
Factors associated with Covid-19 deaths in records of 17M adult NHS patients - gandalfian
https://twitter.com/bengoldacre/status/1258372975004389379
======
mindviews
Here's a link to the paper:
[https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v...](https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1.full.pdf)

This is interesting data. I want to see Vitamin D status included in a large
population study like this because I've been following two smaller studies
covering about a thousand cases total that shows Vitamin D deficiency has a
risk ratio of 10 to 20 (more even than being age 80+ in the above study). The
studies:

[1]
[https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3585561](https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3585561)

[2]
[https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3571484](https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3571484)

Table 1 in each of those papers show Vitamin D status vs Outcomes. The
correlation between Vitamin D status, where Normal is >30 ng/ml (or 75
nmol/L), and death rates is stark.

From [1] (which had n=780 cases) here is the punchline: "98.9% of Vitamin D
deficient cases died while only 1.1% of them were active cases. 87.8% of
Vitamin D insufficient cases died while only 12.2% of them were active cases.
Only 4.1% of cases with normal Vitamin D levels died while 95.9% of them were
active cases."

From [2] (which had n=212 cases) here is the punchline: "Of the 212 (100.0%)
cases of Covid-2019, 49 (23.1%) were identified mild, 59 (27.8%) were
ordinary, 56 (26.4%) were severe, and 48 (22.6%) were critical (Table 1). Mean
serum 25(OH)D level was 23.8 ng/ml. Serum 25(OH)D level of cases with mild
outcome was 31.2 ng/ml, 27.4 ng/ml for ordinary, 21.2 ng/ml for severe, and
17.1 ng/ml for critical."

Note: the classification for outcomes was "(1) mild – mild clinical features
without pneumonia diagnosis, (2) ordinary – confirmed pneumonia in chest
computer tomography with fever and other respiratory symptoms, (3) severe –
hypoxia (at most 93% oxygen saturation) and respiratory distress or abnormal
blood gas analysis results (PaCO2 >50 mm Hg or PaO2 < 0 mm Hg), and (4)
critical – respiratory failure requiring intensive case monitoring."

I want to see a dozen more studies like [1] and [2] to see if this holds up to
replication with larger populations.

~~~
ip26
The critical question remains though- is vitamin D the causal factor, or
instead an indicator of something else?

~~~
excalibur
Sun exposure is far more likely to be the causal factor.

~~~
m463
and/or a diet deficient in D (or whatever gets converted to D with sunlight
exposure)

~~~
gridlockd
There's nothing particular that is required in the diet to synthesize Vitamin
D3 from the sun.

Without sun exposure, you'd have to be eating several pounds of fatty fish
every day to get to "healthy" levels from diet alone. You need a supplement.

Keep in mind, non-severe Vitamin D deficiency doesn't cause any significant
evolutionary pressure, so migrating humans just rolled with it - to this day.

------
smt88
It seems like a lot of people are interpreting this data as causal. I've
already had people tell me they were surprised to learn that smoking protects
against Covid!

Here's a fantastic explanation of why you should not let your brain tell you
that you're learning about things that cause Covid complications and death:

[https://twitter.com/EpiEllie/status/1258607277357006849](https://twitter.com/EpiEllie/status/1258607277357006849)

~~~
tom_mellior
The thread is good, but a possible link with nicotine has been observed
before. This might just be the unlikely case where smoking does indirectly
confer some health benefit.

~~~
phogster
Maybe because it could cause you to go outside, increasing exposure to the
sun.

~~~
tonyedgecombe
Or kill you before you get to a vulnerable age.

~~~
m463
it might work like a mask if you always inhale through a filter and an
inferno.

It might even purify your second-hand smoke.

but yes, you have a very real point. I remember reading about some drug that
seemed to give people heart attacks, but it actually cured what it was
supposed to and heart attacks were the next statistically likely thing to get
you.

------
legerdemain
Notably, this research is being publicized by Ben Goldacre of _Bad Science_
(among other accomplishments). Goldacre also gets last author on the non-
alphabetized list of authors on the preprint, suggesting his primary
involvement.

~~~
chiefalchemist
I wasn't familiar and looked him up. This might save others the effort.

[https://duckduckgo.com/?q=Ben+Goldacre+of+Bad+Science&t=fpas...](https://duckduckgo.com/?q=Ben+Goldacre+of+Bad+Science&t=fpas&ia=web)

~~~
chiefalchemist
Down voted for helping others. HN...you've lost your mind. Your sense of
community is an embarrassment.

~~~
notRobot
A copy-paste of the bio from Wikipedia would be more helpful than a DDG search
link.

~~~
chiefalchemist
For you perhaps. But I didn't see value in imposing my will on others. In
fact, I looked at a few of the articles in that DDG SERP.

------
supernova87a
The title / headline is overstating it a little. The sample only contains
5,683 people who died of the virus. The 17M is the sample of hospital patients
in general. I don't know if this is on purpose, but it makes the study sound
artificially more significant. Every study could claim the "17M" figure by
this practice.

~~~
ckastner
As far as I understand it, they are comparing the statistics of the 5,683
sample to the 17M in order to determine whether anything stands out. If
Covid-19 deaths had no associated factors, then we shouldn't see much of a
difference between the two.

However, we are seeing differences, for example with diabetes.

~~~
supernova87a
Yes that's true, but the 17M figure isn't the interesting / groundbreaking
thing. At least it shouldn't be made out to be as if that's the significant
thing.

17M just provides the baseline of "normal". Tons more data isn't needed to get
that right. 170M wouldn't make a difference. I bet 1.7M wouldn't make a big
difference either.

What we really need to know right now is how the Covid deaths behave. All that
this offers is the 5,683 sample, but the title inflates it to emphasize the
17M. We need the 5,683 sample to be merged with other samples to reach 56,830,
etc. _That_ is the significant thing.

~~~
ckastner
I have to admit, the title does sound misleading in this regard, and (to me)
even more so the tweets advertising the paper as per the submission.

~~~
sebbo
You misunderstand. The only reason the study has enough power to make
statements about the relative risk of, say, obesity _independently of_ age,
sex, and ethnicity is because there are 17 million patients to use as
"controls".

------
lettergram
I think one of the key takeaways is in the abstract:

> People from Asian and black groups are at markedly increased risk of in-
> hospital death from COVID-19, and contrary to some prior speculation is only
> partially attributable to pre-existing clinical risk factors or deprivation

~~~
JPKab
Deprivation equals poverty.

Asian in Britain will primarily be Indian/Pakistani descent.

I wonder if this is vitamin d related? Darker complexion of black and Asian
could cause higher risks of vitamin d deficiency in UK.

~~~
econcon
But Indian/Pakistani aren't dying at much higher rate in their own country or
are they? I've no data.

~~~
champagneben
I would imagine that the sun is hotter and shows itself more often in India
and Pakistan - hence the darker complexion.

------
MontagFTB
From the paper:

> The overall cumulative incidence of COVID-19 hospital death at 80 days from
> the study start date was <0.01% in those aged 18-39 years, rising to 0.35%
> and 0.17% in men and women respectively aged ≥80 years, with a trend by age.

How do those rates compare to the seasonal flu in the UK?

~~~
hristov
It is not very useful to compare them with flu because people are much more
likely to have flu than to have covid. These rates seem very small but
remember that the study started in the beginning of february, when there were
likely only a handful if any covid carriers in the uk.

If you could preselect a group of people that you know had covid and measure
their death rate, the numbers are likely to be much higher. This study did not
do this. This is probably because this would require that all patients are
tested for covid as they visit their doctor and this was obviously not
happening.

~~~
eloff
Also flu deaths have been greatly exaggerated. Which explains how with a
supposed 50k flu deaths in a year in the USA, it has never inundated hospitals
like this.

~~~
jdminhbg
85k coronavirus deaths haven't inundated hospitals in the US either, except in
the absolute epicenter in NYC, and even then not to the point originally
feared. It's very easy to imagine 50k flu deaths geographically spread evenly
not overwhelming US hospitals, especially given that they'd be spread over
something like 3x the current coronavirus epidemic timespan. I'm very
skeptical of the sudden "oh those flu deaths aren't real" narrative.

~~~
eloff
Ok, bad word choice with inundated, although NYC got pretty bad.

You can be skeptical, but it does seem to be the case that flu deaths is
actually a made up number.

[https://blogs.scientificamerican.com/observations/comparing-...](https://blogs.scientificamerican.com/observations/comparing-
covid-19-deaths-to-flu-deaths-is-like-comparing-apples-to-oranges/)

------
fortran77
The whole paper is here:

[https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v...](https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1.full.pdf)

Obesity, of course, is a major factor. It's hard to pull apart Type II
Diabetes and breathing disorders from it, too, so a realistic assessment of
disorders that would be mitigated if the patient lost weight might show it as
the absolute major contributor.

Even Vitamin D deficiency is linked to obesity:
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705328/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705328/)

------
gandalfian
[https://www.economist.com/science-and-
technology/2020/05/14/...](https://www.economist.com/science-and-
technology/2020/05/14/the-pandemic-has-spawned-a-new-way-to-study-medical-
recordshttps://twitter.com/bengoldacre?lang=en)
[https://t.co/j1n12eyz7Y?amp=1](https://t.co/j1n12eyz7Y?amp=1) Datamining 17
million NHS records to find Coronavirus factors.

~~~
gandalfian
Sorry my links seem to have gone wrong try
[https://outline.com/YNRSgm](https://outline.com/YNRSgm)

------
chvid
Judging from the chart at p. 11 age is really the dominant factor. Moving the
"hazard ratio" from 0.25 (<50) to 10+ (>80). Completely dwarfing other factors
such as sex, obesity, and various health problems (that the study has
categorised).

------
mmazing
Full paper -
[https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v...](https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1.full.pdf)

------
0-_-0
Interesting that being an ex-smoker increases the risk, but being a current
smoker decreases it. Seems like there is some short term benefit to smoking
that outweighs its long term negative health effects.

~~~
goblin89
As someone who relatively freshly started smoking 1.5 years ago, I find it
insidious. After stopping for a day or two, I actually feel better as tension
goes away and I sleep a lot. Shortly, however, I start randomly getting
sneezes, runny nose, and slight ill-like feeling in my head.

Part of what makes me start again is the desire to avoid spooking others with
those flu-like symptoms in the middle of an epidemic, since I live in a
densely populated area.

I don’t have a clear idea of what mechanism is at work here, my hypothesis is
that the withdrawal somehow suppresses my immune system.

Unfortunately, as far as I can tell, nicotine patches aren’t as good (or
useful at all) at reducing the respiratory symptoms in short term. I suppose
it’s not purely nicotine withdrawal that’s causing this.

~~~
robinhouston
This is a real effect. Smoking paralyses the cilia; about 4–6 days after
cessation, the cilia become active again and start to bring up mucus from the
lungs.

The good news is that these symptoms are temporary.

Public health communications on the benefits of cessation don’t usually
mention this. I wonder if that’s a mistake. I would have thought it puts a lot
of people off quitting, and maybe if they knew what was happening it would be
easier to deal with.

~~~
goblin89
This is definitely useful to know. I reckon some smokers suffering from this
upon withdrawal would suspect immunosuppression, and choose to continue.

When I have a week or so apart from the crowds, I’ll see how long it takes to
push through those symptoms.

(I thought if withdrawal causes immune system suppression, this effect could
explain the apparent COVID statistic correlation mentioned by 0-_-0 in parent
comment, but from your information it’s unlikely to.)

~~~
robinhouston
I think the leading hypothesis is that nicotine may have a protective effect
against COVID-19, which is strong enough to more than counteract the negative
influence of the lung damage caused by smoking.

(This would explain why former smokers are worse off, since they have residual
lung damage but no protective nicotine.)

Of course this is all quite hypothetical, and may turn out to be wrong, but I
gather it’s biochemically plausible.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192087/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192087/)

------
akeck
What is "Deprivation" in this context?

~~~
hristov
I was wondering about that too. After some research it seems to be something
like poverty. I.e., being deprived of decent living conditions, education
opportunities employment opportunities, etc.

In the paper they used this index which measures deprivation by living
location in the UK:
[https://en.wikipedia.org/wiki/Multiple_deprivation_index](https://en.wikipedia.org/wiki/Multiple_deprivation_index)

------
Ozzie_osman
What is a hazard ratio? Ie if the hazard ratio is 1.25 (for severe asthma),
what does that mean concretely?

~~~
phunge
A hazard rate can be thought of as a patient's one day probability of
mortality. A hazard ratio is a ratio of two hazard rates, so 1.25 would mean
that people in one group were dying at a 1.25x rate relative to a comparison
group.

~~~
logjammin
I'd quibble slightly with the interpretation of the Hazard Ratio (or rate)
here and say that it's more like "the instantaneous relative risk (or
probability, if you like) of the event of interest [in this case mortality but
not necessarily] between those with confirmed coronavirus and those without
it, given that both groups have survived until time _t_ and holding [set of
covariates of interest, e.g. race, age, etc] constant."

Don't mean to sound like a pedant here even though it totally reads that way.
I figured with enough epidemiology in the news these days, people may see a
lot of "Hazard ratios" or "Cox regression" or "survival analysis" and be at
risk of some confusion. I work with these concepts and I get tripped up myself
sometimes.

------
_bxg1
> Deprivation was also found to be a major risk factor

What does this mean? Sleep deprivation?

~~~
tialaramex
Indices of Multiple Deprivation use a bunch of factors to measure how much it
sucks to live somewhere. Other people are saying "poverty" but that's only
_part_ of the problem.

[https://en.wikipedia.org/wiki/Multiple_deprivation_index](https://en.wikipedia.org/wiki/Multiple_deprivation_index)

For example suppose you are very poor but you live where I grew up in
Metroland. Lack of money sucks pretty badly, but in Metroland other
deprivation factors are mostly low.

There are jobs in Metroland. The schools are pretty good. There's a hospital,
and a nearby doctor with a friendly manner (remember Britain has universal
healthcare, but universal does not mean universally excellent). You can't
afford private rent here, but local government can find you somewhere to live,
and not in six months but maybe six days.

The local crime isn't too bad. Vandals, maybe the odd burglary you suspect a
neighbour is on the game (prostitution), but you don't fear for your life. The
surrounding space is nice, there's a play park, rolling hills, fresh air if
you like that sort of thing.

So in Metroland even the poor aren't very deprived.

In contrast, in some deprived Northern cities in particular, even the middle
class suffer pretty badly, and will strive to get out.

~~~
_bxg1
I always forget that "poor" over there doesn't also mean "unable to get
healthcare" and "living in a tent under the highway".

------
maxcan
> being male (hazard ratio 1.99..

It’s an interesting counter factual to imagine how differently the media would
be covering the situation if the genders were reversed and women had about
twice the chance of dying from COVID-19..

~~~
Igelau
I'm surprised they even mentioned this, considering how often my wife has told
me to shut up about my "man cold"

------
netsharc
Obligatory, "Fucking Twitter thread" complaint. I dread reading

\- Bullet point

\- After bullet point

\- In the form of a tweet per bullet point

\- Trying to skip the bullshit

\- And find the conclusion

(I'll stop now) ...and having the anxiety to be disappointed that I'll read so
much bullshit and end up with nothing. Yes, in the end he links to the
abstract which has the (unfortunately harder to parse) meat, but also yes, the
Twitter thread disappoints, because he ends up tooting his own horn that they
were the first, "this [study is] extremely important" and how he needs a
sandwich... and seemingly that's where the thread ends? (TBH, thank god for
that).

~~~
Kliment
I fully agree with you, and therefore:

a) the thread, in readable form
[https://threadreaderapp.com/thread/1258372975004389379.html](https://threadreaderapp.com/thread/1258372975004389379.html)

b) the full publication
[https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v...](https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1.full.pdf)

~~~
dredmorbius
ProTip: DDG bang !thread <twitter url>

So:

    
    
      !thread  https://twitter.com/bengoldacre/status/1258372975004389379
    

...at [https://duckduckgo.com](https://duckduckgo.com), or in your navbar (if
DDG is your default search engine) goes straight there.

------
verdverm
Given "AI's" inability to understand time and temporal relations, and given
the incredible amount of hidden dynamics and game theory in economics, just
going to go ahead and facepalm

~~~
gandalfian
Sorry, what are you saying? This is Epidemiologyists doing statistical
analysis of a vast data set. Where does the ai come in?

~~~
verdverm
Oh, it looks like fat fingers on a phone. I'm not even aware of this OP

~~~
verdverm
This is the one I meant to comment on
[https://news.ycombinator.com/item?id=23192492](https://news.ycombinator.com/item?id=23192492)

------
new_realist
It’s not surprising that historically plague-ridden Europeans would be less
susceptible to a new blight then other ethnicities. Disease resistance has
been selected for.

~~~
peteretep
Asia got all the same plagues as Europe

~~~
dredmorbius
The two regions often responded very dissimilarly. nKyle Harper'sb _The Fate
of Rome_ looks at this in depth.

TL:DR; civilisation's patterns (cities, trade, travel) co-evolve diseases.
Populations tend to evolve resistance to local endemic disease, but are
susceptible to novel agents, including foreign infections. Rome infected China
and vice versa.

