# 3233
The number of deaths in the US linked to the novel H1N1 virus continues to rise, with Arizona and Utah both reporting new fatalities yesterday.
First this report from the AP, then some discussion.
Utah and Ariz. report H1N1 flu-related deaths
SALT LAKE CITY (AP) — Utah officials reported the state's first death associated with swine flu and Arizona recorded that state's third victim, pushing the U.S. death toll to 10 people.
David Sundwall, executive director of the Utah Department of Health, said a 21-year-old man with swine flu died Wednesday morning at a Salt Lake City hospital.
<snip>
In neighboring Arizona, health officials said Wednesday a 13-year-old boy from Tucson also has died with swine flu. The teenager died Friday of complications from the flu. He had been hospitalized May 10th.
The news of these two deaths is a sad and sobering reminder that this influenza, like all influenzas, can be a killer.
No doubt we will continue to hear about deaths related to this virus over the coming months.
But we do need to put things in context.
Each year more than 2.4 million deaths are recorded in the United States. That’s an average (and there is some seasonal variability here) of roughly 6500 deaths each day.
The CDC lists the following as the most common causes of death in the United States:
- Heart disease: 631,636
- Cancer: 559,888
- Stroke (cerebrovascular diseases): 137,119
- Chronic lower respiratory diseases: 124,583
- Accidents (unintentional injuries): 121,599
- Diabetes: 72,449
- Alzheimer's disease: 72,432
- Influenza and Pneumonia: 56,326
Other than accidents (#5 on the list), most of these causes of death predominantly affect the elderly.
Influenza and Pneumonia are listed as the 8th most common cause of death, right after Alzheimer’s.
While the number (56,326) seems very precise, in fact this is an estimate. No one counted or catalogued 56,326 death certificates listing influenza or pneumonia as either the primary or secondary cause of death.
The number of death certificates that actually list influenza as a primary or contributing cause of death is generally quite small.
Often, the victims of influenza are elderly, and have other serious concurrent health problems, which more often end up reflected on death certificates.
The CDC infers the likely number of Influenza and Pneumonia deaths based on statistical models, some of which are based on seasonal mortality patterns.
These models - and the estimates they inspire - are controversial, and not without their critics. But statisticians, bereft of actual counts, are left with little choice other than to make estimates.
As a paramedic, I saw a lot of people who died at home from routine, often ambiguous causes.
Unless there was something overtly suspicious about the death (young age, holes in the body where there shouldn’t be, signs of a struggle, etc.), we usually just contacted the victim’s doctor by phone, relayed our impressions of the cause of death, and asked the doctor if they would sign the death certificate.
Nine times out of ten, they said `yes’.
The doctor would then `verbally release’ the body to a local funeral home, who would then come to do the removal. The doctor would fill out the death certificate without ever examining the deceased.
No doubt, they put something `generic’ under the cause of death. And no doubt, in some of these cases, influenza or pneumonia played some role in their deaths.
While some localities may operate under more stringent rules today, I’m aware of places that continue to operate in this fashion.
The television CSI model of how things are done is fiction.
No city or county could afford to throw those kinds of resources at every crime scene investigation, evidence analysis, or autopsy.
Particularly not for `routine’ cases.
Some counties and municipalities don’t even have a medical examiner’s office or a `crime lab’, and rely instead on the local funeral director to act as `coroner’. If perchance they notice something `unusual’, they send the body out to a better facility.
The point being, people die every day all over the country (and the world), and quite often the cause of death is, to put it kindly, less than conclusively established.
So, in the absence of complete information, the only option is to devise a statistical model. And that’s why the CDC ends up `estimating’ that 36,000 people die from the flu each year.
The point of all of this rambling is twofold.
First, to establish that the number of deaths each year resulting from influenza is an estimate. It may even be a good estimate, but determining that is way above my pay grade.
And second, to point out that while the number of confirmed deaths linked to this novel H1N1 sits at 10 this morning here in the United States, it is highly likely that we are missing some H1N1 related fatalities.
Our surveillance system simply isn’t good enough to pick out every H1N1 related death that occurs, just like it doesn’t pick out every seasonal influenza death.
When someone young dies, we take a hard look at the cause of death. We therefore tend notice pediatric patients, or young adults, who die from influenza – but not so much people in their 70s or 80s.
The CDC may see some statistical bump in the 122 MRS (122 Cities Mortality Reporting System) that will give us a better idea of this influenza’s impact.
Even if the cause of death is poorly differentiated, the 122 MRS reports over the coming weeks may reflect a general rise in mortality, or a rise in mortality across certain age groups.
I don’t expect that they are going to find a huge number of `hidden deaths’ from this virus. At least not in H1N1’s current incarnation.
Even without solid numbers, I believe that we’d have some inkling by now if we were dealing with a really virulent virus.
But like the number of `confirmed’ cases that get reported each day, I suspect the number of H1N1 deaths we see reported may also be just `the tip of the iceberg’.
Maybe of a small iceberg, but a tip nonetheless.
