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Putting the COVID-19 pandemic in perspective (Number 25)

There was no report for July due to personal circumstances (cataract surgery and other activities), but COVID did not end in the meantime, so I'm back to observe how USA compares to the rest of the world in the ongoing pandemic.

This monthly report was spawned by my interest in making sense of numbers that are often misinterpreted in the media or overwhelming in detail (some would say that these reports are too detailed, but I am trying to give you a picture of how the COVID pandemic in the United States compares with the rest of the world, to give you a sense of perspective).

These reports will continue as long as the pandemic persists around the world.

Report Sections:
• August-at-a-glance
• The Continental View • USA Compared with Other Countries
• COVID Deaths Compared to the Leading Causes of Death in the U.S.
• U.S. COVID Cases versus Vaccinations
• Profile of Monitored Continents & Countries • Scope of This Report

August-at-a-glance

Reminder: you can click on any of the charts to enlarge it. It will open in another tab or window. Close it to return here.

GLOBAL SNAPSHOT

To most of us COVID-19 seems to be receding in the rearview mirror, but while it has slowed, the pandemic continues to spread around the world and in the U.S. This is the 25th monthly report, now focused on 33 countries that have been at the top of the COVID statistics. Over more than two years, we have seen surges move around the world, with Australia and several Asian countries added to the list of countries monitored for this report in recent months. Interpreting the numbers and comparing USA with the world has been a primary concern of these reports—and the interpretation of those numbers has changed over time. To see another perspective on this, read Katherine Wu's article "Five COVID Numbers that Don't Make Sense Anymore." An excerpt was posted on SeniorLifestyle, with a link to the full article on The Atlantic website.

EXECUTIVE SUMMARY

• Globally CASES reached 607 million by the end of August 2022, a 5% increase over July, having fallen each month from a recent high of 31% in January 2022 to a low of 4% in .May and June before moving back up to 5% in July and August. The percentage of global population with reported cases of COVID-19 rose from 4.8.% in January to 7.7% in August. (The 1918 pandemic is generally thought to have infected 25% of the global population).
  
  The red "cone" in Figure 1 above shows a high and low projection of Global cases based on the pace of spread in the first year of COVID-19. The bottom (roughly 310 million) represents the trajectory of the lower pact in late summer 2020, the upper (approximately 480 million) represents a continuation of the major surge from November 2020 through January 2021. Even when the delta variant in 2021 was announced with alarm, the Global increase in cases stayed within the projection cone Then came omicron, which hit Europe hard in December 2021, and the curve shot through the projection cone in January then raced ahead at a very steep increase into March as it spread around the world, shooting upward by 200 million cases in three months. Slowing somewhat in April and May of 2021 It took 21 months to reach 287 million in December 2021. By the end of August, cases were approaching 150 million more worldwide than had they stayed within the pace of that first major surge. .
  
  
• DEATHS from COVID around the world, fortunately, continued to rise at a much slower pace than cases. Deaths have increased 1% each of th past four moths,down from the most recent high of 5% in February. The downturn in the global curve for deaths is obvious, falling at least 3 million short of the pace for most of 2021. That still leaves a death toll from COVID of more than 6.5 million worldwide 30 months into this pandemic.
  
  
• BY CONTINENT. At the global level, omicron produced a noticeable bend in the curve for cases as a proportion of population (Fig. 3C),, but the huge increases for North America and Europe were dampened at the global level by much lower increases in Asia and Africa, which dominate global population. The level of global proportion of cases rose from 3.6% in December 2021 to 7.7% in August 2022, with Europe rising dramatically in that time, from 30.5% in December to 36.9% in June before starting a slow decline, ending August at 36.7%. Meanwhile, Asia dropped as Europe rose, but is back to where it was in June 2021, just over 30% of global cases, as South and North America have slowly dropped in proportion, from a combined high of 46% in January 2021 to a low of just under 30% in August.
  
• USA continues to lead the world in the number of reported cases and deaths, and while it leads the world in the number of COVID tests its vaccination rate remains lackluster in comparison to other countries (which keeps the death rate higher than it could be).
  
• While the 96.1 million CASES represents 29.0% of its own population—up from 25.9% in June—the US proportion of world cases dropped from 20.1% in January to 15.8% in August. At the same time, surges in Europe pushed cases in France and Netherlands to half their populations by August.. Europe, with just over 10% of world population, accounts for 36.5% of reported COVID cases in the world.
  
  The blue projection cone surrounding USA cases in Figure 1, based on the same timeline as the global cone described above, stretched from 50 to 145 million cases, with the curve for cases staying well within those bounds. Cases in USA flattened significantly from January through July 2021 after vaccinations became available, Then, it rose slightly through November 2021 with a combination of delta and vaccine resistance. Omicron produced a serious upward bend in January, then slowed in February, staying in the middle of the projection cone since then.
  
  The upward bend for USA cases since December 2021 is clearly visible in Figure 1, but even more pronounced in Figure 10 below, which "zooms in" on USA. Figure 11 provides a detailed view of USA vaccination.
  
  Figure 1 also shows how much lower cases in USA would be—approaching 24-million by now, instead of 96 million—if they were proportional to the global population. It would also mean about 267 thousand deaths instead of more than 1.1 million.
  
• USA DEATHS continue to represent a proportion of world COVID deaths far in excess of its 4% share of world population. (China and India represent roughly one-third of world population between them). USA deaths declined from 20.9% of the world total in September 2020 to 14.5% at the end of August 2021, before inching up again, hitting 16.4% of the world total in February before rising slightly to 16.5% in August 2022.
  
  
• HOSPITALIZATIONS for COVID in USA were reported at 32,519 in August, down 18% from July, and down considerably from the high of 133 thousand in January 2022 when hospitalizations related to omicron peaked.
  
  
• THE OMICRON VARIANT emerged at the end of November 2021 and hit Europe hard, bringing back lockdowns and severe restrictions in several countries. In January the surge became turbo-charged and spread to North America and to a lesser but noticeable extent to South America and Asia. In April, the increase in Asia continued, while North America had slowed considerably. While deaths can follow well behind increases in cases, it appears that both delta and omicron have had minimal impact on the pace of COVID deaths as mortality rates (deaths as a proportion of cases) continue to fall. This also appears to be true of BA-2 and its string of sub- variants, which are causing surges in cases in Asia (and perhaps the slight uptick in USA cases), without a rise in the curve for deaths. While new patterns could emerge, omicron has had the most impact of the three major variant waves so far.
  
  
• TESTING. USA leads in the number of tests, with over 1 billion, followed by India, UK, Russia and France. Of the 33 countries monitored for this report, Ukraine, Mexico, South Korea, Bolivia and Ecuador report the lowest number of tests. By proportion of population (tests-per-million), UK remains far ahead of others, with the equivalent of more than 7 tests per person. USA is just over 3 tests per person, similar to the other top countries. At the low end, the number of tests covers 29% or less of population. (See figures 8A, 8B, 8C, and 8D).
  
  An importaant note on testing: With home tests available more widely in 2022 it will be hard to see their impact on the overall amount of testing, since their use is not reported to health agencies. Because of alternate means of testing which do not contribute to the statistics, I am not sure how meaningful it is is to continue inclusion of it in these reports—except that it shows some continued progress among countries with the lowest testing rates.
  
  
• VACCINATIONS. 68% of the world's population have been reported as receiving at least one dose of vaccine by the end of August. (See figures 5A, 5B, 5C, 9A, 9B and 11).
  
  South America leads the world in vaccination, with Chile reporting 93% fully vaccinated. Ironically, Chile suffered a major surge of cases and deaths in March that continued through May, which may be explained in part by differences in efficacy of available vaccines. USA has plateaued, with 67% fully vaccinated and another 12% partially vaccinated by the end of August, increasing only 19 million since November, a rate that is slower than the growth of cases (19% since February when that curve started to flatten, with vaccinations increasing just over 2% in that time).
  
  
• COUNTRIES TO WATCH. Of the top ten countries by population, Pakistan, Nigeria and Singapore have not reached the threshold (the top-20 in cumulative number cases or deaths) I have used for inclusion in my list of monitored countries.
  
  The weekly comparison report on worldometers.info gives a sense of hot spots to watch. Based on weekly activity, this includes Taiwan, Hong Kong, Austria, Serbia and Thailand,. all in the top 20 of new cases and/or deaths in late August/early September. While some of these have populations too small to make much of an impact on this report, they generally confirm the continued spread of COVID in Europe and Asia.
  

Where you get information on COVID is important. In an atmosphere wary of misinformation, "news-by-anecdote" from otherwise trusted sources can itself be a form of misinformation. As I go through the statistics each month, I am reminded often that the numbers do not always line up with the impressions from the news. With that caveat, let's dig into the numbers for June 2022.

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THE CONTINENTAL VIEW

The most obvious trend in May is accelerating cases in Asia, continued spread in Europe while North America and most of South America has been slowing in the spread of reported cases. It is likely that a significant number of people who have been vaccinated are suffering breakthrough infections, but few require hospitalization and death.

While COVID-19 has been classified as a global pandemic, it is not distributed evenly around the world.

COVID cases now represent 7.7% of world population. (By the end of the 1918 pandemic, it is generally reported to be about one-quarter of the population.) Where Asia and Africa combined represent about three-quarters (76.9%) of the world's 7.9-billion people, Europe, South America and North America still account for 2 out of 3 COVID cases (67.1% - Figure 3A) and nearly three-quarters of COVID deaths (73.3% - Figure 4A).

Europe dropped slightly in May, to 36.9%, then kept going down, ending August at 36.5% of world COVID cases. Asia put on the brakes in late 2021 as Europe was hit with omicron-driven surges, but has been steadily expanding its share of global cases, ending August with 30.2%, still below its high of 32% around this time last year. South America, and to lesser extent North America, have been declining in proportion for more than a year.

Overall, Europe is up 9% in proportion of world COVID cases since the chart begins in November 2020, while Asia is up 4% and the others down: Africa 1%, South American and North America both about 7%.

While Africa shows only the slightest deviation from its low and slow growth in Cases, the presence of omicron is very visible for the other continents, with the pace slowing for each following one to three months of rapid growth.

Europe shows the greatest impact in number of cases since omicron appeared in late November 2021. After being virtually tied with Asia in December, Europe has seen its COVID cases rise 155% since then, while Asia increased by 118%, showing an upward bend the last two months. .Both have slowed since March, but continue to rise faster than the other continents. North America increased significantly in January, then slowed, rising 29% in the next several months.(Had the January rise continued, it would have caught up with Asia in number of cases by March or April). South America saw the lowest post-omicron increase, at 18%. The Americas were obviously hit by omicron, but to a lesser and shorter degree than Europe and Asia, making their curves bend down sooner and deeper.

The raw numbers of Fig. 3B can be deceptive. Fig. 3C gives a more realistic picture of the impact by translating raw case numbers to percentage of population. (By contrast, Figure 3A is distribution of global cases). The shape of the curves is similar to those for raw numbers, but the order and spacing paints a different picture.

The impact of omicron is clearly evident, with the Global share of COVID cases increasing from 3.6% to 7.7% since December, Europe has seen the biggest increase, rising steadily for three months, with a slight slowdown in April and May, then accelerating again in June. North America outpaced Europe in January before slowing. In April it appeared that North America and Europe could meet in May, but an upturn for North America continued its lead over Europe all the way through August. As you will see in the Comparison of Countries section below, however, USA is now behind the top-5 countries by proportion of cases.

South America stays above the Global level, slowing slightly from April to May, then picking up a bit in June.. Asia and Africa remain below the Global level, Asia increasing noticeably since omicron became evident, but at a slower rate than the Global level. Africa remains far below the Global level and shows only the slightest increase due to omicron.

The proportion of deaths between continents shows less extreme change than that for cases. In fact, given the increase in proportion of cases for Europe over the past year (Fig. 3A), the continental share of COVID deaths has remained remarkably stable. The changes in Fig. 4A can be divided into five stages by time (the pattern is similar for cases in Fig. 3A, but not as obvious as it is here):

• November 2020 to March 2021 - Europe and North America expand as Asia and South America contract.
• April to July 2021 - Asia and South America expand as Europe and North America contract
• August 2021 - February 2022 - Europe and North America expand as Asia remains about the same and South America contracts
• March - May 2022 - Europe continues to expand, Asia remains stable, North and South America contract
• June through August 2022 - little change for three months - the first time there has been a "pause" in the otherwise changing mix, and this despite rising cases in Japan, South Korea and Vitenam that would seem to suggest some movement in proportions

Overall, Asia is up 3% in proportion of COVID deaths from where the chart starts in November 2020, Europe is up more than 2%, Africa is up less than 1%, while South America is down nearly 2% and North America is down 4%.

Deaths through August 2022 show that while the trajectory lags behind cases and has progressed at a steadier rate, it does reflect the overall changes in Cases by continent. Having crossed the 1 million mark a year ago, Europe us closing in on 2 million deaths.

While the omicron surge in Europe went "through the roof," what is interesting here is that the death rate actually took a turn downward in January, with a very slight upturn in February and March, and a nearly imperceptible slowdown starting in April. The relative steadiness in the path of each curve shows that the death rate has remained much more constant over time than cases, which tend to surge in varying degrees with each new variant. And, as we'll see later, mortality rates (deaths as a proportion of cases) continue to fall.

Vaccinations

As Fig. 5A shows, two thirds of the global population (68%) has been reported with at least one dose of vaccine, and six in ten (62%) are fully vaccinated. That is still well below what is commonly thought of for "herd immunity," which is closer to 94% of the population being immune (most through vaccination), but is remarkable nonetheless given the enormity of the effort represented in little over a year since vaccines became available.

South America, which was slow to get into testing and vaccination, soared ahead of the other continents toward the end of 2020, then took the lead in total vaccine doses in August 2021. Asia pulled past North America in March 2022 with 74% of total vaccinations, tied at 76% in May, then North America pulled ahead again in June with 79% total vaccinations, though Asia was well ahead in fully vaccinated at 71% (much of this was due to counties like South Korean and Vietnam with high vaccination rates that have been added to the list of monitored countries in recent months). . . Europe, impacted the most with omicron-related surges, remains in fourth place with 69% total vaccinations and 66% fully vaccinated, putting it ahead of North America and the world level for fully vaccinated.

While South America got into vaccinations later and slower than North America and Europe, Figure 5B shows how it steadily pushed its way to the top of total vaccination doses administered by August 2021, expanding its lead since then. Africa remains well below the rest of the world, though it continues to increase in vaccination delivery, while the other continents have slowed through 2022 as they apparently reach saturation, which ranges from 68% for Europe (which seemed poised to take the lead a year ago) to 85% for South America.

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COMPARISON OF USA WITH OTHER COUNTRIES

Cases

Raw numbers are virtually meaningless without relating them to the size of a given country, so looking at cases as a proportion of population helps get a sense of the relative impact. The countries with the greatest proportion of COVID cases illustrates how they amplify the world trend for cases (bottom line in Figure 6A),

All five countries return, in the same order as April.

France ended August with 52% of its population having been reported with COVID infections at some point, passing Netherlands, which has slowed over the last six months, but still ended August at the 50% mark. Following a pattern closer to France were South Korea and Australia, while Belgium and USA (not in the top 5) were closer to Netherlands.

Another way to look at population proportion is the measure "1 in." The global figure of 7.7% means that 1 in 13 people in the world have been reported with COVID-19 since it began (and that only by official record keeping, not including any unreported and likely asymptomatic cases). For Netherlands, France and South Korea it is 1 in 2; for Belgium, Australia and USA it is 1 in 3.

All five countries (of the 33 monitored) in the bottom-5 by proportion of population have been there, in this order, since December 2021.

At the scale of this chart, the rise in Global case proportion is magnified compared to the previous chart, so it clearly shows the acceleration of cases produced by omicron around the world since November. Al five countries show a rapid upturn followed by a leveling off (with no apparent correlation with BA-2 and its sub-variants as this point).

These countries represent a considerable spread in size, from India, the second largest country, to Ecuador, ranked number 67 of the 215 countries tracked by worldometers. For Ecuador, its 5.2% of population means that 1 in 18 have been reported as having had the COVID virus; for India it is 1 in 31, and for Indonesia 1 in 43. .

Because the size of countries makes the use of raw case numbers illusory, another measure I find helpful is the rate of change from month to month (Figure 6C). The focus of the selection is on recent changes, but the chart covers 12 months.. For this chart, countries are selected based on the change over two-months (end of June to the end of August). For the chart this month Bolivia replaces Chile. .

The overall trend (red line, reflecting global level) had been climbing, up to a 31% change in January, reflecting the large impact of the omicron variant. Since then it has dropped to a monthly change of the global rate of 4% in May and June, then up to 5% for July and August.. While the global level did climb significantly, the trend line was damped by the short duration of that increase and likewise took a nosedive in August. As the January peak fades in time we should see the trend line level off more. .

Japan saw another surge in cases, with a 34% increase in August, following a similar large bump of 31% in March, with a decline to 5% last month. South Korea had a 32% in April, went down then back up to 13% in July and 12% in August, putting it second behind Japan in two-month change. Australia, Bolivia and Italy had lower and similar patterns for July and August, all combined to put them in the top-five for change over two months.

The chart below shows how the top-5 has shifted since May 2021, from dominance by Asia and South America in mid-2021, to resounding impact of omicron on Europe in the past four months, before broadening out in March 2022. By June, Europe was down to two countries in the top-5 by 2-month change, Asia down to one, and new entries for Oceania (see not at bottom of chart) and South America. North America, dominated by USA but influenced by Canada and Mexico, has made the fewest appearances in this chart.

Deaths

Because deaths as a percentage of population is such a small number, the "Deaths-per-Million" metric shown in Figure 7A provides a comparable measure. It is different than mortality rate, which is a measure bases on deaths as a proportion of cases.

The same five countries return to this month's top-5, with USA easing past Brazil to move into third place.

The Global curve for deaths-per-million shows a very steady growth, despite surges, vaccinations and variants that had a much more obvious influence on cases.

As Figure 7A shows, Peru still soars over the others following a correction to its death data in June 2021. It shows a slight increase in the death rate with omicron starting in January, remaining about double the remaining four, which all rose faster than the Global rate.

USA tracks along the bottom of the top-5, with an upward movement during the delta variant (also the time of debate over the impact of vaccine resisters),then tracks with Poland during omicron and reaching a virtual tie in March between Brazil, Poland and USA.

Given lower death rates in European and Asian countries that experienced much higher surges in cases, it is striking that USA, whose case rate has been much more moderate, finds itself in the company of countries with the highest death rates as measured by deaths-per-million-population. That situation should lead to serious consideration of what could have been done better, especially as political and ideological division drove the split between over-zealous use of lockdowns in the name of Science and the ethos of a "don't tread on me" individualism, a division that soured the often heroic efforts of the health care system.

All of the countries on the chart are well above the Global level, and (except for Peru) remain fairly close to each other.

All five countries return from last month.

Australia South Korea an Japan, all recent additions to the list of monitored countries show are all increasing faster than the Global rate. Australia, representing Oceania (the "continent" largely untouched by COVID and too small to count in my continental comparisons) is seeing death-per-million surge as it did in India early in 2021, even before delta and omicron.

The Global rate of increase in deaths-per-million was very steady through March 2022 when it began a noticeable slowdown, even as BA-2 and its sub-variants began to emerge, increasing the widening gap between cases and deaths—the bit of good news in this pandemic.

As with the comparable chart for Rate of Change for Cases (Figure 6C), countries for Rate of Change for Deaths (Figure 7C) are selected based on the change over two-months (end of June to end of August) in reported COVID deaths. The focus of the selection is on recent changes, but the chart goes back 12 months for perspective.

Spain replaced Germany in July, with the same five countries showing the highest increases in deaths over two months.

The global rate of change by month (red trend line) fell from 6% in September 2021 to 1% in May and June 2022 before going back up to 2% in July and August.

Australia increased 37% over two months, 17% in August. Japan increased 27%, 12% in August. South Korea had a one-month change of 391% in April, followed by increases below 10% but above the Global level since then, enough to put it in the top-5 for increases over two months. From there, the increases in death falls to a level at or below the Global rate of change, with Canada and Spain having the rather dubious honor of falling into the top-5.

Fifteen of the 33 monitored countries (including USA) had two month changes of 2% or more, three more than matched the global two-month change last month. That leaves more than half below the global rate. A similar increase was seen in the growth of cases, with 12 exceeding the Global two-month change in August, compared to only 8 in June.

A note about percentages: The actual increase in the number of deaths in South Korea in March was 4,638, then soared to 22,794 in April (391%) and slowed to 24,178 in May 96%). As the base number increases, the relative percentage of change goes down--thus, even if the increase of 18 thousand deaths in one month initially produced a four-fold change early on when the base number is low, if deaths increased at the same rate, the percentage of change from month to month would continue to fall because the base number is growing.

Contrast this chart with the one for cases above. The chart below shows how the top-5 has shifted since May 2021, from dominance by South America to a mix of Asia and Europe, then a dominance of Europe, followed by a broadening mix as omicron spread and renewed evidence of increasing deaths in Asia in May 2022, while June shifts to include Oceania (see note at bottom of chart)) and North America.

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Mortality Rate

Mortality Rates (percentage of deaths against reported cases) have generally been declining. This is not surprising as several factors came into play:

• In the early days of the pandemic, there was a high proportion of "outbreak" cases (nursing homes, retirement communities, other settings with a concentration of more vulnerable people). As the pandemic continued the ratio of "community spread" (with lower death rates) to "outbreaks" increased and the overall Mortality Rate went down.
• As knowledge about treatment increased, mortality went down.
• Since the death count is more certain (though not without inaccuracies), the side of the equation that can change the most is cases. As testing revealed more cases, the Mortality Rate would naturally go down because it would only affect cases and not deaths. In addition, the official numbers do not take into account a potentially higher number of people with the virus who are unreported and asymptomatic, so the real mortality rate could be even lower. (This will be a factor with availability now of home testing, where positives may escape official reporting).
• Vaccinations started in January 2021 and available in January 2022 was the first anti-viral drug (though these should impact both cases and deaths).
• So far, the omicron and subsequent variants have produced a continued rise in cases, but not in deaths,which is the reason the Global mortality rate started to decline more noticeably in 2022, with very steep drop in mortality as omicron drove up cases in Peru, Brazil and Ecuador.

The Global mortality rate had dropped from 2.6% in October 2020 to 2.0% by September 2021, where it stayed for three months. Interestingly and—proving the point about death rates remaining steady and actually slowing down even as cases surged—the Global mortality rate dropped to 1.2% by the end of April, 2022 before heading down to 1.1% by the end of August,—in a kind of mirror image to the upward slope of the curve for cases.

The same five countries return this month. Because of a correction in its data in June 2021, Peru saw a major spike in its mortality rate, which slowly went down through December, followed by the largest decline in mortality among the five at the same time omicron was pushing up case numbers. Since February, all five have leveled off, with little or no change in mortality rate, Indonesia and South Africa have been vying for fourth place for seven months.

Since these represent the best mortality rates, where low is good, the "rank" order is actually in reverse.

The same five countries return, in the same order, from last month. South Korea and Australia have the lowest mortality rates among the 33 monitored countries, both ties at 0.1% from May through August, followed by Netherlands, Japan and Vietnam. Japan is partially hidden because of ties with Netherlands and Vietnam.

USA had been stuck at 1.2% for six months before dropping to 1.1% in July and August (tracking the Global level now for five months). Relatively speaking, that is a good mortality rate, yet one-third of the monitored countries, including Belgium, Germany and Netherlands have rates below 1.0% by now, largely because huge omicron-related surges were not matched with a similar increase in deaths. USA should have been able to keep deaths much lower since the surges here were well below those experienced in Europe and parts of Asia. (It is ironic that perhaps had USA experienced higher case surges its mortality rate would also have dropped, but that would only happen if hospitalizations and deaths were kept down).

Even so, without a relatively low mortality rate, the USA death rate would be far higher. Compared to the mortality rate during the 1918 pandemic, it could be ten times worse than it is. Matching the Global mortality rate of 1.1%, USA has had more than 1.1 million deaths (out of 96 million cases) by the end of August, As pointed out in Figure 1, however, if USA had cases closer to its proportion of world population, we would be looking at 267-thousand deaths out of 24-million cases. The response of the health care system and availability of vaccines are part of keeping mortality down, but the high case rate points to the conflicts already mentioned between opposing sides of the approach to COVID (extreme lockdowns in the name of science versus extreme individualims in the name of freedom). .

How real is the threat of death from COVID? That's where successful mitigation comes in. Worldwide, by the end of August, 1 in 13 people have been reported as having contracted COVID and 1 in 1,217 people have died. In USA, while the mortality rate is low, because the number of cases is so high, 1 in 309 have died through August 2022—between Brazil (1 in 311) and Romania (1 in 288). Japan and Australia, recent additions because of surging cases,are at 1 death in 3,197 and 1,873 respectively (COVID in both countries, however, has increased to the point that both were added to my list of monitored countries and those numbers, while still in sharp contrast with USA, are moving in the wrong direction). .A closer comparison would be neighboring but sparsely populated Canada, at 1 in 862, or Mexico, at 1 in 391, with most European countries between those two.

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Tests

The same five countries remain on top in COVID testings, having been in the same order since March 2021.

USA remains ahead of other countries in reported COVID tests administered, with more than 1.1 billion, 24% ahead of India, which widened that gap slightly since June.. UK has slowed noticeably, and Russia is a virtual tie with France, which was posited to move ahead, but it too has slowed.

Since these are raw numbers, it is important to recognize the size of the country. It is also the case that COVID tests can be administered multiple times to the same person, so it cannot be assumed that USA has tested almost all of its population of some 331-million. Some schools and organizations with in-person gatherings are testing as frequently as once a week or more for those who are not yet fully vaccinated. That's a lot of testing!

Another wrinkle in the statistics for tests that brings this statistic into question is the increasing availability of home tests, so we may able to track sales but not tests administered since they are not like PCR and rapid tests offered by agencies that report testing to health authorities. When a person tests positive with a home test, it is recommended they have a more reliable lab test to confirm their status. Testing remains very important, and while the statistics for tests have a growing degree of ambiguity, they are useful in showing the problem of equity, which is evident in the next chart.

Netherlands replaced South Korea in July,primarily because Netherlands has not reported any growth in official testing for all of 2022. Meanwhile, Bolivia and Ecuador have seemingly been fighting to stay at the bottom spot during the entire span of the chart.

Not surprisingly, Ukraine has reported no new testing since the Russian invasion in late February. Mexico continues to increase its testing, the only one of the five to show any real progress. Bolivia and Ecuador remain at the bottom, with little change in testing since the beginning the chart in October 2021.

As questions arise about equity of testing between countries, check the number of tests for countries of similar size (within the 33 monitored countries):

• Mexico: 18.1M tests for 128.9M population, compared to Japan: 71.4M tests for 126.5M population (3.9X the tests)
• Ukraine: 19.5M tests for 43.7M population, compared to Argentina: 35.7M tests for 45.7M population (1.8X)
  no change in either country since my last report in June
• Peru: 34.3M tests for 33.0M population, compared to Malaysia: 63.8M tests for 56.1M population (1.9X)
• Ecuador: 3.1M tests for 17.6M population, compared to Netherlands: 21.1M tests for 17.1M population (6.5X)
• Bolivia: 2.7M tests for 11.7M population, compared to Belgium: 35.3M tests for 11.6M population (13.0X)

Tests per million adds another perspective. Fig. 8C shows the five countries with the highest tests per million. Al five have been in the top-5 since the chart began in October 2021 and the current order since January 2022.

UK, while slowing down the last five months, remains well ahead of the other leaders, with an equivalent of 7.6 tests per person. France also has leveled off in recent months, allowing Italy to draw close, ready to move into second place in a month or two. All five countries, however, remain relatively close and represent testing equivalent to multiple times per person.

Anything over 1,000 (or "x-million tests-per-million") represents more tests than people (1,000 on the chart actually means 1,000,000), but as mentioned above, that does not mean that everyone had been tested. Some people have been tested more than once, and some are being tested regularly or with increased frequency.

The same five countries return, in the same order since February 2022.

Brazil has reported no increase in testing for eleven months. Bolivia has also leveled off, for the past six months, while Philippines shows the most progress. Ecuador began to climb again after leveling off for five months, while Mexico continued to make very slow progress.

While some improvement is seen, the equivalent proportion of tests to population remains very low, from roughly 14% for Mexico to 30% for Brazil (and that would be reduced if some individuals receive more than one test). This illustrates the arguments over inequity in resources among countries.

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Vaccinations

Figure 9A compares USA with the top-5 and bottom-5 of monitored countries by total doses administered. As you can see USA leans toward the upper countries, its total vaccination rate showed virtually no increase in August*, and that remains below the full vaccination rate for all of the top-5. On the other hand, USA is well ahead of the bottom five of the 33 monitored countries for both total doses and fully vaccinated.

As pointed out in other parts of this analysis, Figure 9A does not tell the whole story. It's a bit of an apples and oranges comparison, with one major factor being the population of each country.

*Numbers for this chart come from ourworldindata.org. The CDC numbers, used in Figure 11, show similar results, with less than 1% increase in doses administered and less than half a percent for those fully vaccinated (two doses), producing a one percent increase in partial vaccination and no increase in fully vaccinated (by percentage) since my last report in June.

Taking population into account paints a somewhat different picture for USA compared to other monitored countries. In Figure 9B you see the five most populous countries on the left and the five smallest (of those monitored for this report) on the right.

China and Brazil are ahead of USA in both full and total vaccinations. USA is ahead of India and Indonesia in both total doses and full vaccination. .

On the side of the smallest countries, Chile is ahead of all five of the largest countries, but the disparity in earlier months is decreasing as the larger countries (except for USA) continue to improve their vaccination rates.

In USA and perhaps in other large countries, individual regions, provinces or states may be doing as well as some smaller countries, while the entire country lags behind the smaller ones.

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CAUSES OF DEATH IN USA

Early in the reporting on COVID, as the death rate climbed in USA, a great deal of attention was given to benchmarks, most notably as it approached 58,000, matching the number of American military deaths in the Vietnam War. At that time, I wrote the first article in this series, "About Those Numbers," looking at ways of viewing the data, which at the time of that writing in May 2020 was still focused on worst-case models and familiar benchmarks, like Vietnam.

Three Critical Curves

Figure 10 shows the number of USA COVID cases and deaths against the top-10 causes of death as reported by CDC. That data reflects 2019 figures, the latest year available. More recently, I added a curve for hospitalizations, with data going back to October 2020.

Notice that for nearly nine months, the curve for deaths was increasing at a faster rate than cases. Then, starting in October 2020 the curve for cases took a decided turn upward, while deaths increased at a more moderate pace (the two curves use different scales, but reflect the relative rate of growth between them).

Unlike the case and death curves, which are cumulative, hospitalizations reflects the number of cases requiring hospitalization each month. You can see three peaks: the first with the initial surge (before vaccines became available) in December 2020, followed by August 2021 (delta) and January 2022 (omicron), which now represents the peak of hospitalizations. Notice, however, that the relative spread of cases-to-hospitalization is enormously different for omicron. In December of 2020, there were roughly 6.5-million new cases where January 2022 saw 20.3-million (a 212% increase), yet hospitalizations were only 11-thousand higher (8%).

Benchmarking the Numbers

Media reporting tended to focus on easily grasped benchmarks—deaths in Vietnam or World War II, or major milestones like 500,000 (crossed in February 2021).

In August 2021 we passed the 2018 level for #1 heart disease (655-thousand), then passed it again in September when the 2019 data "moved the goal post" to 659-thousand. Another significant benchmark, pointed out in some news reports, was the 675-thousand estimate for deaths in USA during the 1918 pandemic. Adjusted for population growth, however, that number would now be around 2-mllion.

Having passed the annual death benchmarks and 1918 deaths, now we can only watch as the numbers continue to climb . . . .

The latest "Ensemble Forecast" from CDC suggests that by our next report we should see:

...tthe number of newly reported COVID-19 deaths will remain stable or have an uncertain trend over the next 4 weeks, with 1,800 to 4,900 new deaths likely reported in the week ending September 24, 2022. The national ensemble predicts that a total of 1,052,000 to 1,061,000 COVID-19 deaths will be reported by this date......

Note: As I've referenced in the notes for several charts that data from worldometers.info tends to be ahead of CDC and Johns Hopkins by about 3%, because of reporting methodology and timing. I use it as a primary source because its main table is very easy to sort and provides the relevant data for these reports. Such differences are also found in the vaccine data from ourworldindata. Over time, however, trends track with reasonable consistency between sources.

Perspective

The 1918-19 Spanish Flu pandemic is estimated to have struck 500 million people, 26.3% of the world population of 1.9-billion at that time. By contrast, we're now at 7.7% of the global population. Deaths a century ago have been widely estimated at between 50- and 100-million worldwide, putting the global mortality rate somewhere between 10 and 20-percent. It has been estimated that 675,000 died in the U.S.

IF COVID-19 hit at the same rate as 1918, we would see about 2-billion cases worldwide by the time COVID-19 is over, with the global population now at 7.9-billion—four times what it was in 1918. There would be 200- to 400-million deaths. The U.S. is estimated to have had 27-million cases (one-quarter of the population of 108-million) and 675,000 deaths. Today, with a population of 331-million (a three-fold increase from 1918) this would mean more than 80-million cases, and 2- to 4-million deaths.

However, at the present rate of confirmed cases and mortality while the total number of global cases has already surpassed 500 million—comparable to 1918 in raw numbers—that would be one-quarter of 1918 when taking population growth into account . .. and assuming the pandemic persists as long as the Spanish Flu, which went on in three waves over a two year period. (We entered a third year in March 2022). We broke the global 500-million case benchmark in April 2022, propelled by delta and omicron surges since July 2021.

With global cases in August at 607 million, global deaths of 6.5 million represents a mortality rate of 1.1%. Tragic but far below the number reported for 1918 (50-million) with an even wider gap (200 million) when taking population growth into account.

Despite the forecasts for continued spread of COVID since delta, omicron, BA-2 and its sub- variants,, the vast difference in scale between the Spanish Flu pandemic a century ago and COVID-19 cannot be denied. Cases may be soaring in some parts of the world but are behind 1918 when adjusted for population growth, and either way deaths are far below 1918 mortality. The key differences are the mitigation efforts, treatments available today (leaving the health care system overwhelmed in some areas during surges), the availability of vaccines and the first anti-viral drug for those recently infected.

In addition, in 1918 much of the world was focused on a brutal war among nations (World War I) rather than waging a war against the pandemic, which ran its course and was undoubtedly made much worse by the war, with trans-national troop movements, the close quarters of trench warfare, and large public gatherings supporting or protesting the war. While you will see pictures of police and others wearing masks during the 1918-19 pandemic, the need to promote the war effort and maintain morale took precedence over the kind of mitigation associated with major virus outbreaks since then, including COVID-19. Another factor clearly shown in the charts in these reports has been that the rate of increase in deaths has for some time now been well below the increase in cases, especially since vaccines became available in January 2021.

While we are not engaged in a world war as was the case in 1918, today we are now fighting glabal fatgue from a threat that in some ways seems less dangerous yet refueses to go away.

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VACCINATIONS IN USA

With remarkable speed (it usually takes years to develop vaccines), two COVID vaccines were granted emergency approval for use in USA starting in January 2021—the one by Pfizer requires super-cold storage, which limits its deployment. The other, by Moderna, requires cold storage similar to other vaccines. Both of these require two doses, which means that vaccine dosages available must be divided in two to determine the number of people covered. By March 2021 Johnson & Johnson had been granted approval for a single-dose vaccine, though that approval has since been rescinded because of a rare but significant heart-related side effect. The numbers in Figure 11 represent the status of vaccination at the end of August as reported by CDC) which is very close to ourworldindata.org data used in earlier vaccination charts). .

A person is considered "fully vaccinated" two weeks after the final vaccine dose; roughly five to six weeks from the first dose for Pfizer and Moderna.

After a rapid start, vaccination slowed in late spring of 2021. Figure 11 shows a sudden decline that summer, followed by an upturn, perhaps spurred by the delta and omicron variants, that continued through January 2022. After another slowdown, distribution and administration once again picked up somewhat in recent months. The number fully vaccinated (red line) increased rapidly as vaccinations became available than slowed considerably, increasing only one or two million each month in 2022. (This curve should be expected to be lower than either distribution or administration since it requires two does of the most commonly used vaccines to be considered fully vaccinated).

Those getting boosters is up to 109 million in eleven months, but stubbornly short of 50% of those who are already fully vaccinated.. During March 2022, the FDA announced approval of a second booster for those over 65 and those with certain medical conditions, but the response has been cautious because of a lower sense of urgency than with the initial vaccination and booster. As the months have progressed and COVID remains active, boosters are now recommended for everyone over 65, especially with early vaccinations. At this writing a new booster formulated for the latest variants by both Pfizer and Moderna is becoming available.

In addition, in early November 2021 the CDC expanded vaccination approval for children ages 5-12 and in December 2021 the FDA approved the first anti-viral drug, Pfizer's Paxlovid. Despite that, USA fully vaccinated stands at 67%, not bad compared to other large countries, but well behind the best among the 33 countries monitored for this report (see Figures 9A and 9B above). Approval for a long-anticipated vaccine for children five and under was announced in May 2022.

A year ago we were debating lock-downs. Today with most states fully opened, the debate—if there is one—is whether things have moved too quickly, motivated more by politics than public health. Indeed, questions are being raised about the long-term impacts of severe lockdowns, on the economy and particularly on children severely impacted by school closings and the switch to remote learning. It is clear USA is still far below other countries in total vaccination, still regarded as the best defense. And, the number of surge-inducing variants continues.

The most telling sign for me is that our mortality rate only last month dropped to 1.1% after being stuck at 1.2% for six months, where most of the countries we would compare ourselves with have seen steadily declining mortality. That is complicated, however, because USA has not seen the intensity of surges experienced in other countries (which, because of low deaths drives the mortality rate down). Yet, I would dare say that all of us are aware of the growing number of breakthrough infections caught by home testing, which are typically fairly mild and rarely lead to hospitalization and/or death. So, in the end, the number of actual cases may be greatly underreported. If this is the case, our mortality rate would continue to go down. That is part of the paradoxical and complicated nature of this pandemic and the numbers it generates.

As the richer countries with access to more resources make progress, the global situation has raised issues of equity and fairness within and between countries. Even as USA. and other countries launched large scale vaccine distribution to a needy world community, the immensity of the need is so great that a common refrain heard now is whether this aid is too little, too late. As COVID fades into a bad memory in countries able to provide help, will the sense of urgency remain high enough to produce the results needed to end this global pandemic?

Maintaining Perspective

In the tendency to turn everything into a binary right-wrong or agree-disagree with science or government, we ignore the need to recognize the nature of science and the fact that we are dealing with very complicated issues. So, in addition to recommending excellent sources like the Centers for Disease Control and Prevention (CDC), it is also wise to consider multiple qualified sources.

While there has been much focus placed in trusting "the science," it is important to recognize that science itself changes over time based on research and available data. In the highly volatile political atmosphere we find ourselves in (not just in the U.S., but around the world), there is a danger of not allowing the experts to change their views as their own understanding expands, or of trying to silence voices of experts whose views are out of sync with "the science" as reported by the majority of media outlets.

In an earlier report, I mentioned the Greater Barrington Declaration, currently signed by more than 63-thousand medical & public health scientists and medical practitioners (and 869-thousand "concerned citizens"), which states "As infectious disease epidemiologists and public health scientists we have grave concerns about the damaging physical and mental health impacts of the prevailing COVID-19 policies, and recommend an approach we call Focused Protection."

For a personal perspective from a scholar and practitioner who espouses an approach similar to the Focused Protection of the Greater Harrington Declaration, see comments by Scott W. Atlas, Robert Wesson Senior Fellow at the Hoover Institution at Stanford University, in an article "Science, Politics, and COVID: Will Truth Prevail?"

Several months ago on SeniorLifestyle I posted an article by Mallory Pickett of The New Yorker, "Sweden's Pandemic Experiment," which provides a fair evaluation of the very loose protocols adopted by Sweden, essentially a variation of the "Focused Protection" approach. The "jury is still out" on this one, so judge for yourself whether Sweden hit the mark any better than the area in which you live.

UPDATE ON SWEDEN: As of September 4, Sweden reported 2.5 million cases of COVID, or 25% of its 10.2 million population (up 0.6% since June). Three have been 19,873 deaths,an increase of 102 since my previous report for June, for a mortality rate of 0.71%. Ranked 89 in population, Sweden was #41 in cases and #44 in deaths among the 215 countries reported by worldometers (the same as May for cases, up one rank for deaths). Hospitalizations were last reported at 1,148 in mid-March. The high was 33,035 in January 2021, the low 907 in May 2021.

Compared to the countries monitored for this report, that puts Sweden (25%) between Chile (23.6%) and Spain (28.5%) in cases as a proportion of population), with its 0.71% mortality rate between Germany (0.5%) and Belgium (0.8%, near the bottom (best) among the 33 countries monitored for this report (South Korea and Australia are 0.1%) and well below the global rate of 1.1%.

FROM PANDEMIC TO ENDEMIC: In November 2021 I posted on SeniorLifestyle an article by Sarah Zhang from The Atlantic, "America Has Lost the Plot on COVID." In it, she suggests that America (and the world) is headed not toward the eradication of COVID-19, but its transformation from pandemic to endemic, joining the seasonal flu as something we will deal with for some time. Getting there, she contends, is more a matter of mixed policy strategies than "following the science," but coming to grips with its inevitability could help lead to more effective strategies.

Zhang mentions Denmark as a counterpoint to what is happening in America, saying

One country that has excelled at vaccinating its elderly population is Denmark. Ninety-five percent of those over 50 have taken a COVID-19 vaccine, on top of a 90 percent overall vaccination rate in those eligible. (Children under 12 are still not eligible.) On September 10, Denmark lifted all restrictions. No face masks. No restrictions on bars or nightclubs. Life feels completely back to normal, says Lone Simonsen, an epidemiologist at Roskilde University, who was among the scientists advising the Danish government. In deciding when the country would be ready to reopen, she told me, “I was looking at, simply, vaccination coverage in people over 50.” COVID-19 cases in Denmark have since risen—under CDC mask guidelines, the country would even qualify as an area of “high” transmission where vaccinated people should still mask indoors. But hospitalizations are at a fraction of their January peak, relatively few people are in intensive care, and deaths in particular have remained low.

Crucially, Simonsen said, decisions about COVID measures are made on a short-term basis. If the situation changes, these restrictions can come back—and indeed, the health minister is now talking about that possibility. Simonsen continues to scrutinize new hospitalizations everyday. Depending on how the country’s transition to endemicity goes, it could be a model for the rest of the world.

UPDATE ON DENMARK: As of September 4, Denmark reported 3.1 million cases of COVID or 53.0% of its 5.8 million population, up 1% from June. In November 2021 cases stood at 497 thousand, or 8% of the population. There were 6,936 deaths, up 426 since my last report for June. The mortality rate remains at 0.2%, where it had been for five months. Denmark was #40 in cases and #79 in deaths (down one in cases, up2 in deaths over two months. Hospitalizations at the end of August stood at 305, almost the same as June and down from a rise to 487 in July. The high was 9,982 in December 2020, the low was 55 in June 2021.

Denmark's case-to-population proportion is more than 7 times times the global rate of 7.7% and 1% higher than France, the worst among the 33 countries monitored for this report. Despite that, it's mortality rate remains striking. At 0.2% it is between Australia and South Korea (01%) and Japan and Netherlands (0.3%), the lowest among monitored countries.

Both Sweden and Denmark, illustrate a seeming irony, pairing super high case rates with extremely low mortality rates. Does this prove the point of Zhang's observation about focusing on the prevention of hospitalization? Or the Greater Barrington Declaraton's "focused protection."

Resonating with the growing discussion over the impacts of severe lockdowns, columnist Debra J. Saunders wrote about the impact of school closures and the turnabout in thinking by some politicians who had been its strongest advocates. Her column was titled "Worse Than a Crime, a Mistake." Perhaps it's a bit of 20-20 hindsight, but it is another perspective on the "Focused Protection" idea that may help us better shape responses to future pandemics or similar widespread crises.

How we evaluate the many approaches used to deal with COVID will determine how we prepare for and approach the next global event—including the eventual transition from pandemic to endemic.

My purpose in mentioning these sources is to recognize that there are multiple, sometimes conflicting, sometimes dissenting, voices that should be part of the conversation. The purpose of these monthly reports remains first and foremost to present the numbers about COVID-19 in a manner that helps you understand how the pandemic is progressing and how the U.S. compares to the world—and how to gain more perspective than might be gathered from the news alone.

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Profile of Monitored Continents & Countries

(Data from worldometers.info).

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Scope of This Report

What I track

From the worldometers.info website I track the following Categories:

• Total Cases • Cases per Million
• Total Deaths • Deaths per Million
• Total Tests • Tests per Million (not reported at a Continental level)
• From Cases and Deaths, I calculate the Mortality Rate

Instead of reporting Cases per Million directly, I try to put raw numbers in the perspective of several key measures. These are a different way of expressing "per Million" statistics, but it seems easier to grasp.

• Country population as a proportion of global population
• Country cases and deaths as a proportion of global cases and deaths
• Country cases as a proportion of its own population
• Cases and deaths expressed as "1 in X" number of people

Who I monitor

My analysis covers countries that have appeared in the top-20 of the worldometers case and deaths categories since September 2020. This includes most of the world's largest countries as well as some that are much smaller (see the chart in the previous section). Vaccination data is taken from ourworldindata.org and CDC. Hospitalization date is found at ourworldindata.org.

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This article was also posted on SeniorLifestyle, which I edit