Death rate

This graph from Indiana’s COVID-19 dashboard charts the moving average of daily deaths in Indiana, showing a peak around late April and a steady decline since. Even as cases, positivity rates and hospitalizations have increased lately, deaths remain low.

INDIANAPOLIS — As several COVID-19 metrics in Indiana have been increasing throughout July, one important measure continues to see improvement — the death rate.

Fewer people are dying from COVID-19 on a day-to-day basis.

Although state health officials have expressed some concern that increasing hospitalizations and increasing cases could eventually translate to more deaths, for now, the number of Hoosiers succumbing to the virus has hit lows.

After reporting its first COVID-19 death on March 16, daily deaths were increasing on a day-to-day basis until hitting a peak of 50 deaths on April 22.

Since that point, however, deaths have been in a steady decline.

Falling from a late-April peak

While Indiana hasn’t had a day yet where it hasn’t reported at least one COVID-19 death, the state has gotten close recently.

Tracking daily numbers on deaths is a little trickier than new cases, as deaths are often reported on a lag sometimes of a week or more. Those delays generally occur because reporting agencies have to confirm and report the death and the state has to ensure that it was connected to a positive COVID-19 case before logging it.

Deaths are only logged as COVID-19 deaths if they meet two criteria — one, that the person has a positive COVID-19 test and, two, that the virus contributed to the death in some way.

Deaths that look like COVID-19 due to symptoms or chest X-rays but don’t have an associated positive test result are tracked by the state as “probable” deaths, but are not included in the state’s official count.

That reporting process leads to uneven day-to-day reporting.

For example, the death count as of Tuesday’s Indiana State Department of Health report increased by 20, but those deaths covered one each from July 6, July 10 and July 11; two from July 15; one from July 17; two on July 18; five from July 19 and seven from July 20.

Despite cases sometimes being logged to dates several days past, the general trajectory of Indiana’s death rate has been downward, even as cases, positivity rates and hospitalizations have continued increasing since late June.

Indiana’s average deaths reported per day was 32 in April and 30 in May, but decreased to 16 per day in June and have fallen further to just about 10 per day on average in July.

In July, the state has already had 12 days reporting fewer than 10 deaths.

The death rate among all known cases of COVID-19 had hit as high as 5.89% in late May, but has also been in decline since.

As testing has widened and a greater number of less-severe cases are being identified, that metric has been in steady decline to a mark of 4.58% as of Tuesday.

The known-case death rate is a high-side statistic, since it only captures deaths among known cases and does not incorporate that numerous people who either were never tested or never knew they had the virus because they were asymptomatic, which may be close to half of all cases.

The ongoing IUPUI Fairbanks School of Public Health study aimed to estimate a true mortality rate — deaths per all infections including the minor and asymptomatic cases.

In April, after determining that only about 1 in every 11 actual cases was being identified by testing at that time, the Fairbanks team determined COVID-19’s actual mortality rate was around 0.58% in Indiana. That’s still about six times more deadly than the typical seasonal flu, but significantly lower than figures that can be gathered from only known cases.

That estimated total mortality rate was about half the death rate previously observed during cruise ship outbreaks, but was similar to a rate measured by Chinese scientists who were calculating mortality rates following the start of the outbreak in Wuhan, China, the Fairbanks team reported in its results.

The Fairbanks study released a second round of data in June, but did not have any updates to its previously determined mortality rate.

As the rate was estimated as a true death rate and trying to account for all cases regardless of severity, that rate wouldn’t necessarily be affected significantly up or down by changes in the volume of testing or case numbers.

Although the overall mortality rate is estimated at approximately 0.58% and the known-case rate sits at about 4.5%, it’s important to remember those overall average hide disparities by age group.

To date, death rates among people age 50 and younger remain small, but probability of serious complications and death increases greatly for older Hoosiers.

For the oldest Hoosiers, close to 1-in-3 people who tested positive for COVID-19 went on to die from the virus, while that same rate for people younger than 50 is a tiny 0.2%.

Older people, people with chronic or other serious health conditions and people with compromised immune systems continue to be advised to take additional steps to protect themselves, as COVID-19 can be more threatening to their life than younger, healthier people.

State leaders and health officials continue to advise younger, healthier people to continue practicing social distancing, hygiene and mask usage, however, because, although they are less likely to suffer serious consequences from the virus, the potential for them to carry and spread to more vulnerable populations remains an ongoing threat.

Why are deaths decreasing?

One of the main reasons why Indiana has seen a marked decrease in deaths is due to the state gaining better control over outbreaks in nursing homes.

Back on July 1, Dr. Dan Rusyniak, chief medical officer for the Indiana Family and Social Services Administration and leader of the state’s long-term care facility response, discussed that the state had seen significant improvements since a peak in late-April, the same time frame as the state’s overall peak in cases.

In total, 92% of the more than 2,600 Hoosiers who have died to date from COVID-19 were 60 years old or older and 1,262 of those deaths — 47.6% — were nursing home residents.

That’s been the case locally, too, as almost all of the 28 deaths in Noble County were related to nursing home outbreaks.

As of Friday, Noble County Health Officer Dr. Terry Gaff reported that nursing homes in Noble County were free of active COVID-19 cases for the first time since the outbreaks started.

“From a peak that occurred in late April, we have seen marked decreases in COVID outbreaks. Weekly cases reported to us have decreased by 77% and weekly deaths reported to us by 88%,” Rusyniak said on July 1.

Closing nursing homes to public access, implementing infection control measures and having rapid-response strike teams available around the state to assist nursing homes all helped improve mortality rates among those very vulnerable populations.

Rusyniak also gave credit to the general population too, as safety precautions being practiced by the wider population helped to keep nursing home workers safe, thereby reducing the chance that they might carry the virus into those closed facilities.

“No doubt the behavior of Hoosiers has also contributed to the decreases we’ve seen. By decreasing community spread through social distancing, washing your hands, and wearing masks, fewer nursing home staff were exposed and unknowingly went to work with COVID-19,” Rusyniak said.

The state is supposed to be releasing more detailed nursing home data this month — a request that was made often earlier in the pandemic by state media outlets but resisted by state officials for months — that will for the first time help identify not only what communities and facilities were affected but help visualize the rise and fall of the virus in those facilities.

As for other deaths, reductions in mortality may be attributable to both improved treatments for COVID-19 patients as well as an overall decrease in hospitalizations.

Dr. Hariom Joshi, the director of the medical intensive care unit at Parkview Regional Medical Center in Fort Wayne, said hospitals are equipped and capable of treating inflows of a few COVID-19 patients ever week.

But as hospital admissions increase and patients begin overflowing to areas of the hospital not normally tasked with treating critical patients, overall outcomes tends to worsen.

“If people can understand that, as a physician, if you give me 15 patients with COVID, I can take care of them and have a good outcome,” Joshi said. “But, as a physician, as a hospital system, if you give me 30 patients, I’m sure that the outcome is not going to be better for them.

“If you overwhelm your system, your mortality will go up,” Joshi said.

Although statewide hospitalizations have been on a slight increase since a low point in late June — sitting at 803 patients statewide as of Monday, higher than the state’s all-time low point of 595 on June 26 — Joshi said Parkview’s capacity is good right now.

Overall across the state, about 37% of intensive care unit beds are available and more than 80% of ventilators, numbers that have held steady at those rates for weeks.

One other factor that can’t be discounted — health care workers are just more experienced at treating COVID-19 patients now.

COVID-19 is a novel coronavirus, with “novel” meaning it was a brand-new disease at the time of its discovery, one that health care workers had not encountered before.

Health care workers are familiar with other types of coronaviruses, including some that cause common colds and other non-serious complications, as well as a different strain that came to be known as Severe Acute Respiratory Syndrome (SARS) following an outbreak from 2002-2004 that killed about 10% of the 8,000 known patients.

But COVID-19 was a completely new and different malady when it arrived on American shores and then entered Indiana in March.

While vaccines are still in development, doctors have gained experience in effective treatment measures, learned about how COVID-19 attacks the system and also gained medical remedies including drugs like remdesivir, which has been shown in studies to improve patient outcomes.

Those interventions and experience didn’t exist back in March and early April, so as time as gone on, treatment has improved.

Dr. Jennifer Sullivan, secretary of the Indiana Family and Social Services Administration, however, warned that death typically lag new cases and hospitalizations, so Indiana could potentially start seeing an uptick in deaths.

“We see death increase later,” Sullivan said. “It is still our fear that we’ll see that lagging indicator later.”

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