TOKYO, Mar 21, 2020 - Consultants at Azabu Insights wanted to understand the stark differences between mortality rates in Korea (currently 1.1%) and Italy (8.3%). We felt that current explanations suggested by virologists, while making a number of valid points, have ultimately been unsatisfactory.


Azabu Insights presents the hypothesis that hospitals may have been one of the breeding grounds for virus infection in Italy and this may have been one of the causes of the high mortality rates. This is a major concern, going forward, for other countries including the United States.


Azabu Insights recommends that policy experts and hospital management carefully consider existing practices to ensure that potential carriers of coronavirus can access to testing and appropriate treatment without spreading the virus to other persons in the healthcare facility. We think that the highly contagious nature of COVID-19 suggests a need for more isolated facilities and stricter measures than have been implemented, in many cases, thus far.



We urge that the successful policies implemented to curb the early outbreaks in China and Korea, including those around hospital isolation and safe testing, should be examined and implemented when appropriate.


Exploring Macro Drivers Behind Infection and Mortality


Previous articles have noted that many of those who died in Italy were older, male, and often smokers. Experts agree that these traits are key risk factors in severe COVID-19 infections (as they are for many other respiratory diseases). It has been argued that these attributes are reflective of broader Italian society, particularly citing Italy's age profile, and by extension proving why Italy's outbreak has been so deadly. We contrasted this with Japan and Korea, which share Italy's characteristics of aging populations with high smoking rates and have also seen coronavirus outbreaks in recent weeks.


Firstly, we examined the key macro data. According to the World Bank, 23% of Italians are over the age of 65, making it the oldest nation in Europe. Note however, there are 16 European countries where at least 20% of the population is over 65, so Italy is by no means a large outlier. Compared with Italy, Korea is a little younger with 18% of its citizens over 65 however Japan is significantly older with 27% of its populace 65 or older. Digging a little further we see that in Cremona, one of the areas hit hard by the northern Italy outbreak, almost 33% of people were over the age of 60 compared with 38% over 60 in Japans Kitami, the site of Japans main outbeak. With regards to smoking, overall smoking rates are higher in Korea (24%) and Italy (22%) than in Japan (18%). However in Korea, men's smoking rates are much higher at 34% than the 27% of Japanese males and the 23% of Italian men who currently smoke.

These numbers suggest that Japan and Korea, at best, both share similar risk factors to Italy and arguably look much poorer than their European counterpart. Given this, Azabu Insights asserts there are other factors that are driving the speed and intensity of the Italian outbreak.


Partly Result of Tested Populations


Part of the effect of the disparity can be accounted for by the disparity in tested populations. Korea has tested aggressively, with over 286 thousand people (second only to China's 320 thousand) tested and 3% testing positive. They tested broadly across all age groups with 28% of test subjects 20-29 years old and 58% under the age of 50. In turn many of the younger Koreans tested positive for COVID-19. It should come as no surprise that the mortality rate would be lower amongst this group of younger people because younger people have a lower mortality risk from the outset.


Italians have conversely seen a high 21% of those tested, return positive COVID-19 results (seven times higher than Korea). This says to us that the people who received the tests may have been chosen differently. Perhaps, in Italy, they prioritized (as would make sense) testing of the old, those at risk and those with severe symptoms. We know that the survival rates decrease significantly over 70 and further after 80, so the widespread reports that most people who died were over 70 did not surprise us.

To state it simply: if you find a large number of positive cases among young people, who are not at risk, you would expect few of them to die. If you find a large number of positive cases amongst older at-risk people, you would expect more of them to die. It is an example of Bayess theorem.


But testing differences alone, likely do not account for the sheer numbers of deaths in Italy, which have now surpassed those in China.


Risk of Infection at Hospitals


At Azabu Insights we have interviewed hundreds of doctors face to face over the last five years. We travel to all corners of Japan to meet directly with doctors in their hospitals. A key observation, something that nearly everyone who visits a hospital should know by gut intuition: the primary demographic in a hospital is the elderly. Confirming the data we see that in Japan, 73% of all people in hospitals are 65 or above and 53% are 75 or above. We are confident that these percentages are likely similar in demographically comparable Italy and in many other parts of the world.


This leads to examination of testing procedures for highly infectious diseases. Korea's testing regime, discussed earlier, has seen a number of novel and innovative solutions. It is possible to be tested for coronavirus in a drive through in just a few minutes. Other than the obvious convenience, this has the core benefit of not needing to walk through a hospital waiting room and risk infecting the other patients and the hospital staff.

In Japan interviews with the president and vice president of two major Japanese hospitals highlighted similar concerns. The first doctor was actively sending people with symptoms away from the hospital to get treated elsewhere. The second doctor had temporarily refused to see measles patients at his hospital. Both of these health practitioners did this to protect their own patients from in hospital spread.


In contrast we see that 10% of healthcare workers in the Lombardy region of Italy have contracted coronavirus. In one region, 20% of all GPs are confirmed to have coronavirus. In both cases, many of them are continuing to work given the well documented shortage of healthcare workers in Italy right now. On top of this, a study of 138 patients in Wuhan, China, suggests 41% of patients may have been victims of hospital-related transmission. This further suggests to us that hospitals are perhaps the worst place to be during a viral epidemic. Yet hospitals are hard to avoid for people in need of medical care. This is especially challenging for the elderly (age 75) who are 6.5 times more likely to be in a hospital than younger adults (age 35).


Full press release can be viewed at: acnnewswire.com/press-release/english/57944/

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