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During a busy shift at the height of Beijing's COVID wave, a physician at a private hospital saw a printed notice in the emergency department: doctors should "try not to" write COVID-induced respiratory failure on death certificates.
Instead, if the deceased had an underlying disease, that should be named as the main cause of death, according to the notice, a copy of which was seen by Reuters.
If doctors believe that the death was caused solely by COVID-19 pneumonia, they must report to their superiors, who will arrange for two levels of "expert consultations" before a COVID death is confirmed, it said.
AS COVID RAVAGES CHINA, US EXPANDS TESTING SYSTEM FOR INCOMING TRAVELERS
Six doctors at public hospitals across China told Reuters they had either received similar oral instructions discouraging them from attributing deaths to COVID or were aware that their hospitals had such policies.
Some relatives of people who have died with COVID say the disease did not appear on their death certificates, and some patients have reported not being tested for coronavirus despite arriving with respiratory symptoms.
"We have stopped classifying COVID deaths since the reopening in December," said a doctor at a large public hospital in Shanghai. "It is pointless to do that because almost everyone is positive."
Such directives have led to criticism by global health experts and the World Health Organization that China has drastically underreported COVID deaths as the coronavirus runs rampant in the country, which abandoned its strict "zero-COVID" regime in December.
On Saturday, officials said 60,000 people with COVID-19 had died in hospitals since China's policy U-turn, a roughly ten-fold increase from previously reported figures, but still short of expectations of international experts, who have said China could see more than a million COVID-related deaths this year.
China's Center for Disease Control (CDC) and National Health Commission (NHC) did not immediately respond to Reuters' requests for comment.
The doctors in this article declined to be named because they are not permitted to speak to the media.
Several said they were told such guidance came from "the government", though none knew from which department, a common situation in China when politically sensitive instructions are disseminated.
Three other doctors at public hospitals in different cities said they were unaware of any such guidance.
One of them, a senior emergency room doctor in Shandong province, said doctors were issuing death certificates based on the actual cause of death, but "how to categorise" those deaths is up to the hospitals or local officials.
Medical workers attend to COVID patients at a hospital in Cangzhou, Hebei province, China, on Jan. 11, 2023. (China Daily via REUTERS)
'Looks Low'
Since the start of the pandemic, which first emerged three years ago in its central city of Wuhan, China has drawn heavy criticism for not being transparent over the virus - an accusation it has repeatedly rejected.
Before Saturday, China was reporting five or fewer COVID deaths per day. Of the nearly 60,000 COVID-related fatalities since Dec. 8 it announced on Saturday since, fewer than 10% were caused by respiratory failure because of COVID. The rest resulted from a combination of COVID and other diseases, Jiao Yahui, head of the Bureau of Medical Administration under the National Health Commission (NHC), said on Saturday.
Michael Baker, a public health scholar at the University of Otago in New Zealand, said the updated death toll still "looks low" compared with the high level of infection in China.
"Most countries are finding that most deaths from COVID are caused directly by the infection rather than by a combination of COVID and other diseases," he said. "By contrast, reported deaths in China are mainly (90%) a combination of COVID and other infections, which also suggests that deaths directly from COVID infection are under-reported in China."
Yanzhong Huang, senior fellow for global health at the Council on Foreign Relations in New York, said it was unclear whether the new data accurately reflected actual fatalities, in part because the numbers include only deaths in hospitals.
The World Health Organization (WHO) on Monday recommended that China monitor excess mortality to gain a fuller picture of the impact of the surge in COVID.
Excess mortality is when the number of deaths for a given period is higher than it should be relative to historical averages.
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Testing Ends
Seven people told Reuters that COVID was not mentioned on the death certificates of their recently deceased relatives, although the relatives had either tested positive for the virus or displayed COVID-like symptoms.
Social media has been full of similar reports.
When a Beijing resident surnamed Yao brought his COVID-positive 87-year-old aunt to a large public hospital late last month with breathing problems, doctors did not ask whether she had the virus and did not mention COVID, Yao said.
"The hospital was full of patients, all in their 80s or 90s, and doctors had no time to talk to anyone," Yao said, adding that everyone seemed to have similar COVID-like symptoms.
Patients, including his aunt, were rigorously tested, although not for COVID, before being told they had pneumonia. But the hospital told him it had run out of medicine, so they could only go home.
Ten days later she recovered.
Medical staff at public hospitals in several cities in China said PCR testing, which under "zero COVID" was a near daily requirement for large parts of the population, has now been all but abandoned.
Taking the focus off testing may be the best way to maximise resources when hospitals have been overwhelmed, two experts told Reuters.
Ben Cowling, an epidemiologist at Hong Kong University, said almost all patients with acute respiratory problems would have COVID: "Since antivirals are in very short supply, I don't think laboratory testing will make much difference to case management."
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'Be Cautious'
A senior doctor in the eastern city of Ningbo said physicians there were told to be "cautious" about saying someone had died of COVID, but if they did wish to do so they would need to get approval.
No other disease required the same level of "caution" for entry on a death certificate, he said.
The doctor at a large public hospital in Shanghai said that weekly death rates since the recent COVID wave were three or four times higher than normal for this time of year. Most had more than one illness, but COVID worsened their conditions, she said.
"On the death certificate we fill in one main cause of death, and two to three sub-causes of death, so we basically leave out COVID," she said.
"Theres no other way but for us to follow the orders given by the hospital, which come from the government. I am too unimportant to make any decision," she said.
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In the fourth year of the pandemic, Covid-19 is once again spreading across America and being driven by the recent holidays, fewer precautions and the continuing evolution of Omicron subvariants of the virus.
New sub-variants are causing concern for their increased transmissibility and ability to evade some antibodies, but the same tools continue to curtail the spread of Covid, especially bivalent boosters, masks, ventilation, antivirals and other precautions, experts said.
Yet booster uptake has been pitiful, said Neil Sehgal, an assistant professor of health policy and management at the University of Maryland School of Public Health. Antiviral uptake has been low, and few mandates on masking, vaccination and testing have resumed in the face of the winter surge, which is once again putting pressure on health systems.
New Covid hospital admissions are now at the fourth-highest rate of the pandemic, according to the US Centers for Disease Control and Prevention (CDC). Covid hospitalizations declined somewhat after the summer wave, but never dropped to the low levels seen after previous spikes, persisting through the fall and rising again with the winter holidays.
Hospitals are at maximum capacity, said Brendan Williams, president and CEO of the New Hampshire Health Care Association, of his regions current rates. Im not sure what the trajectory of this things going to be, but I am worried.
The majority of Covid hospitalizations are among those 65 and older, although the share for children under four roughly doubled in 2022.
In the past week, Covid deaths rose by 44%, from 2,705 in the week ending 4 January to 3,907 in the week ending 11 January.
This is one of the greatest surges of Covid cases in the entire pandemic, according to wastewater analyses of the virus. Its much lower than the peak in January 2022, but similar to the summer 2022 surge, which was the second biggest.
And its not done yet. Certainly it does not appear that we are peaking yet, Sehgal said.
The Omicron subvariants BQ.1.1 and BQ.1 as well as the quickly expanding XBB.1.5 make up the majority of cases, according to CDC estimates. The north-east, where more than 80% of cases are estimated to be from the XBB.1.5 subvariant, has the highest proportion of cases, according to wastewater data.
With XBB, theres such a significant transmission advantage that exposure is really risky its riskier now than its ever been in terms of transmissibility, Sehgal said.
Official case counts have been slower to rise, because of the prevalence of at-home tests and because of a general reluctance to test at all, experts say. Of the tests that are reported, however, positivity rates have been very high, with about one in six tests (16%) turning positive.
Despite the high rates of Covid spread, hospitalizations have not yet reached previous peaks seen earlier in the pandemic, probably due to immunity from vaccinations and prior cases, said Stuart Ray, a professor of medicine and infectious diseases at the Johns Hopkins University School of Medicine.
But that protection should not be taken for granted, he said, particularly because immunity wanes.
Boosters really do make a difference, he said. The severe cases we are seeing are probably at least somewhat avoidable, if folks make sure that they stay updated on vaccination, because thats still the safest way to gain immunity.
Boosters, especially the updated bivalent boosters, are highly effective at reducing the risk of severe disease and death. Yet only 15.4% of Americans over the age of five have received the new boosters.
Youre just fighting a lot of misinformation and also some political missteps when it comes to the vaccines, Williams said. When Joe Biden declared the pandemic was over in September, he said, it probably stalled public enthusiasm for the new booster and spurred further inaction from Congress on more funding to address the pandemic.
Its challenging to strike that parallel narrative that you shouldnt worry about Covid but also go get a shot, said Sehgal, calling the declaration another unforced error.
While vaccines are very important, other precautions also help prevent infection, disease, and death, Sehgal said particularly important during a surge like this. Yet because of poor messaging from officials, many people may not even realize the US is experiencing a surge and precautions are still necessary, he added.
I think the majority of people who arent masking today, just dont know that they should.
Even if the US reaches the point where surges do not cause a corresponding increase in hospitalizations and death, they will still increase the number of people sickened and disabled by long Covid, experts said.
Theres accumulating data that repeated Covid accumulates risk for short- and long-term complications, including cardiovascular, mental health and other problems, Ray said. We will only know in retrospect exactly how big this cost is. But evolving data suggests that there is a cost thats incremental as we accumulate infections.
Williams is worried that hospitals are reaching maximum capacity even as long-term care facilities see outbreaks among residents and staff, after years of worker shortages.
In New Hampshire, nursing homes will not admit those that they feel that they cannot staff to care for, which I think is admirable, but the consequence of that is that the hospitals are jammed up, he said. Hospitals that might release patients to care facilities for transitional or long-term care will see beds filled for longer, putting even more pressure on the hospitals, patients and health workers.
Its a continuum, but right now the continuum is broken, Williams said.
Health workers have experienced three years of burnout, disability and death, and some have needed to exit the workforce. Others have been alarmed by unsafe working conditions and the continued crises caused by the pandemic. Nurses in New York reached a tentative agreement this week after striking for safer working conditions.
Nursing homes and residential care facilities have roughly 300,000 fewer workers today than there were in March 2020, Williams said. Its hard to see how its going to get better, he said.
In the meantime, Covid continues circulating, with nursing home residents and staff seeing one of the biggest rises in cases of the pandemic.
The first key to keeping people healthy in a nursing home is to keep people in the community healthy, Williams said. But it just doesnt seem like people are wearing masks and getting boosted people arent taking any of this seriously. We just seemed to declare that when it comes to Covid mortality, were number one, and thats a title that were not going to relinquish to any other country.
Sehgal calls it a collective forgetting about how and why we need to protect ourselves and one another. There are people for whom a mild infection actually isnt so mild, either because of their underlying health, or because of social factors in their life, he said. Its just a tremendous self-inflicted wound.
And the more the virus spreads, the more opportunities it has to evolve, potentially picking up mutations that make it easier to overcome immunity.
Yet the same measures that helped curb previous surges still work today. And they dont just prevent illness and death they also minimize social disruption, like lost hours at work and school. Those steps that we can take to protect ourselves and protect other people they dont seem onerous in the face of a Covid infection, Sehgal said.
As Ray put it: When we could be wearing a mask, why arent we?
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People arent taking this seriously: experts say US Covid surge is ...
The symptoms of COVID-19, including fever and cough, are similar to the symptoms in a host of other common diseases, including the seasonal flu.
With flu season in full swing, how can you tell if a fever is a symptom of the flu or COVID-19? A previous study shed light on how COVID-19 symptoms present, which may help people trying to figure out if their cough is just a cough or something worse.
The research from the University of Southern California (USC) was able to determine that COVID-19 symptoms often start in a certain order.
This finding might help people with COVID-19 self-isolate and get treatment sooner, which could significantly improve patient outcomes.
This order is especially important to know when we have overlapping cycles of illnesses like the flu that coincide with infections of COVID-19, said Peter Kuhn, PhD, one of the study authors and professor of medicine, biomedical engineering, and aerospace and mechanical engineering at USC. Doctors can determine what steps to take to care for the patient, and they may prevent the patients condition from worsening.
To predict the order of symptoms, researchers analyzed rates of symptom incidence collected by the World Health Organization (WHO) for more than 55,000 confirmed COVID-19 cases in China.
They also looked at a data set of almost 1,100 cases collected between December 2019 and January 2020 by the China Medical Treatment Expert Group for COVID-19 and provided by the National Health Commission of China.
To compare the order of COVID-19 symptoms to influenza, the researchers analyzed data from more than 2,000 influenza cases in North America, Europe, and the Southern Hemisphere reported to health authorities between 1994 and 1998.
The order of the symptoms matters, said Joseph Larsen, lead study author and USC Dornsife doctoral candidate. Knowing that each illness progresses differently means that doctors can identify sooner whether someone likely has COVID-19, or another illness, which can help them make better treatment decisions.
According to the studys findings, this is the order of symptoms that people with COVID-19 can experience:
The study found that patients with seasonal flu more commonly developed a cough before the onset of fever, Dr. Robert Glatter, emergency physician at Lenox Hill Hospital in New York, told Healthline. In reality, this may be difficult to discern since the flu often begins abruptly with a triad of symptoms, including back pain, chills, along with a dry cough.
Glatter said that the findings are potentially useful when evaluating multiple patients in a busy clinical setting.
According to the study, while influenza typically begins with a cough, the first symptom of COVID-19 is fever.
Our results support the notion that fever should be used to screen for entry into facilities as regions begin to reopen after the outbreak of spring 2020, the study authors wrote.
Glatter shared his experience treating patients with COVID-19 in New York City.
In general, while fever is usually the most commonly described initial symptom of COVID-19 infection, the reality of what I see on the front lines is more variable, he said.
In fact, some patients may present only with loss of taste or smell and otherwise feel well, Glatter said. I have also seen patients present with COVID-toes, or chilblains. A livedo-type [reddish-blue discoloration] of skin reaction in response to acute inflammation, in the absence of fever, cough or other respiratory symptoms.
Glatter said that other patients have also presented with malaise, headache, and dizziness, that in some ways resemble the symptoms of stroke, but without fever, cough, or any evidence of upper respiratory symptoms.
I have also seen patients present only with chest pain, devoid of any respiratory symptoms, he said. The onset of nausea, vomiting, and diarrhea after onset of respiratory symptoms such as fever and cough may also suggest that a person may have COVID-19.
According to Glatter, the bottom line is that healthcare professionals need to be vigilant and keep an open mind when evaluating patients who may have symptoms associated with the disease. They dont always present according to the book, so you must cast a wide net when thinking about who may or may not have COVID-19, he said.
Its critically important to understand the progression of symptoms of people with the COVID-19 infection so you stop the spread of the disease in effect, isolate and then initiate effective contact tracing, Glatter said. This is quite relevant for a virus that is 2 to 3 times more transmissible than influenza, leading to outbreaks in clusters.
He also said that understanding the first symptoms not only helps patients seek testing more rapidly, but also to begin physically distancing themselves after the first symptoms begin.
It also underscores the importance of wearing masks and hand hygiene upon learning of symptoms, Glatter said.
He also finds that sudden loss of smell and taste and inflammatory skin reactions like chilblains may be important clinical clues that may distinguish COVID-19 from seasonal influenza.
According to the Centers for Disease Control and Prevention, Omicron variant COVID-19 was first reported to the World Health Organization (WHO) by South Africa on November 25, and the first case was found in the United States in a person recently arrived from South Africa.
One of the first doctors to suspect a different COVID-19 strain among patients told Reuters that symptoms of the new variant were so far mild and could be treated at home.
Most of them are seeing very, very mild symptoms, and none of them so far have admitted patients to surgeries. We have been able to treat these patients conservatively at home, Dr. Angelique Coetzee, a private practitioner and chair of the South African Medical Association, said.
She noted that patients with Omicron havent reported loss of smell or taste, and the new variant hasnt yet caused a major drop in oxygen levels with the new variant.
Researchers analyzed data from more than 50,000 patients with COVID-19 and compared their symptoms with previous records from people who had the flu to find that COVID-19 symptoms occur in a particular order.
Experts with frontline experience emphasize that this progression isnt always how the disease manifests, but its still a useful guide for healthcare professionals.
The new Omicron variant is too new to say for certain what kind of symptoms will develop.
Experts are also monitoring how new variants affect the body and if there are any changes in symptoms.
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COVID-19 Symptoms Usually Show Up in This Order - Healthline
In the wake of the Golden Globes last week, several celebrities said they have tested positive for COVID-19.
At least four stars, including Jamie Lee Curtis and Michelle Pfeiffer, revealed they contracted the virus following the awards show.
In response, the Critics Choice Awards, which was held on Sunday, announced that all attendees would be required to submit a negative COVID-19 test before entering the venue, according to Deadline.
Public health experts said the news of actors and actresses falling ill is not surprising due to the relaxed regulations and people gathering indoors.
Jamie Lee Curtis and Tracy Morgan speak onstage at the 80th Annual Golden Globe Awards held at the Beverly Hilton Hotel, Jan. 10, 2023, in Los Angeles.
Rich Polk/NBC via Getty Images
"This is sort of a window into what our future holds," said Dr. John Brownstein, an epidemiologist and chief innovation officer at Boston Children's Hospital and an ABC News contributor. "I mean, this is not unexpected. You have indoor gatherings during a time when a lot of virus is circulating, whether it's cold or flu, and proximity without masking and especially if there was also no testing requirements."
He continued, "It's not surprising that you're going to have active transmission of viruses, one of the many respiratory viruses that are circulating now."
According to data from the Centers for Disease Control and Prevention, weekly COVID-19 cases have topped 400,000 for the last six weeks, which are figures not seen since late September although the overall number has declined from last week.
Meanwhile, weekly COVID-19 deaths are trending upward with 3,907 reported as of Jan. 11, CDC data shows, although some of this may be due to reporting lags over the holidays.
Additionally, CDC data shows that while flu cases are declining the cumulative hospitalization rate of 54.4 per 100,000 is 1.8 times higher than the highest figure recorded at this point in the year dating back to the 2010-11 season.
It is well known that infected individuals can expel droplets that move throughout an entire indoor space and even linger after a person leaves the area.
What's more, with lack of ventilation -- be it high-efficiency particle arresting filters or open windows -- and people gathered closely together with no masks, Brownstein said it's no wonder people contracted COVID.
"We sort of have to decide collectively, as a society, what we want to do to keep transmission down," he said. "Obviously, we know mitigation strategies help and then we recognize that we still have a lot of vulnerable people that are succumbing to COVID."
Brownstein added, "But I think the idea of testing pre-gathering is still a very good idea, so it makes sense that the Critics Choice Awards used that as a tool to help limit the amount of risk of transmission at the event."
Honoree Ryan Murphy accepts the Carol Burnett Award onstage at the 80th Annual Golden Globe Awards held at the Beverly Hilton Hotel, Jan. 10, 2023, in Los Angeles.
Christopher Polk/NBC via Getty Images
Brownstein said this doesn't mean that every event will turn into a super-spreader or that it signals trouble for the U.S. Rather, Americans shouldn't let their guard down.
"As much as people want to assume that we've moved on from the pandemic, the pandemic hasn't yet moved on from us," he said. "We're still dealing with events where that super-spreading can occur and there's a bivalent vaccine out there that can lower your risk of severe illness and help reduce your risk of severe consequences and deaths from this virus."
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Govt Admits to Multiple Side-Effects of COVID-19 Vaccines | Weather.com The Weather Channel
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