of the younger Koreans tested positive for COVID-19. It should come as no surprise that the mortality rate would be lower amongst this group of younger people because younger people have a lower mortality risk from the outset.
Italians have conversely seen a high 21% of those tested, return positive COVID-19 results (seven times higher than Korea). This says to us that the people who received the tests may have been chosen differently. Perhaps, in Italy, they prioritized (as would make sense) testing of the old, those at risk and those with severe symptoms. We know that the survival rates decrease significantly over 70 and further after 80, so the widespread reports that most people who died were over 70 did not surprise us.
To state it simply: if you find a large number of positive cases among young people, who are not at risk, you would expect few of them to die. If you find a large number of positive cases amongst older at-risk people, you would expect more of them to die. It is an example of Bayess theorem.
But testing differences alone, likely do not account for the sheer numbers of deaths in Italy, which have now surpassed those in China.
Risk of Infection at Hospitals
At Azabu Insights we have interviewed hundreds of doctors face to face over the last five years. We travel to all corners of Japan to meet directly with doctors in their hospitals. A key observation, something that nearly everyone who visits a hospital should know by gut intuition: the primary demographic in a hospital is the elderly. Confirming the data we see that in Japan, 73% of all people in hospitals are 65 or above and 53% are 75 or above. We are confident that these percentages are likely similar in demographically comparable Italy and in many other parts of the world.
This leads to examination of testing procedures for highly infectious diseases. Korea's testing regime, discussed earlier, has seen a number of novel and innovative solutions. It is possible to be tested for coronavirus in a drive through in just a few minutes. Other than the obvious convenience, this has the core benefit of not needing to walk through a hospital waiting room and risk infecting the other patients and the hospital staff.
In Japan interviews with the president and vice president of two major Japanese hospitals highlighted similar concerns. The first doctor was actively sending people with symptoms away from the hospital to get treated elsewhere. The second doctor had temporarily refused to see measles patients at his hospital. Both of these health practitioners did this to protect their own patients from in hospital spread.
In contrast we see that 10% of healthcare workers in the Lombardy region of Italy have contracted coronavirus. In one region, 20% of all GPs are confirmed to have coronavirus. In both cases, many of them are continuing to work given the well documented shortage of healthcare workers in Italy right now. On top of this, a study of 138 patients in Wuhan, China, suggests 41% of patients may have been victims of hospital-related transmission. This further suggests to us that hospitals are perhaps the worst place to be during a viral epidemic. Yet hospitals are hard to avoid for people in need of medical care. This is especially challenging for the elderly (age 75) who are 6.5 times more likely to be in a hospital than younger adults (age 35).
The SARS Effect on Treatment Patterns
We have extensively reviewed published data and studies, looked at various government recommendations, as well as examining popular published media outlets. In past outbreaks such as SARS, cases of asymptomatic spread were low and in-hospital spread was considered controllable through the use of masks and other standard procedures. In the case of coronavirus however we see clear evidence of both asymptomatic spread and spread from within the hospital system. However we believe that the role of asymptomatic spread and from within the hospital system remains significantly underestimated.
We believe that public policy and messaging in many countries is still largely based on previous outbreaks such as SARS and has failed to keep pace with the reality of how the coronavirus is spread. In contrast, China and Korea have adapted quickly and changed how they approach the management of this pandemic. In particular, they have shown that aggressive isolation of patients from the regular hospital system, including preventing congregation at test centers and separating coronavirus patients from regular patients in completely separate hospitals, can be an effective tool in controlling the spread of the coronavirus. We encourage policy makers in other countries, such as the US, to look to their example for ways to update their approach to better manage the current crisis.
Available Beds and Isolated Treatment Facilities
For patients that require treatment due to more severe coronavirus symptoms, the availability of physically separated treatment or in hospital isolation facilities is key to limit the hospital related transmission alluded to in the above paragraphs. We believe that China for example, did this very effectively by building two hospitals and acquiring gyms just to treat COVID-19 patients.
We examined available hospital capacity, with a focus on the ability to isolate and treat infectious disease. For standard hospital treatment, research shows that Japan is the most equipped globally with 13.4 beds per thousand people, followed by Korea with 11.5 beds per thousand people. This contrasts with most other developed countries which typically have anywhere from two to eight beds (2.9 in USA, 2.8 in UK, 3.4 in Italy) per thousand people. The real concern however is the number of beds that are available to treat highly infectious diseases. Taking conservative Japan as our baseline, we found that only 0.12% of all of Japan's beds are set up for infectious diseases and 0.32% are tuberculosis certified.
We know from reports that 16% of people in Lombardy hospitals had coronavirus. We believe that its very likely that small hospitals in the countryside of Italy were over run with too many people that had the virus. Despite reports of operating rooms being turned into seclusion units on a best effort basis, we have serious concerns about the ability of the hospitals to limit the spread of coronavirus within their institutions. This can lead to the worst case scenario where the infected patients spread the disease both to healthcare workers and to other patients resulting in the deaths of the already at-risk patients. From this perspective we think that the typical concern of running out of respirators, though important, the earlier measures of keeping the patients from spreading the virus may be more important.
Next Steps and Best Practices
We believe that the risk of testing and of treating people in regular hospitals is being fully underestimated. We feel that hospitals overestimate their ability to keep the virus from spreading in their hospitals.
Our suggestion is that as the United States begins its testing and particularly as it ramps up, they should be extremely careful and learn from the experience of countries such as China and Korea. All testing should be conducted at designated locations that are not physically connected to hospitals where there are other patients. No patients should be allowed to congregate or wait.
An ideal situation would be one in which coronavirus patients could be treated in their own, completely separate hospitals, as has begun to happen in Northern Italy, and in parts of the United States, but, we feel, not broadly enough.
Further, the major hospitals must immediately decrease the number of people they treat. This goes for Japan as well, no longer should hospitals allow large waiting rooms filled with people. All non-essential procedures should be delayed. Again we have heard anecdotal reports of this occurring in the US and other countries already, but not universally.
In addition we recommend that any worker at a major hospital should be tested, at least for temperature, before going into hospitals and aged care facilities. Visitation, by people who may be asymptomatic carriers, should be severely limited. Everyone who goes into hospitals should wear masks, minimize touching and speaking, and should not be waiting in centers together.
Azabu Insights believes that these best practices should be implemented in conjunction with existing recommendations for limiting community spread including, but not limited to, hygiene and hand washing, wearing masks in public places if available, avoiding crowded places and working from home where possible.
About Azabu Insights
Azabu Insights is a boutique strategic consulting company based in Azabu Juban, Tokyo, Japan. Our teams work collaboratively with clients to build strategies that lead to positive change. Our multilingual team members have top tier academic backgrounds and deep industry experience that we leverage to provide first class, fully engaged, strategic consulting. Core specializations include life sciences, finance, electronics, automotive, aerospace and other industries. For more information contact: firstname.lastname@example.org
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