October 7, 2020 By [email protected]_84 Off

Arizona deaths up dramatically in 2020

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The COVID-19 pandemic appears to have driven an increase in Arizona deaths, which are up statewide by 22% through August. (Photo: Nick Oza/The Republic)

The COVID-19 pandemic appears to have driven an increase in Arizona deaths, which are up statewide by 22% through August.

When the number of COVID-19 deaths reported by the Arizona Department of Health Services through August are subtracted, Arizona deaths are still up by nearly 10% over the first eight months of the previous year, the data shows. 

Year-over-year increases in overall deaths in Arizona typically range between 1% and 4%.

There’s no definitive evidence to explain the excess deaths beyond COVID-19 fatalities in 2020, but there are theories.

Some health experts say that while COVID-19 accounts for a majority of the jump in deaths, excess deaths could be from factors related to the pandemic, including delayed medical care and a general reluctance to go to hospital emergency rooms.

Some excess deaths could be because of an undercount of COVID-19 deaths during the early days of the pandemic when testing was not widely available.

Another factor could be a lag in deaths showing up in official COVID-19 counts. Some COVID-19 deaths may be misclassified as other causes such as pneumonia and will be adjusted in the future.

By Aug. 31, Arizona had reported 5,029 known deaths from COVID-19 and the state had also recorded 49,304 deaths from all known causes in 2020. 

Those raw numbers are up by 22% over the 40,278 deaths reported through August 2019, state data shows.

There were 8,182 deaths recorded in Arizona in July, which was 66% higher than the 4,923 deaths the state reported in July 2019. July was also when hospitalizations for COVID-19 surged at Arizona hospitals.

The all-cause death rate in Arizona for the first eight months of the year typically ranges from 65 per 100,000 people to 77 per 100,000 people, but this year the range has been much higher, said Will Humble, who is executive director of the Arizona Public Health Association.

In July, the rate was 111.9 deaths per 100,000 people, according to an association analysis — a 63% jump over the rate of deaths in July 2019.

“All-cause mortality doesn’t lie,” Humble said. “To me, that makes the case that this is a pretty lethal pandemic that we’re in.”

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Deadly delays in cardiac care

Hospitals across the state have been reporting lower emergency room volumes and general delays in seeking care.

National and state data have shown a significant drop in the number of patients with cardiac arrests showing up in emergency departments, said Dr. Jaskamal Kahlon, an interventional cardiologist at the Banner Heart Hospital in Mesa.

“Overall, the number of patients coming in with heart attacks has gone down dramatically. We have definitive data on that; it’s in Arizona and all across the country,” Kahlon said.

“We have data on how many people come to Arizona hospitals every year for a heart attack, and this year has been significantly lower — close to less than half. … A year-to-year sudden drop is very uncharacteristic.”

The same trend has been observed in stroke patients with symptoms seeking hospital care, he said.

Some of the lower numbers could be because people with existing heart and vascular health problems may have become infected with SARS-CoV-2, the virus that causes COVID-19, and died, Kahlon said.

Other patients may have delayed care and died of a cardiac arrest outside the hospital, he said, though he emphasized that is speculation.

Anecdotally, Kahlon said has noticed an uptick in patients with serious symptoms who are seeking care in the cardiologist’s office, rather than going to an emergency department.

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“Normally, they would go to the hospital for something like chest pain, but now they are coming to us, even sometimes against medical advice,” Kahlon said. “In the office, we have to convince them to go to the hospital to get a workup done.”

With a heart attack or stroke, waiting even minutes too long can affect the heart’s ejection fraction and diminish long-term recovery, he said. Ejection fraction refers to the percentage of blood leaving the heart each time it contracts.

“We say time is muscle,” he said. “At 30 minutes, if you can open up the artery, you can have almost negligible effects on your heart from the heart attack. Up to 90 minutes can still be close to normal recovery. After 90 minutes you start noticing a drop-off in the benefit.”

Cardiac and cardiovascular problems are a risk factor for developing complications of COVID-19, which could have heightened fear for some of those patients, Kahlon confirmed.

“Quite a few people canceled or postponed routine care,” Kahlon said. “We’re seeing them now. There’s actually a little bit of a rush.”

Humble attributes excess deaths to delayed care that people weren’t able to get because hospitals were overwhelmed by COVID-19 patients, and to unaddressed chronic disease complications that patients were either afraid or unable to get addressed.

“I think it’s probably dominated by chronic diseases that got out of control because patients didn’t seek the earlier interventions that can prevent a bad outcome,” Humble said.

Humble has not seen any data that shows suicides are up, but state officials held a news conference last month expressing concern about mental health conditions that could lead to suicide during the pandemic.

Similarly, fatal drug-related overdoses could have climbed during the pandemic, but final data is not yet available.

Don’t delay calling 911

Health providers and public health officials are reminding the public that it’s better to seek medical care for an emergency than to avoid the hospital. The risk of having permanent damage from delayed care for a heart attack or stroke is much higher than contracting COVID-19 in a hospital setting, Kahlon said.

“At this point, if you have any symptoms, which are urgent like chest pain, shortness of breath, or if you have stroke-like symptoms, you’ve still got to call 911 and seek hospital attention,” Kahlon said.

Stroke symptoms include sudden weakness, numbness, or confusion.

Symptoms of a heart attack include chest pain, shortness of breath or nausea. It is not unusual for women to have additional symptoms, such as unexplained tiredness and vomiting.

The Arizona Department of Health Services on Sept. 17 issued a news release that stressed the importance of continuing to seek routine medical care such as wellness visits to primary healthcare providers, cancer screenings, management for chronic health conditions, and keeping children up to date on routine vaccinations.

“Arizonans have done a great job of helping to reduce the spread of COVID-19 by staying home and avoiding large gatherings. While we all must remain vigilant, now is not the time to skip routine medical care,” state health director Dr. Cara Christ said.

“This is especially important for people with chronic health conditions such as diabetes and asthma who are at higher risk for serious complications from COVID-19 and the flu.”

COVID death count is ‘reasonably accurate’

When COVID-19 is reported as a cause of death on the death certificate, it is coded and counted as a death due to COVID-19, federal officials say.

The Centers for Disease Control and Prevention says COVID-19 should not be reported on the death certificate “if it did not cause or contribute to the death.”

The state and Arizona counties follow the CDC’s guidelines and definition of a COVID-19 death, which since March has had its own ICD (International Classification of Diseases) medical code.

“COVID-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death,” the definition says.

The guidelines say anyone writing the death certificate should include as much detail as possible based on their knowledge of the case, including medical records, laboratory testing, and chronic conditions such as COPD or asthma that may have also contributed to the death.

Some critics have argued throughout the pandemic that the death count is being exaggerated by the media and public health officials. That’s one of the reasons the Arizona Public Health Association analyzed overall mortality rates of deaths from all causes during the pandemic and compared them to prior years.

“No matter how the deaths are classified, that chart doesn’t lie. That chart tells a dramatic story,” Humble said. “It shows how dramatically different this year has been than any other year.”

The COVID-19 death count in Maricopa County, Arizona’s largest county, is “reasonably accurate,” county spokesman Fields Moseley wrote in an email. But he emphasized the data-driven disease surveillance results for deaths caused by the novel virus are done quickly, which means the number is imperfect.

“Healthcare providers or the medical examiner fill out death certificates after reviewing records and determining the most likely cause of death based on the information they have,” he wrote.

“Death certificates are an imperfect record because they have to be signed quickly (under state law) and a healthcare provider might not have all of the information about a patient who has died.”

The Maricopa County Department of Public Health uses death certificate and laboratory test information to estimate the number of COVID-associated deaths. 

A cancer patient may be terminally ill but if they test positive for COVID-19 and then die, for example, it’s likely going to be a COVID-19-associated death.

Deaths that epidemiologists don’t want to be counted as COVID-19 would include someone whose death was the direct result of a car crash or a gunshot wound, for example, but that person also happened to test positive for the new coronavirus.

Epidemiologists are reviewing and removing such deaths on a monthly basis, though so far they account for a very small number of deaths recorded in Maricopa County — seven since the onset of the pandemic, Moseley wrote.

“There is no reason to believe removing the deaths will substantially change the number,” he wrote but added that a final count of deaths caused by and associated with COVID-19 will not be available until after the pandemic.

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More cancer deaths indirectly related to COVID-19 are possible

Looking forward, deaths could occur months into the future because of the pandemic.

Humble of the Arizona Public Health Association noted emerging evidence that COVID-19 is causing heart damage. That damage could end up weakening a patient’s health, and causing their death months in the future, he said.

While cancer mortality rates have been falling in recent years, COVID-19 could reverse that trend, USC Norris Comprehensive Cancer Center director Caryn Lerman wrote in the Los Angeles Times.

Lerman cited recent research published online Aug. 4 in JAMA, a prominent medical journal, that showed weekly diagnoses of six common cancers — breast, colorectal, lung, gastric, pancreatic and esophageal — fell by more than 45% from March to mid-April of this year compared with the previous two months.

In response to worries borne by such cancer data during the pandemic, scientists and oncologists at the University of Michigan recently developed a free web-based application to calculate the risks individual patients face by postponing various kinds of care, such as surgery and chemotherapy.

The OncCOVID app draws on large, national cancer data sets to help assess the risk from of immediate treatment versus delayed treatment, University of Michigan officials said. The app calculates the risk that COVID-19 poses to specific cancer patients depending on a variety of factors, including the level of transmission in their community.

Research published by the CDC on Sept. 11 showed that by June 30, an estimated 41% of U.S. adults had delayed or avoided medical care, including urgent or emergency care, because of COVID-19 concerns.

Avoidance of urgent or emergency care was more prevalent among unpaid caregivers for adults, persons with underlying medical conditions, Black adults, Hispanic adults, young adults, and persons with disabilities, researchers found.

“Further exploration of underlying reasons for medical care avoidance is needed, including among persons with disabilities, persons with underlying health conditions, unpaid caregivers for adults, and those who face structural inequities,” the report says. “Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay.”

Arizona Republic reporter Alison Steinbach contributed to this article

Reach health care reporter at [email protected] or at 602-444-8369. Follow her on Twitter @stephanieinnes

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