The Great Pneumonia Epidemic

COVID-19 has gotten an enormous amount of coverage over the past few years. Over 6 million deaths have been attributed to the disease, though it is unclear what percentage of those deaths could be solely attributed to COVID.

During the panic, while everyone cowered in fear of the new disease, another common disease was killing more people than it had in previous years.

The disease was pneumonia, an inflammatory condition in the lungs often caused by bacterial or viral infection.

I’ve written previously about the pneumonia epidemic that was raging during 2020 and 2021 in the United States but got little media attention. The combined amount of pneumonia deaths and COVID-19 deaths from these two years was comparable to the number of excess deaths in the United States.

Pneumonia can be caused by numerous pathogens. In order to determine whether a case is due to bacterial or viral infection, doctors typically examine the breathing of a patient and take an x-ray of the lungs. A culture performed at a lab is needed in order to confirm for certain the cause of pneumonia, but it is an added expense that may not always be performed during a diagnosis.

People generally don’t just catch pneumonia. They typically catch another respiratory virus such as influenza. If the immune system cannot mount an effective attack against the virus, severe symptoms develop and the body weakens. Other pathogens will then infect the lungs, causing them to inflame. Pneumonia is particularly dangerous for people with weak immune systems such as young children and the elderly. Influenza on its own is not likely to kill anyone, but when pneumonia sets in, the chances of survival decrease.

If the pneumonia is due to a bacterial infection, then a patient is typically treated with antibiotics. However, doctors need to exercise caution when prescribing these drugs. Too much antibiotic usage in the population leads to antibiotic resistance. There has thus been a concerted effort in many countries to reduce antibiotic usage in humans and livestock.

In the United States, around half of all deaths attributed to COVID were accompanied by pneumonia. What likely happened in such cases was that a patient became infected with COVID-19, developed severe symptoms, and eventually became infected with another pathogen that caused inflammation in the lungs.

When determining the cause of death with pneumonia, it is difficult to define what exactly caused the the person to die. Was it the respiratory virus that started it all, or was it the lung inflammation that finished the job? In the case of COVID, many doctors may have had incentives to attribute the death to COVID, even if the patient had cleared the virus by the time of death.

Another level of complexity is added when trying to determine whether the infection was viral or bacterial. That’s why many governments tend to group pneumonia deaths with other respiratory deaths. It’s easy to determine whether a death is due to a respiratory illness, but not always easy to determine whether pneumonia was at fault.

So why were there all these pneumonia deaths in 2020? Was it due to COVID? Or was there something else going on?

Antibiotic Prescription Data from the United States

I mentioned in my previous article that COVID was a likely factor contributing to rising pneumonia deaths, but another curious trend was developing in April of 2020. Antibiotic prescriptions plummeted.

The use of Azithromycin, which is an antibiotic used for various types of infections, including respiratory infections, likewise collapsed.

We can see that in the first few months of 2020, antibiotic prescriptions were closely aligned with the trend from the previous year. However, after the United States declared a pandemic in March, we see that prescriptions plummeted by nearly 40% in the month of April.

We know that this isn’t because people were getting COVID instead of pneumonia. Pneumonia deaths skyrocketed in 2020, and nearly half of all COVID deaths in the U.S. were with pneumonia. According to a paper from the CDC, approximately 80% of patients hospitalized with COVID-19 were receiving antibiotics.

So what was going on?

Based on the reports from the CDC, it’s hard to know exactly what was happening in 2020. Usage of antibiotics apparently increased in hospital settings, but outpatient usage decreased dramatically. The CDC attributes this to the decreased spread of other respiratory infections other than COVID-19. I doubt this is the case, mainly because the recorded number of pneumonia deaths sans COVID went through the roof.

The more likely case is that people were too scared to go to the doctor during the lockdown panic and weren’t getting the medication they needed. Another possibility, which was brought up in a Danish paper that I will discuss later, is that patients were being underdiagnosed.

Either way, even though antibiotic resistance is a legitimate reason to reduce antibiotic usage, there was a clear need to maintain typical usage levels in 2020.

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