Mild or Moderate Covid-19

Authors. Rajesh T. Gandhi, M.D.,  John B. Lynch, M.D., M.P.H.,  nd Carlos del Rio, M.D. NEJM 10/29/2022

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.

A 73-year-old man with hypertension and chronic obstructive pulmonary disease reports that he has had fever, cough, and shortness of breath for 2 days. His medications include losartan and inhaled glucocorticoids. He lives alone. How should he be evaluated? If he has coronavirus disease 2019 (Covid-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), then how should he be treated?

The Clinical Problem

Coronaviruses typically cause common cold symptoms, but two betacoronaviruses — SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV) — can cause pneumonia, respiratory failure, and death. In late 2019, infection with a novel betacoronavirus, subsequently named SARS-CoV-2, was reported in people who had been exposed to a market in Wuhan, China, where live animals were sold. Since then, there has been rapid spread of the virus, leading to a global pandemic of Covid-19. Here, we discuss the presentation and management of Covid-19 in patients with mild or moderate illness, as well as prevention and control of the infection. Discussion of Covid-19 that occurs in children and during pregnancy and of severe disease is beyond the scope of this article.

KEY CLINICAL POINTS

Mild or Moderate Covid-19

  • Covid-19 has a range of clinical manifestations, including cough, fever, myalgias, gastrointestinal symptoms, and anosmia.
  • Diagnosis of Covid-19 is commonly made through detection of SARS-CoV-2 RNA by PCR testing of a nasopharyngeal swab or other specimens, including saliva. Antigen tests are generally less sensitive than PCR tests but are less expensive and can be used at the point of care with rapid results.
  • Evaluation and management of Covid-19 depend on the severity of the disease. Patients with mild disease usually recover at home, whereas patients with moderate disease should be monitored closely and sometimes hospitalized.
  • Remdesivir and dexamethasone have demonstrated benefits in hospitalized patients with severe Covid-19, but in patients with moderate disease, dexamethasone is not efficacious (and may be harmful) and data are insufficient to recommend for or against routine use of remdesivir.
  • Infection control efforts center on personal protective equipment for health care workers, social distancing, and testing.

Strategies and Evidence

Coronaviruses are RNA viruses that are divided into four genera; alphacoronaviruses and betacoronaviruses are known to infect humans.1 SARS-CoV-2 is related to bat coronaviruses and to SARS-CoV, the virus that causes SARS.2 Similar to SARS-CoV, SARS-CoV-2 enters human cells through the angiotensin-converting–enzyme 2 (ACE2) receptor.3 SARS-CoV-2 has RNA-dependent RNA polymerase and proteases, which are targets of drugs under investigation.

TRANSMISSION

SARS-CoV-2 is primarily spread from person to person through respiratory particles, probably of varying sizes, which are released when an infected person coughs, sneezes, or speaks.4 Because both smaller particles (aerosols) and larger particles (droplets) are concentrated within a few meters, the likelihood of transmission decreases with physical distancing and increased ventilation. Most SARS-CoV-2 infections are spread by respiratory-particle transmission within a short distance (when a person is <2 m from an infected person).5,6 Aerosols can be generated during certain procedures (e.g., intubation or the use of nebulizers) but also occur with other activities and under special circumstances, such as talking, singing, or shouting indoors in poorly ventilated environments7-10; in these situations, transmission over longer distances may occur.5,6 Because respiratory transmission is so prominent, masking and physical distancing markedly decrease the chance of transmission.11 SARS-CoV-2 RNA has been detected in blood and stool, although fecal–oral spread has not been documented. An environmental and epidemiologic study of a small cluster of cases suggested the possibility of fecal aerosol–associated airborne transmission after toilet flushing, but this is likely to be rare.12 Under laboratory conditions, SARS-CoV-2 may persist on cardboard, plastic, and stainless steel for days.8,13 Contamination of inanimate surfaces has been proposed to play a role in transmission,9 but its contribution is uncertain and may be relatively small.

A major challenge to containing the spread of SARS-CoV-2 is that asymptomatic and presymptomatic people are infectious.14 Patients may be infectious 1 to 3 days before symptom onset, and up to 40 to 50% of cases may be attributable to transmission from asymptomatic or presymptomatic people.7,15 Just before and soon after symptom onset, patients have high nasopharyngeal viral levels, which then fall over a period of 1 to 2 weeks.16 Patients may have detectable SARS-CoV-2 RNA on polymerase-chain-reaction (PCR) tests for weeks to months, but studies that detect viable virus and contact-tracing assessments suggest that the duration of infectivity is much shorter; current expert recommendations support lifting isolation in most patients 10 days after symptom onset if fever has been absent for at least 24 hours (without the use of antipyretic agents) and other symptoms have decreased.17-19

CLINICAL MANIFESTATIONS

The clinical spectrum of SARS-CoV-2 infection ranges from asymptomatic infection to critical illness. Among patients who are symptomatic, the median incubation period is approximately 4 to 5 days, and 97.5% have symptoms within 11.5 days after infection.20 Symptoms may include fever, cough, sore throat, malaise, and myalgias. Some patients have gastrointestinal symptoms, including anorexia, nausea, and diarrhea.21,22 Anosmia and ageusia have been reported in up to 68% of patients and are more common in women than in men.23 In some series of hospitalized patients, shortness of breath developed a median of 5 to 8 days after initial symptom onset21,24; its occurrence is suggestive of worsening disease.Table 1.Risk Factors for Severe Covid-19.

Risk factors for complications of Covid-19 include older age, cardiovascular disease, chronic lung disease, diabetes, and obesity (Table 1).24,26-29 It is unclear whether other conditions (e.g., uncontrolled human immunodeficiency virus infection or use of immunosuppressive medications) confer an increased risk of complications, but because these conditions may be associated with worse outcomes after infection with other respiratory pathogens, close monitoring of patients with Covid-19 who have these conditions is warranted.

Laboratory findings in hospitalized patients may include lymphopenia and elevated levels of d-dimer, lactate dehydrogenase, C-reactive protein, and ferritin. At presentation, the procalcitonin level is typically normal. Findings associated with poor outcomes include an increasing white-cell count with lymphopenia, prolonged prothrombin time, and elevated levels of liver enzymes, lactate dehydrogenase, d-dimer, interleukin-6, C-reactive protein, and procalcitonin.21,27,30-32 When abnormalities are present on imaging, typical findings are ground-glass opacifications or consolidation.33

DIAGNOSIS

Diagnostic testing to identify persons currently infected with SARS-CoV-2 usually involves the detection of SARS-CoV-2 nucleic acid by means of PCR assay. Just before and soon after symptom onset, the sensitivity of PCR testing of nasopharyngeal swabs is high.34 If testing is negative in a person who is suspected to have Covid-19, then repeat testing is recommended.35 The specificity of most SARS-CoV-2 PCR assays is nearly 100% as long as no cross-contamination occurs during specimen processing.

The Food and Drug Administration (FDA) has issued emergency use authorizations (EUAs) for commercial PCR assays validated for use with multiple specimen types, including nasopharyngeal, oropharyngeal, and mid-turbinate and anterior nares (nasal) swabs, as well as the most recently validated specimen type, saliva.36 (A video demonstrating how to obtain a nasopharyngeal swab specimen is available at NEJM.org.) The FDA EUA allows patient collection of an anterior nares specimen with observation by a health care worker,37 which can reduce exposures for health care workers. Patient collection at home with shipment to a laboratory has been shown to be safe and effective, but access is limited in the United States.38 Testing of lower respiratory tract specimens may have higher sensitivity than testing of nasopharyngeal swabs.16

The FDA has also granted EUAs for rapid antigen testing to identify SARS-CoV-2 in a nasopharyngeal or nasal swab. Antigen tests are generally less sensitive than reverse-transcriptase–PCR tests but are less expensive and can be used at the point of care with results in 15 minutes. They may be particularly useful when rapid turnaround is critical, such as in high-risk congregate settings.39

In addition, EUAs have been issued for several serologic tests for SARS-CoV-2. The tests measure different immunoglobulins and detect antibodies against various viral antigens with the use of different analytic methods, so direct comparison of the tests is challenging. Anti–SARS-CoV-2 antibodies are detectable in the majority of patients 14 days or more after the development of symptoms.40 Their use in diagnosis is generally reserved for people who are suspected to have Covid-19 but have negative PCR testing and in whom symptoms began at least 14 days earlier. Antibody testing after 2 weeks also may be considered when there is a clinical or epidemiologic reason for detecting past infection, such as serosurveillance. Because antibody levels may decrease over time and the correlates of immunity are not yet known, serologic test results cannot currently inform whether a person is protected against reinfection.40

EVALUATION

Figure 1.Characteristics, Diagnosis, and Management of Covid-19 According to Disease Stage or Severity.

Evaluation of Covid-19 is guided by the severity of illness (Figure 1). According to data from China, 81% of people with Covid-19 had mild or moderate disease (including people without pneumonia and people with mild pneumonia), 14% had severe disease, and 5% had critical illness.42

Patients who have mild signs and symptoms generally do not need additional evaluation. However, some patients who have mild symptoms initially will subsequently have precipitous clinical deterioration that occurs approximately 1 week after symptom onset.24,26 In patients who have risk factors for severe disease (Table 1), close monitoring for clinical progression is warranted, with a low threshold for additional evaluation.

If new or worsening symptoms (e.g., dyspnea) develop in patients with initially mild illness, additional evaluation is warranted. Physical examination should be performed to assess for tachypnea, hypoxemia, and abnormal lung findings. In addition, testing for other pathogens (e.g., influenza virus, depending on the season, and other respiratory viruses) should be performed, if available, and chest imaging should be done.

Hallmarks of moderate disease are the presence of clinical or radiographic evidence of lower respiratory tract disease but with a blood oxygen saturation of 94% or higher while the patient is breathing ambient air. Indicators of severe disease are marked tachypnea (respiratory rate, ≥30 breaths per minute), hypoxemia (oxygen saturation, ≤93%; ratio of partial pressure of arterial oxygen to fraction of inspired oxygen, <300), and lung infiltrates (>50% of the lung field involved within 24 to 48 hours).42

Laboratory testing in hospitalized patients should include a complete blood count and a comprehensive metabolic panel. In most instances, and especially if a medication that affects the corrected QT (QTc) interval is considered, a baseline electrocardiogram should be obtained.

Chest radiography is usually the initial imaging method. Some centers also use lung ultrasonography. The American College of Radiology recommends against the use of computed tomography as a screening or initial imaging study to diagnose Covid-19, urging that it should be used “sparingly” and only in hospitalized patients when there are specific indications.43

Additional tests that are sometimes performed include coagulation studies (e.g., d-dimer measurement) and tests for inflammatory markers (e.g., C-reactive protein and ferritin), lactate dehydrogenase, creatine kinase, and procalcitonin.

MANAGEMENT OF COVID-19

Patients who have mild illness usually recover at home, with supportive care and isolation. It may be useful for people who are at high risk for complications to have a pulse oximeter to self-monitor the oxygen saturation.

Patients who have moderate disease should be monitored closely and sometimes hospitalized; those with severe disease should be hospitalized. If there is clinical evidence of bacterial pneumonia, empirical antibacterial therapy is reasonable but should be stopped as soon as possible. Empirical treatment for influenza may be considered when seasonal influenza transmission is occurring until results of specific testing are known.

Treatment of Covid-19 depends on the stage and severity of disease (Figure 1).41 Because SARS-CoV-2 replication is greatest just before or soon after symptom onset, antiviral medications (e.g., remdesivir and antibody-based treatments) are likely to be most effective when used early. Later in the disease, a hyperinflammatory state and coagulopathy are thought to lead to clinical complications; in this stage, antiinflammatory medications, immunomodulators, anticoagulants, or a combination of these treatments may be more effective than antiviral agents. There are no approved treatments for Covid-19 but some medications have been shown to be beneficial.

Hydroxychloroquine and Chloroquine with or without Azithromycin

Chloroquine and hydroxychloroquine have in vitro activity against SARS-CoV-2, perhaps by blocking endosomal transport.44 Results from single-group observational studies and small randomized trials led to initial interest in hydroxychloroquine for the treatment of Covid-19, but subsequent randomized trials did not show a benefit. The Randomized Evaluation of Covid-19 Therapy (RECOVERY) trial showed that, as compared with standard care, hydroxychloroquine did not decrease mortality among hospitalized patients.45 In another randomized trial involving hospitalized patients with mild-to-moderate Covid-19, hydroxychloroquine with or without azithromycin did not improve clinical outcomes.46 Moreover, no benefit was observed with hydroxychloroquine in randomized trials involving outpatients with Covid-1947,48 or patients who had recent exposure to SARS-CoV-2 (with hydroxychloroquine used as postexposure prophylaxis).49,50 Current guidelines recommend that hydroxychloroquine not be used outside clinical trials for the treatment of patients with Covid-19.51,52

Remdesivir

Remdesivir, an inhibitor of RNA-dependent RNA polymerase, has activity against SARS-CoV-2 in vitro53 and in animals.54 In the final report of the Adaptive Covid-19 Treatment Trial 1 (ACTT-1),55 which involved hospitalized patients with evidence of lower respiratory tract infection, those randomly assigned to receive 10 days of intravenous remdesivir recovered more rapidly than those assigned to receive placebo (median recovery time, 10 vs. 15 days); mortality estimates by day 29 were 11.4% and 15.2%, respectively (hazard ratio, 0.73; 95% confidence interval, 0.52 to 1.03). In another trial, clinical outcomes with 5 days of remdesivir were similar to those with 10 days of remdesivir.56 In an open-label, randomized trial involving hospitalized patients with moderate Covid-19 (with pulmonary infiltrates and an oxygen saturation of ≥94%), clinical status was better with 5 days of remdesivir (but not with 10 days of remdesivir) than with standard care, but the benefit was small and of uncertain clinical importance.57 The FDA has issued an EUA for remdesivir for hospitalized patients with Covid-19.58 Guidelines recommend remdesivir for the treatment of hospitalized patients with severe Covid-19 but consider data to be insufficient to recommend for or against the routine use of this drug for moderate disease.51,52 Decisions about the use of remdesivir in hospitalized patients with moderate disease should be individualized and based on judgment regarding the risk of clinical deterioration.

Convalescent Plasma and Monoclonal Antibodies

Small randomized trials of convalescent plasma obtained from people who have recovered from Covid-19 have not shown a clear benefit.59 Data from patients with Covid-19 who were enrolled in a large expanded-access program for convalescent plasma in the United States suggested that mortality might be lower with receipt of plasma with a high titer of antibody than with receipt of plasma with a low titer of antibody; the data also suggested that mortality might be lower when plasma is given within 3 days after diagnosis than when plasma is given more than 3 days after diagnosis.60,61 Interpretation of these data is complicated by the lack of an untreated control group and the possibility of confounding or a deleterious effect of receiving plasma with a low titer of antibody. The National Institutes of Health Covid-19 Treatment Guidelines Panel51 and the FDA, which issued an EUA for convalescent plasma in August 2020,60 emphasize that convalescent plasma is not the standard of care for the treatment of Covid-19. Ongoing randomized trials must be completed to determine the role of convalescent plasma.

Monoclonal antibodies directed against the SARS-CoV-2 spike protein are being evaluated in randomized trials as treatment for people with mild or moderate Covid-19 and as prophylaxis for household contacts of persons with Covid-19. Published data are not yet available to inform clinical practice.

Glucocorticoids

Because of concerns that a hyperinflammatory state may drive severe manifestations of Covid-19, immunomodulating therapies have been or are being investigated. In the RECOVERY trial, dexamethasone reduced mortality among hospitalized patients with Covid-19, but the benefit was limited to patients who received supplemental oxygen and was greatest among patients who underwent mechanical ventilation.62 Dexamethasone did not improve outcomes, and may have caused harm, among patients who did not receive supplemental oxygen, and thus it is not recommended for the treatment of mild or moderate Covid-19.

USE OF CONCOMITANT MEDICATIONS IN PEOPLE WITH COVID-19

Because SARS-CoV-2 enters human cells through the ACE2 receptor,3 questions were raised regarding whether the use of ACE inhibitors or angiotensin-receptor blockers (ARBs) — which may increase ACE2 levels — might affect the course of Covid-19.63 However, large observational studies have not shown an association with increased risk,64 and patients who are receiving ACE inhibitors or ARBs for another indication should not stop taking these agents, even if they have Covid-19.63,65 In addition, several authoritative organizations have noted the absence of clinical data to support a potential concern about the use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients with Covid-19,66 and results from a cohort study were reassuring.67

INFECTION CONTROL AND PREVENTION

Table 2.SARS-CoV-2 Transmission According to Stage of Infection.

Health care workers must be protected from acquiring SARS-CoV-2 when they are providing clinical care (Table 2). Using telehealth when possible, reducing the number of health care workers who interact with infected patients, ensuring appropriate ventilation, and performing assiduous environmental cleaning are critical. Personal protective equipment (PPE) used while caring for patients with known or suspected Covid-19 should include, at a minimum, an isolation gown, gloves, a face mask, and eye protection (goggles or a face shield). The use of these droplet and contact precautions for the routine care of patients with Covid-19 appears to be effective5,68 and is consistent with guidelines from the World Health Organization (WHO)69; however, the Centers for Disease Control and Prevention (CDC) prefers the use of a respirator (usually an N95 filtering facepiece respirator, a powered air-purifying respirator [PAPR] unit, or a contained air-purifying respirator [CAPR] unit) instead of a face mask70 but considers face masks to be acceptable where there are supply shortages. The CDC and WHO recommend the use of enhanced protection for aerosol-generating procedures, including the use of a respirator and an airborne infection isolation room. At sites where enhanced protection is not available, the use of nebulizers and other aerosol-generating procedures should be avoided, when possible. In the context of the ongoing pandemic, the possibility of transmission in the absence of symptoms supports the universal use of masks and eye protection for all patient encounters.7,71

Strategies to facilitate infection prevention and control are needed for people with unstable housing or people who live in crowded facilities or congregate settings, where physical distancing is inconsistent or impossible (e.g., dormitories, jails, prisons, detention centers, long-term care facilities, and behavioral health facilities).

Areas of Uncertainty

Many uncertainties remain in our understanding of the spread of Covid-19 and its management. More data are needed to establish the standard of care for patients with mild or moderate disease and to evaluate potential strategies to reduce the risk of infection in exposed persons; numerous clinical trials are registered and ongoing. Studies are under way to develop an effective vaccine; several candidates have been shown to boost immune responses, and large trials are under way to assess their safety and efficacy in preventing Covid-19. It is unknown whether infection confers immunity (and, if so, for how long) and whether results of serologic testing can be used to inform when health care workers and others can safely return to work.

Guidelines in a Rapidly Changing Pandemic

Many professional organizations have developed guidelines for the management and prevention of Covid-19 (see the Supplementary Appendix, available with the full text of this article at NEJM.org).

Conclusions and Recommendations

The patient in the vignette is at high risk for having Covid-19 with potential complications. Given his dyspnea and risk factors for severe illness, we would refer him for SARS-CoV-2 PCR testing of a nasopharyngeal swab, along with an examination and chest radiography. At a health care facility, he should wear a surgical mask and be promptly escorted to an examination room. He should be assessed for hypoxemia, which, if present, would prompt admission and specific therapies. We would continue his treatment with an ARB and inhaled glucocorticoids. In accordance with current guidelines, we would advise that he remain isolated for 10 days after symptom onset and until he has had resolution of fever for at least 24 hours (without the use of antipyretics) and alleviation of other symptoms.

Scientists Fear New COVID Strains Are Deadly—Just Like 2020 Wave

Authors: David Axe Fri, October 28, 2022

The new COVID-19 subvariants that are becoming dominant all over the world aren’t just more contagious than previous variants and subvariants—they might cause more severe disease, too.

That’s an ominous sign if, as experts predict, there’s a new global wave of COVID in the coming months. It’s one thing to weather a surge in infections that mostly results in mild disease. Cases go up but hospitalizations and deaths don’t. But a surge in serious disease could lead to a surge in hospitalizations and deaths, too.

It could be like 2020 or 2021, all over again. The big difference is that we now have easy access to safe and effective vaccines. And the vaccines still work, even against the new subvariants.

A new study from The Ohio State University is the first red flag. A team led by Shan-Lu Liu, co-director of HSU’s Viruses and Emerging Pathogens Program, modeled new SARS-CoV-2 subvariants including BQ.1 and its close cousin, BQ.1.1.

The team confirmed what we already knew: BQ.1 and other new subvariants, most of them the offspring of the BA.4 and BA.5 forms of the Omicron variant, are highly contagious. And the same mutations that make them so transmissible also make them unrecognizable to the antibodies produced by monoclonal therapies, rendering those therapies useless.

That should be reason enough to pay close attention as BQ.1 and its cousins outcompete BA.4 and BA.5 and become dominant in more countries and states. But then Liu and his teammates also checked the subvariants’ “fusogenicity.” That is, how well they fuse to our own cells. “Fusion between viral and cellular membrane is an important step of viral entry,” Liu told The Daily Beast.

In general, the greater the fusogenicity, the more severe the disease. Liu and his colleagues “observed increased cell-cell fusion in several new Omicron subvariants compared to their respective parental subvariants,” they wrote in their study, which appeared online on Oct. 20 and is still under peer review at New England Journal of Medicine.

This Could Be the Only Way to Beat COVID for Good

If these new subvariants are indeed more transmissible and more severe, they could reverse an important trend as the COVID pandemic grinds toward its fourth year. The trend, so far, has for each successive major variant or subvariant to be more contagious but cause less severe disease.

That trend, combined with widespread vaccination and new therapies, led to what scientists call a “decoupling” of infections and deaths. COVID cases occasionally spike as some new, highly-contagious new variant or subvariant becomes dominant. But because these new forms of SARS-CoV-2 cause less severe disease, deaths don’t increase nearly as much.

That decoupling, along with the availability of vaccines and therapies, has allowed most people all over the world to get back to some kind of normal in the past year or so. If BQ.1 or another highly fusogenic subvariant re-couples infections and deaths, that new normal could become a new nightmare. “More hospitalizations and deaths,” is how Ali Mokdad, a professor of health metrics sciences at the University of Washington Institute for Health who was not involved in the OSU study, summed it up.

It’s possible we’ve already seen the first recoupling. Since the new subvariants began seriously competing for dominance in recent months, epidemiologists watched COVID statistics carefully in order to spot any real-world impacts.

Singapore was a false flag. The tiny Asian city-state had a quick, up-and-down surge in cases this month that some experts initially worried might involve a dangerous new subvariant. But the country’s health ministry sequenced a lot of viral samples, fast, and determined that BA.5 was the culprit. Singapore’s high rate of vaccination and boosting—92 percent of residents have their prime jabs and 80 percent are boosted—tamped down the BA.5 surge without a major spike in deaths.

But then there’s Germany, where cases also surged this month. German authorities haven’t yet determined which variant or subvariant is to blame, but it’s worth noting that BQ.1 is spreading fast all over Europe.

And there are signs of recoupling in Germany. In October, the country registered as many as 175,000 new cases a day—matching the peak of the previous wave back in July. But 160 Germans died every day on average in the worst week of the current surge, whereas just 125 died per day in the worst week of the summer surge. “We could see the same patterns in other European countries… and in the U.S.,” Mokdad said.

There’s still a lot we don’t know about the latest COVID subvariants. And their real-world impact won’t come into focus until we get good data out of Germany. “Close monitoring of new variants and studying their properties are critical,” Liu said.

But one thing is clear. For all their transmissibility and fusogenicity, the new subvariants haven’t significantly escaped the immune effects of the leading vaccines. And the latest “bivalent” boosters, formulated specifically for BA.4 and BA.5, should maintain the vaccines’ effectiveness as long as the dominant subvariants are closely related to Omicron.

Get vaccinated and stay current on your boosters. It’s impossible to stress this too much. Yes, BQ.1 and its cousins exhibit some alarming qualities that could bend the arc of the pandemic back toward widespread death and disruption.

But only if you’re unvaccinated or way behind on your boosters.

COVID-19 linked to increase in US pregnancy-related deaths

Authors: Amanda Seitz/APPosted: OCT 19, 2022 News Nation

WASHINGTON (AP) — COVID-19 drove a dramatic increase in the number of women who died from pregnancy or childbirth complications in the U.S. last year, a crisis that has disproportionately claimed Black and Hispanic women as victims, according to a government report released Wednesday.

The report lays out grim trends across the country for expectant mothers and their newborn babies.

It finds that pregnancy-related deaths have spiked nearly 80% since 2018, with COVID-19 being a factor in a quarter of the 1,178 deaths reported last year. The percentage of preterm and low birthweight babies also went up last year, after holding steady for years. More pregnant or postpartum women are also reporting symptoms of depression.

“We were already in the middle of a crisis with maternal mortality in our country,” said Karen Tabb Dina, a maternal health researcher at the University of Illinois at Urbana-Champaign. “This really shows that COVID-19 has exacerbated that crisis to rates that we, as a country, are not able to handle.”

The nonpartisan U.S. Government Accountability Office, which authored the report, analyzed pregnancy-related deaths after Congress mandated that it review maternal health outcomes in the 2020 coronavirus relief bill.

UK Cardiologist: Pause the COVID Vaccine Program

Authors:  Michelle Edwards September 27, 2022 Nature Reports

One of Britain’s most influential cardiologists, Dr. Aseem Malhotra—citing a duty to his patients, scientific integrity, and the truth—just published what he describes as perhaps the most critical research paper of his prestigious career. His work, fueled by the sudden death of his “very fit and well” father in July 2021, critically appraised the real-world data around the mRNA COVID jab. After nine months of rigorous research and extensive peer review, Malhotra’s paper concludes what many heavily censored brave experts have been saying for months—the massive push to get the mRNA COVID-19 jab into the arms of humanity serves a purely sinister purpose: increased pharmaceutical shareholder profits at any cost. Indeed, with Pfizer in the lead, Malhotra is convinced the current system, which gives big pharma way too much power, is “encouraging good people to do bad things.” On that note, he is calling for all COVID-19 vaccines to be withdrawn. 

In conducting research for his paper titled ‘Curing the pandemic of misinformation on COVID-19 mRNA vaccines through real evidence-based medicine,’ Dr. Malhotra commented on the early headlines around the world making “very bold claims of 95% effectiveness” with the jabs. Likewise, he underscored the slippery way “efficacy” and “effectiveness” were used interchangeably to gloss over the significant difference between controlled trials and real-world conditions. Dr. Molhotra quickly realized the gaping holes in Pfizer’s mRNA clinical trials, noting he was alarmed to learn that there were four cardiac arrests in those who took the vaccine in the trial versus only one in the placebo group. He wrote:

“During early 2021, I was both surprised and concerned by a number of my vaccine-hesitant patients and people in my social network who were asking me to comment on what I regarded at the time as merely ‘anti-vax’ propaganda.

But a very unexpected and extremely harrowing personal tragedy was to happen a few months later that would be the start of my own journey into what would ultimately prove to be a revelatory and eye-opening experience so profound that after six months of critically appraising the data myself, speaking to eminent scientists involved in COVID-19 research, vaccine safety and development, and two investigative medical journalists, I have slowly and reluctantly concluded that contrary to my own initial dogmatic beliefs, Pfizer’s mRNA vaccine is far from being as safe and effective as we first thought.”

In January 2021, Dr. Malhotra, an NHS consultant, Fellow of the Royal College of Physicians, President of the Scientific Advisory Committee of The Public Health Collaboration, and internationally renowned expert in the prevention, diagnosis, and management of heart disease, was one of the first to receive the two-dose Pfizer jab. A firm believer in the “safe and highly effective” vaccines produced during the latter half of the 20th century, Dr. Malhotra states he got the mRNA shots mainly to “prevent transmission of the virus” to his vulnerable patients. In an appearance on Good Morning Britain, he even convinced “vaccine-hesitant” British film director Gurinder Chadha to take the jab.

Nevertheless, following his father’s sudden death, Malhotra was distraught after examining the post-mortem findings. Not long before his death, Malhotra had assessed his 73-year-old father’s heart and determined overall he was in excellent health. His dad, who also received the Pfizer mRNA jabs, walked 10 to 15,000 steps daily and was extremely conscientious of his diet. Yet, with no evidence of an actual heart attack, Malhotra couldn’t explain how his healthy father had two severe blockages in his coronary arteries, which caused his death. He explained:

“There were two severe blockages in his Corona arteries, which didn’t really make any sense with everything. I know [this] both as a cardiologist—someone who has expertise in this particular area—but also by intimately knowing my dad’s lifestyle and his health. 

Not long after that, data started to emerge [that] suggested a possible link between the mRNA vaccine and increased risk of heart attacks from a mechanism of increasing inflammation around the coronary arteries. But on top of that, I was then contacted by a whistleblower at a very prestigious university in the UK. A cardiologist himself, he explained to me that there was similar research findings in his department—and that those researchers have decided to essentially cover it up because they were worried about losing research funding from the pharmaceutical industry.” 

Presently, the sinister, big-pharma profit-driven, tyrannical, Great Reset reality in which we live is unmistakable to many. Still, to have Dr. Malhotra come forward in such a tremendous way indicates the voice of logic and reason is gaining momentum and getting louder. While talk of Sudden Adult Death Syndrome (SADS) and the myriad of sudden deaths we witness daily might yet fool some, many more are becoming increasingly aware of the fraudulent scheme at hand. Pointing to a burgeoning list of adverse events and the long-term uncertainty of vaccine-induced myocarditis, Malhotra’s paper calls out the crooked big pharma business model being employed by the global elite to coerce the world into being injected with the mRNA COVID jab. Published in the Journal of Insulin Resistance, it is well worth reading Dr. Malhotra’s two-part paper in full (here), and watching his Sept. 27 interview with the World Council for Health (here). Meanwhile, with his eyes wide open, in a recent interview, Malhotra conveyed a message he believes every human being needs to hear, declaring:

“[People] need to understand that the current system is encouraging good people to do bad things. At the root of this problem are big, very powerful corporations that have too much influence on government, on healthcare, and on media. And their primary responsibility is to produce profit for their shareholders, not to give you the best treatment. And when you understand that, then we can start doing something to transform the system.

And I don’t say this lightly. It has been well documented that these corporations, unfortunately, in how they go about their business, by misleading people, by their business model being fraudulent, they act like psychopaths—they are a psychopathic entity. Ultimately the conclusion is that we have a psychopathic entity influencing health policy, and that needs to stop—and it needs to stop now.”

Crisis” due to Diseases and Deaths Caused by COVID-19 Vaccines

Authors: Jim Hoft eptember 10, 2022 The Gateway Pundit

Around 403 doctors, scientists, and professionals from more than 34 countries declared that there is an international medical crisis due to the diseases and deaths following the administration of products known as “COVID-19 vaccines,” according to James Roguski Substack.

“We are currently witnessing an excess in mortality in those countries where the majority of the population has received the so-called “COVID-19 vaccines,” according to the news release. “To date, this excess mortality has neither been sufficiently investigated nor studied by national and international health institutions.”

From the Declaration:

The large number of sudden deaths in previously healthy young people who were inoculated with these “vaccines”, is particularly worrying, as is the high incidence of miscarriages and perinatal deaths which have not been investigated.

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A large number of adverse side effects, including hospitalisations, permanent disabilities and deaths related to the so-called “COVID-19 vaccines”, have been reported officially.
The registered number has no precedent in world vaccination history.

Examining the reports on CDC’s VAERS, the UK’s Yellow Card System, the Australian Adverse Event Monitoring System, Europe’s EudraVigilance System and the WHO’s VigiAccess Database, to date there have been more than 11 million reports of adverse effects and more than 70,000 deaths co-related to the inoculation of the products known as “covid vaccines”.
We know that these numbers just about represent between 1% and 10% of all real events.

Therefore, we consider that we are facing a serious international medical crisis, which must be accepted and treated as critical by all states, health institutions and medical personnel worldwide.
Therefore, the following measures must be undertaken on an urgent basis:

  1. A worldwide ‘stop’ to the national inoculation campaigns with the products known as “COVID-19 vaccines”.
  2. Investigation of all sudden deaths of people who were healthy previous to the inoculation.
  3. Implementation of early detection programmes of cardiovascular events which could lead to sudden deaths with analysis such as D-dimer and Troponin, in all those that were inoculated with the products known as “COVID-19 vaccines”, as well as the early detection of serious tumours.
  4. Implementation of research and treatment programmes for victims of adverse effects after receiving the so called “COVID-19 vaccine”.
  5. Undertaking analyses of the composition of vials of Pfizer, Moderna, Astra Zeneca, Janssen, Sinovac, Sputnik V and any other product known as “COVID-19 vaccines”,
    by independent research groups with no affiliation to pharmaceutical companies, nor any conflict of interest.
  6. Studies to be conducted on the interactions between the different components of the so called “COVID-19 vaccines” and their molecular, cellular and biological effects.
  7. Implemention of psychological help and compensation programmes for any person that has developed a disease or disability as a consequence of the so called “COVID-19 vaccines”.
  8. Implemention and promotion of psychological help and compensation programmes for the family members of any person who died as a result of having been inoculated with the product known as “Covid-19 vaccines”.

Consequently we declare that we find ourselves in an unprecedented international medical crisis in the history of medicine, due to the large number of diseases and deaths associated with the “vaccines against Covid-19”. Therefore, we demand that the regulatory agencies that oversee drug safety as well as the health institutions in all countries, together with the international institutions such as the WHO, PHO, EMA, FDA, UK-MHRA and NIH respond to this declaration and act in accordance with the eight measures demanded in this manifesto.

This Declaration is a joint initiative of several professionals who have been fighting for this cause. We call on all doctors, scientists and professionals to endorse this statement in order to put pressure on the entities involved and promote a more transparent health policy, do consider signing.

On Saturday, September 10, 2022, leading physicians from all around India also members of the Universal Health Organization (UHO) convened virtually with doctors from 34 other countries to sign a Declaration of International Medical Crisis.

UHO is a forum to ensure impartial, truthful, unbiased and relevant information on health reaches every citizen of the world to make informed choices pertaining to their health.

UHO is a forum to ensure impartial, truthful, unbiased and relevant information on health reaches every citizen of the world to make informed choices pertaining to their health.

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New ivermectin study shows 92% lower chance of COVID death

Protection increases with increased usage of politically charged drug

Authors: Art Moore WND News Center

A large study on the impact of using ivermectin as a prophylaxis for COVID-19 found that regular users of the drug experienced up to a 92% reduction in mortality compared to those who did not.

Brazilian research scientist Dr. Flavio A. Cadegiani said via Twitter that his study in his home country showed a “dose-response effect,” meaning that “the more you used, the more protection you had.”

He observed that people who use ivermectin regularly every 15 days for at least six to eight weeks had up to a 92% reduction in mortality.

Cadegiani conducted a previous study of drug that evaluated whether its use could impact COVID-19 infection and mortality rates.

Last fall, esteemed epidemiologist Dr. Harvey Risch of Yale Medical School was among scientists and physicians who said in Senate testimony that thousands of lives could have been saved if treatments such as ivermectin and hydroxychloroquine had not been suppressed.

In April, after noticing that the word ivermectin was trending on Twitter amid Elon Musk’s move to buy the company, the FDA reprised its disingenuous “horse dewormer” smear of the drug as a treatment for COVID-19.

“Hold your horses, y’all. Ivermectin may be trending, but it still isn’t authorized or approved to treat COVID-19,” said a post on the FDA’s Twitter account.

The reference to horses played on the explosion last fall of media articles and social media posts mocking people who treated COVID-19 with the drug as ignorant rubes who were sneaking into farms or patronizing Tractor Supply stores in quest of “horse dewormer.”

During the pandemic, Twitter and other social media platforms censored positive mention of ivermectin and hydroxychloroquine despite the countless testimonies and dozens of studies from around the world showing the drugs to be effective in treating COVID-19.

A follow-up FDA post said: “Also, a reminder that a study showed it didn’t actually work against COVID.”

Dr. Pierre Kory, who has testified to the Senate of the effectiveness of ivermectin against COVID-19, fired back.

“You are not a horse, you are not a cow, you are Big Pharma’s ass,” he tweeted.

The FDA, he wrote, was “messaging BS” by citing “one corrupt study” while ignoring 82 trials, including 33 randomized controlled trials with 129,000 patients from 27 countries that show “massive benefits” of ivermectin in treating COVID-19.

“Stop lying man, people are dying,” he wrote, adding the hashtag “earlytreatmentworks.”

In an article published in April for the Brownstone Institute, Kory wrote that it’s “a tried-and-true tactic with effective and dastardly results” for “Big Pharma and other well-financed interests” to sponsor purportedly impartial medical trials “aimed at discrediting cheaper generic alternatives.’

“Ignoring the flaws in the methodology, the media runs wild with the desired narrative, which is amplified by a well-orchestrated public relations effort,” he wrote.

Kory cited as an example the newly reported clinical trial from Brazil known as “TOGETHER,” which he said ostensibly aimed at studying the effectiveness of ivermectin to treat COVID.

Among the flaws was the lack of explicit exclusion criteria for trial participants on ivermectin, meaning both trial groups had access to the same drug.  Further, the treatment window was set for only three days, which didn’t allow for adequate dosing, and the trial was conducted during the massive gamma variant surge, which was one of the most virulent and deadly COVID variants.

“The dosage of the trial was far lower than everyday Brazilian clinicians were prescribing patients at the time to match the strength of the strain,” Kory pointed out.

“In spite of these and other readily apparent shortcomings, the nation’s leading media gobbled up the results. ‘Ivermectin Didn’t Reduce Covid-19 Hospitalizations in Largest Trial to Date’ blared the Wall Street Journal, while a New York Times headlined announced, ‘Ivermectin Does Not Reduce Risk of Covid Hospitalization, Large Study Finds.’”

Meanwhile, social media platforms stifled conversations while California pushed potentially precedent-setting legislation to punish doctors “who dare question phony studies,” threatening loss of a medical license.

A similar study of ivermectin “of far larger size, conducted by investigators without any conflicts of interest, found the drug led to massive reductions in Covid infection, hospitalization and mortality—yet it received virtually no media coverage.”

Kory said that ending “this cycle of perpetual disinformation requires revamping our dysfunctional drug approval process.”

“An independent board free of pharma industry conflicts must be established to oversee trials for re-purposed medicines,” he said. “Recommendations should be based on trials designed by impartial experts and actual results, not the desired ones, and policymakers or prescribers who ignore the findings should be held accountable.”

And academia and the regulatory agencies must be reminded, he said, “that observational trials data – wherein a sample of population who take a drug are compared to those who do not – is equally valid at informing policy.”

“Randomized controlled trials can yield useful information, but their complexity, costs, and delays to treatment lead to errors and effectively shut out low-cost drugs from the approval process, regardless of their efficacy,” he said.

Covid linked to 33-fold increase in risk of potentially fatal blood clot

Infection with virus also associated with fivefold increase in risk of deep vein thrombosis, data suggests

Authors: Linda Geddes The Guardian

Catching Covid is associated with a fivefold increase in the risk of deep vein thrombosis (DVT) and a 33-fold increase in risk of a potentially fatal blood clot on the lung in the 30 days after becoming infected, data suggests.

The findings, published in the British Medical Journal on Thursday, could help explain a doubling in the incidence of, and deaths from, blood clots in England since the start of the pandemic compared with the same periods in 2018 and 2019.

They also help to put the very small increased risk of blood clots associated with Covid-19 vaccination into context. “The degree of complications associated with Covid-19 is much stronger and lasts for much longer than what we might be getting after vaccination,” said Dr Frederick Ho, a lecturer in public health at the University of Glasgow, who was not involved in the research.

“Even those people with mild symptoms who do not need to be hospitalised might have a small increase in the risk of [blood clots].”

Although previous research had suggested that catching Covid was associated with an increased risk of blood clots, it was unclear for how long this risk remained, and whether mild infections also increased people’s risk.

To address these uncertainties, Anne-Marie Fors Connolly at Umeå University in Sweden and her colleagues measured the risk of DVT, pulmonary embolism – a blood clot on the lung – and various types of bleeding, such as gastrointestinal bleeding or a burst blood vessel in the brain, in more than 1 million people with confirmed Covid infections and more than 4 million uninfected individuals.

Overall, they identified a 33-fold increase in the risk of pulmonary embolism, a fivefold increase in the risk of DVT and an almost twofold increase in the risk of bleeding in the 30 days after infection. People remained at increased risk of pulmonary embolism for six months after becoming infected, and for two and three months for bleeding and DVT.

Although the risks were highest in patients with more severe illness, even those with mild Covid had a threefold increased risk of DVT and a sevenfold increased risk of pulmonary embolism. No increased risk of bleeding was found in those who experienced mild infections.

“Pulmonary embolism can be fatal, so it is important to be aware [of this risk],” said Connolly. “If you suddenly find yourself short of breath, and it doesn’t pass, [and] you’ve been infected with the coronavirus, then it might be an idea to seek help, because we find this increased risk for up to six months.”

Ho said the results remained relevant even in the Omicron era, since current vaccines were highly effective against severe Covid but breakthrough infections were common, even after a third dose of a vaccine.

“Despite the potential for new variants of concern, most governments are removing restrictions and shifting their focus to determining how best to live with Covid. This study reminds us of the need to remain vigilant to the complications associated with even mild Sars-CoV-2 infection, including [blood clots].”

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What’s to blame for the surge in excess deaths?

Authors: Ross Clark 19 August 2022, The Spectator

From the beginning, the debate over lockdowns was skewed by the fact that Covid deaths were imminent – and any other effects from lockdown would become apparent over a longer period. But are we beginning to see that now? Over the past few months the Office for National Statistics has been recording ‘excess’ non-covid deaths of around 1,000 a week in England and Wales – that is to say deaths above and beyond the level which would be expected at this time of year. Deaths over the summer months have been more in line with the number of deaths which might be expected in a normal winter.

Many of the excess deaths appear to be from heart and circulatory diseases. Recent heatwaves may have contributed negatively to this – warmer weather has long been associated with excess deaths. But the current bulge in excess deaths can be traced back to April, long before the heatwave. There have been suggestions that Covid could have weakened people’s health and that we are seeing a delayed reaction to being infected with the virus. Others point to delays in NHS treatment, with long waits in A&E.

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But the possibility remains that we are seeing the result of lockdowns – in particular, the failure of people to seek treatment or the difficulty of obtaining a consultation when we were all ordered to stay at home. The first lockdown, for example, resulted in a 33 per cent fall in diagnosis of early-stage cancers. The government was forced to change its messaging when it became clear that telling people to ‘stay at home’ and ‘protect the NHS’ was dissuading many from seeking treatment, even when they had ominous symptoms.

That lockdowns could themselves cause significant excess deaths was suspected by the government. In July 2020, the Department for Health quietly published a study which concluded that the number of Quality Adjusted Life Years (QALYS) from the indirect effects of the pandemic could eventually outstrip the number of QALYS which had been lost to Covid at that point. Covid, it estimated, would cost 530,000 QALYS. But 41,000 would be lost to reduced access to A&E, 73,000 lost to early discharge from hospital and reduced access to primary care services and 45,000 would be lost to delays in elective surgery. An additional 157,000 QALYS would eventually be lost to the effects of recession – and 294,000 to deprivation as a result of lower economic growth in the long term.

This is just modelling, of course – the limitations of which became plain during the pandemic. Moreover, not all these effects can be laid at the door of the government’s decision to order a lockdown. Had the NHS become overwhelmed by Covid cases, there would have been all manner of delays to treatment for other conditions. Lockdown or not, the economy would have taken a hit – although Sweden, which decided against the measure, suffered a lot less, in economic terms, than Britain and other European countries which did call lockdowns.

Nevertheless, the debate on the wisdom of ordering a lockdown in respect to an outbreak of infectious disease is far from over. Studies on the long-term effects are likely to rumble on for years. But the possibility that a lockdown could itself cause excess deaths was certainly known to the government in July 2020 – well before it decided to repeatedly resort to the measure.

Excess Mortality in the USA

Stuart SilvermanJustin LiChelsea Wang

The COVID-19 pandemic has caused approximately one million deaths in the United States and continues to impact our daily life. Since the beginning of the COVID-19 pandemic in early 2020, we now have much more insight into COVID-19 deaths in the US, including hopes for how the pandemic may wind down because of widespread vaccinations and protection generated from prior infections.

While the media has reported how COVID-19 impacts the elderly the most, the data provided by the Centers for Disease Control and Prevention (CDC) may be telling us a more insightful story for middle-aged and younger individuals on the relative to expected mortality rate basis. As such, the experience over the past two years may be instructive for the life insurance industry going forward.

Excess mortality vs. “normal”

To determine the excess mortality during the COVID-19 pandemic, we utilized the general population data provided by the CDC for our analysis. Currently, the CDC has provided the final official data for 20201 and the provisional data for 20212.

Mortality data used in our analysis are based on all causes of death (not just COVID-19), as the COVID-19 pandemic is impacting the population both directly and indirectly. Though some of these extra deaths were not directly linked to COVID-19 (i.e. not coded as COVID-19 deaths), they may be ascribed to the broader effects of the pandemic, including the societal stress from lockdowns and unemployment, and the pandemic stress both on hospitals’ ability to serve and on sick people’s willingness to go to the hospital.

For our analysis, we define “normal” mortality to be the average mortality of 2017-2019. The following graphs show the excess mortality in 2020 and 2021 versus the “normal” mortality by age group. We first show the deaths with COVID-19 listed as the underlying cause on the death certificate as a percentage of the normal mortality, and then remaining excess deaths are shown as non-COVID deaths.

2020 Male mortality increase (%) over “normal”

2020 Male mortality increase (%) over "normal" mortality

2020 Female mortality increase (%) over “normal”

2020 Female mortality increase (%) over "normal" mortality

2021 Male mortality increase (%) over “normal”

2021 Male mortality increase (%) over "normal" mortality

2021 Female mortality increase (%) over “normal”

2021 Female mortality increase (%) over "normal" mortality

The press may have reported that the majority of COVID-19 deaths were among the elderly (which is certainly true on an absolute count basis), but there has been limited discussion about the increased mortality risk relative to the expected level of mortality at all adult ages. Obviously, these relative increases are particularly important for insurers, which price for and hold reserves based on mortality rates that vary by age.

While the overall percentages of total mortality increase (vs. “normal”) were near 18% for 2020 and 20% for 2021, the percentage of total mortality increase for different age groups could be significantly different depending on the time elapsed since the pandemic, with a wide range of 4% to 54%. As shown in the above graphs, in both 2020 and 2021, the total relative mortality increase peaks in the 35-44 age group for both males and females. In general, smaller total relative mortality increases were experienced in the older age groups.

In 2020, the relative increase in mortality attributable to COVID-19 was fairly consistent for middle-aged people and the elderly. However, the relative increase in mortality attributable to COVID-19 in 2021 was materially higher for middle-aged people compared to the elderly.

While COVID-19 was one of the main medical causes of increased mortality during the pandemic, the impact of societal changes as a response to the pandemic (e.g. societal stress, delayed healthcare) should also be considered when evaluating the overall mortality impact from the pandemic. These deaths attributable to these societal changes have caused a significant relative increase in the mortality rates of the younger age groups. For example, deaths caused by drug overdose increased by more than 35% during the pandemic for the age group of 35-44.

While slightly higher for younger age groups, in 2020 the total relative mortality increase per age group is relatively steady across age groups. We suspect that there were fewer societal differences between the age groups contributing to the excess levels of mortality in 2020. However, in 2021, the differential is much higher. While the virus may have been similarly lethal by calendar year, there were significant societal differences.

  • In 2021, the vaccine became available, first to older-aged people, but then soon after to everyone. Vaccination rates for older-aged people are higher than for younger individuals.
  • By 2021, younger and middle-aged people were becoming more comfortable in public settings compared to elderly individuals. As such, younger and middle-aged people may have been more exposed to the virus (as per the comment above, with a lower chance of being vaccinated).
  • By 2021, we learned how to prevent catastrophic spreading in nursing homes, which was a significant contributor to the levels of elderly excess mortality in 2020. We also learned more about how to mitigate spreading in general (e.g. being outdoors).
  • The cumulative financial and social implications of the lockdowns may have also had a significant impact on the non-COVID relative mortality increase in young and middle-aged people compared to the elderly.
  • Medical treatment for the disease also improved by 2021, but it is not clear why that would lead to differences across age groups. One hypothesis is that older people were more inclined to be in communication with their medical professionals soon after being diagnosed with COVID-19 while there still was an opportunity for successful treatment.

Implications and considerations

While COVID-19 has not yet finished running its course, we now have more experience to assess the impact of the COVID-19 pandemic on the life insurance industry. There is no doubt that the COVID-19 pandemic has been impacting the insurance industry in many ways (e.g. product development, assumption setting, economic capital). It’s important to consider and understand the potential implications of the COVID-19 pandemic to the industry and the changes life insurers need to consider as a result of the COVID-19 pandemic.

  • Mortality assumptions. Mortality rates across all adult ages have been significantly higher since the beginning of the COVID-19 pandemic. However, there may be a mixture of push-pull effects on the mortality from the near to long term:
    • There may be some chronic complications from COVID-19 infection (“Long COVID”), which may result in people “aging” faster than if they weren’t infected with COVID-19. Long COVID may turn out to be a substantive phenomenon and, in turn, may cause future mortality rates to be higher than otherwise expected.
    • Many people delayed elective healthcare, which may have led to reduced diagnoses of conditions (either delayed or missed entirely). This dynamic may cause future mortality rates to be higher than otherwise expected.
    • However, it is possible that COVID-19 may have mostly accelerated deaths from people in poor health already who may have otherwise died earlier than the average person in their age group. Colin Powell, former U.S. Secretary of State, may be a noteworthy example of this – he died with COVID-19, but was suffering from cancer, and COVID-19 may have accelerated his death, which otherwise may have been caused by his cancer within a year or two. We may see a scenario in which the “strong survived” may cause future mortality rates to be lower than expected, thus leading to higher levels of mortality improvement.
  • Pandemic modeling and economic capital. We had envisioned the 1918 influenza pandemic as approximately a one-in-400-year event, but now the COVID-19 pandemic has shown a level of excess mortality comparable to that from the 1918 influenza pandemic. Thus, we have had two pandemics with similar severity in the last 100 to 105 years, so frequency estimates may need to be updated. The question we must ask is whether we view it as one pandemic in each of the last two 100-year periods (suggesting a frequency around 1% per year), or could we consider two pandemics in the last 100 years (suggesting a frequency higher than 1% per year)? This could be an essential consideration in catastrophic modeling and capital requirements.
  • Mergers and acquisitions (M&A) and reinsurance. Buyers of life insurance and annuity blocks of business are considering the implications of the pandemic and how future experience may unfold. Further, life insurers are considering exposures to mortality risk in light of what was experienced under the pandemic.
  • Long-term care (LTC) and annuity living benefits. While the COVID-19 pandemic increased life insurance claims, at the same time, it may have reduced liabilities for payout annuities, long-term care and disability income claims, as well as the living benefit claims associated with fixed and variable annuities. While those types of business may have benefited over the last couple of years from higher levels of reserves released than expected, companies may want to examine the implications of higher levels of mortality improvement if we follow with a “strong survived” scenario.
  • Pricing, product development, and underwriting. Clearly, the implications on assumptions and economic capital will ultimately impact pricing. However, the industry should examine how changed attitudes from the pandemic may impact people’s views of insurance products, which in turn can have implications for effective product design. Also, the unknown long-term chronic complications from COVID-19 infections may create challenges for accurate underwriting – for example, should insurers begin to ask about potential insureds medical history with COVID-19?
  • Sales. Life insurance sales may have increased due to higher awareness of life insurance protection needs raised by the COVID-19 pandemic. According to LIMRA, 31% of consumers said they were more likely to buy insurance due to the pandemic3. The potential increased need for life insurance (especially among younger people) may have created an opportunity for insurers to boost sales. However, this dynamic may reverse as the impact of the pandemic lessens. If so, insurers will have to develop alternative strategies to drive sales growth.
  • Sensitivities. As more experience and data unfolds, companies may want to consider various sensitivities to assess the potential financial impacts from future pandemics.
  • Mental health. The COVID-19 pandemic not only impacted people’s physical health but also their mental health. While the pandemic increases the general population’s mortality rates, it may also increase mental health-related deaths caused by the stress from the COVID-19 pandemic, e.g., suicide, drug overdoses, etc. While the overall suicide rate declined during the pandemic, deaths caused by drug overdoses increased significantly. Consideration should be given to how a more anxious population may influence future mortality rates.

Conclusion

While the media has reported that the COVID-19 pandemic mostly affected older aged people, the data shows that there was an elevated level of relative mortality increase across all age groups, including the main age groups that own life insurance. As we look back on the last couple of years, we collectively have learned a lot about disease, pandemics, and the implications on society. Though insurers may have different experiences from the general population, it is important for the life insurance industry to learn from the experience and make sound decisions for the many implications of how COVID-19 will affect the industry going forward.

This article was first published at https://www.milliman.com/en/insight/How-does-COVID-19-impact-the-life-insurance-industry-going-forward#. Re-used with permission.

References

1 CDC. Multiple Cause of Death, 1999-2020 Request. Retrieved March 6, 2022, from https://wonder.cdc.gov/mcd-icd10.html.

2 CDC. Provisional Mortality Statistics, 2018 Through Last Month Request. Retrieved March 6, 2022, from https://wonder.cdc.gov/mcd-icd10-provisional.html.

3 LIMRA (March 23, 2022). LIMRA: Challenges Brought On by the Pandemic Highlight the Importance of Family. Retrieved May 19, 2022, from https://www.limra.com/en/newsroom/industry-trends/2022/limra-challenges-brought-on-by-the-pandemic-highlight-the-importance-of-family/#:~:text=According%20to%20LIMRA’s%20and%20Life,highest%20growth%20recorded%20since%201983.

The unexplained rise in excess deaths around the world

This phenomenon requires an urgent inquiry and research into the actual causes

Authors: Murray Hunter Jul 6, 2022

Since the beginning of 2022, there has been a significant rise in excess deaths. Covid-19 has made up only a small percentage of these excess deaths. Excess deaths is a measurement of the number of deaths from all causes above what we would expect, based upon a five year rolling average. The mainstream media is not carrying this story, even though this is a major concern to public health.

As an example, according to Our World in Data excess mortality for the week ending June 19 in New Zealand was 205 above the average for the same time between 2015-2019, before the pandemic. This is not just exclusive to New Zealand, where the United Kingdom was 15% above the average, in Germany 12%. In early weeks the excess averages were even higher in many countries.

However, if one looks at UK statistics to the week June 24, Covid deaths were 309, only 2.8% of 12,278 deaths for the week. Out of that figure 1,308 were excess non-Covid related deaths. UK government statistical data also tells us that 31.5% of excess deaths occurred at home, 12.1% in hospitals, 10.3% in care homes, and 10.1% in other settings.

This rise in excess deaths is not exclusive to the countries mentioned above.

There needs to be an urgent investigation into the rise in excess deaths around the world. At this point of time, it is unknown what the precise reasons for these deaths really are.

Some of the possible reasons could be;

·        Stress from the lockdowns and restrictions (often the health effects are delayed),

·        Suicides,

·        Lack of access to healthcare during the pandemic, where people weren’t being diagnosed for diseases,

·        Delays in the treatment of non-Covid diseases,

·        Stress from the current food and inflation crisis,

·        Long term effects from Covid that haven’t been picked up by research, for example increase in the risk of heart attacks and strokes,

·        Vaccinations,

·        Increasing autoimmune diseases, and/or

·        New medicines utilized for the treatment of Covid.

During the pandemic we saw headlines and graphic pictures portraying a single Covid related death. However, now statistics are showing up an unusual bump up in the number of excess deaths, this is hardly reported.

This lesson to public health authorities here is that there are other risks to public health than Covid-19.

Rising excess death rates around the world is a matter of concern, particularly in this endemic period. Public health authorities must urgently sanction studies into this issue. If these deaths have occurred from latent effects of lockdowns and restrictions, this must be known for future public policy.

The statistics indicate that this has gone much further than anecdotal reports of people dying suddenly.