Jonathan Bullington, Louisville Courier Journal
LOUISVILLE, Ky. – Officially, Jim Haswell died of pneumonia.
The 73-year-old grandfather was susceptible to the potentially fatal lung infection after undergoing radiation treatments for throat cancer years earlier. But his doctors took steps to lower his risk, and he could usually tell when he was starting to feel ill.
One Sunday last month, he had no such early warning. He seemed fine when his daughter talked to him two days earlier.
But by April 12, he was coughing repeatedly during a phone call with his girlfriend. He was lethargic when she went to check on him later that day.
She called for an ambulance about 5 p.m., and he was placed on a ventilator at the hospital when his oxygen levels dropped dangerously low.
Twelve hours later, doctors told his daughter there was nothing more they could do.
Haswell was tested at the hospital for COVID-19. The results came back negative.
His daughter isn’t convinced COVID-19 didn’t kill him — especially after talking to the family doctor and hearing examples of virus tests returning false-negatives.
“I can only go off what the test tells me,” said his daughter, Sara Westerman, 44. “But it just came on so suddenly. It was just different this time.”
Her suspicions could be right.
A massive spike in pneumonia deaths this year in the commonwealth suggests the coronavirus outbreak has killed far more Kentuckians than the 391 and counting that have been officially reported as of Saturday.
As of noon on Monday, Kentucky has seen at least 1,243 deaths caused by pneumonia from February to early May, according to preliminary data from the Centers for Disease Control and Prevention.
The commonwealth averaged 330 pneumonia and flu deaths over a similar 15-week stretch from 2014 through 2018, CDC data show.
That is nearly 913 more pneumonia deaths than Kentucky typically averages this time of year.
And experts say the coronavirus almost certainly is a culprit.
“I think clearly there are cases that are not getting counted as COVID deaths,” said Dr. Derek Forster, medical director for infection prevention and control at UK HealthCare. “How much of that is completely COVID-19, I don’t know. But I do think there are more deaths than accounted for in the testing numbers.”
Several reasons explain why many of those pneumonia deaths weren’t attributed to the pandemic — from a lack of available testing in the early days of the outbreak to false-negative test results.
But Kentucky doctors say it’s essential to understand how deadly the novel coronavirus has been, especially as the commonwealth joins the rest of the country in weighing the continued public health risks against its desire to reopen a severely crippled economy.
“The message I’m hearing is we go back to work with limitations,” said Dr. Forest Arnold, an epidemiologist and associate professor of medicine at U of L School of Medicine. “And so, for people who don’t like that message, they need to understand the severity of coronavirus and admit that not everybody understands everything about the virus.”
Spikes in deaths go beyond Kentucky
Pneumonia is a lung infection in which the air sacs in the lungs get filled with fluid and become inflamed, making it difficult to breathe.
The infection is most commonly caused by bacteria or a virus, said Dr. Bashar Alhariri, medical director of the intensive care unit at Norton Healthcare’s downtown campus.
Pneumonia kills about 50,000 people each year in the U.S., according to the CDC.
This year, at least 89,555 deaths have been attributed nationwide to pneumonia between February and mid-May.
It tends to follow a typical flu season, coming on in December and peaking in January and February before declining in March to April.
But preliminary CDC data from this year show pneumonia deaths steadily climbed in March to peak in April, mirroring the trend line for deaths linked to the coronavirus outbreak.
“Pneumonia deaths don’t peak until April, at the same time as COVID deaths, which tells me hypothetically that what’s being counted as pneumonia is COVID deaths,” Forster said.
Spikes in pneumonia deaths between February and early May have been seen beyond Kentucky. Surrounding states are also seeing death counts several times greater than normal:
- Indiana: 1,832 COVID-19 deaths; 2,149 pneumonia deaths (five-year average: 384)
- Illinois: 4,856 COVID-19 deaths; 3,986 pneumonia deaths (five-year average: 782)
- Tennessee: 336 COVID-19 deaths; 1,704 pneumonia deaths (five-year average: 611)
- Ohio: 1,969 COVID-19 deaths; 2,327 pneumonia deaths (five-year average: 820)
- Virginia: 1,208 COVID-19 deaths; 1,394 pneumonia deaths (five-year average: 451)
- West Virginia: 72 COVID-19 deaths; 438 pneumonia deaths (five-year average: 117)
While contracting the COVID-19 coronavirus does not necessarily lead to pneumonia, when it does, it’s particularly dangerous, particularly for the elderly and people with pre-existing conditions.
“The pneumonia we’re seeing from COVID is one of the worst pneumonias we’ve seen in the last several years,” Alhariri said. “It’s very difficult and tricky to treat.”
Limited testing, inaccurate results
Why would so many pneumonia deaths not be attributed to the coronavirus?
First, there’s the issue of false-negative test results.
Doctors typically rely on a patient’s symptoms and the results of an X-ray or CT scan to determine whether they have pneumonia.
Those same chest images can also give radiologists a good idea of whether someone contracted the virus. But to be considered a positive COVID-19 case, hospitals typically will wait for the results of a test.
Arnold and Alhariri each said they’ve treated patients whose nasal swab tests came back negative, only to have additional antibody or fecal tests return positive results.
And federal health officials recently raised concerns over the accuracy of some virus tests.
A bigger reason may be the sheer lack of testing, especially in the early days of the pandemic in Kentucky.
By late May, the state’s daily average of tests administered per 100,000 residents was 138. In April, the rate was below 20 tests per 100,000 residents.
“Testing was limited in the beginning,” Forster said. “There were certain criteria that had to be met to be tested. It was probably up until mid-March that testing just wasn’t available enough to test everybody with pneumonia.”
It also could be that people came down with pneumonia unrelated to the virus but did not go to the hospital either because they were worried about contracting COVID-19 or because they thought their doctor’s office was closed, said Dr. Sean Muldoon, a Louisville doctor who serves as a board member for the American Lung Association.
“They suffered so long that it was too late for them,” he said.
That kind of delayed medical care could contribute to deaths across the country being higher than the “expected” totals from previous years, according to CDC data.
Does it matter if we missed COVID-19 deaths?
Knowing how deadly this outbreak has been matters, some experts say, for the families of those who have died and for the recorded history of this pandemic.
“We know it’s a disease capable of severe illness and death,” Forster said. “We know it’s capable of overwhelming health systems because of a lack of immunity. Does a 2% death rate versus a 4% death rate matter? In my mind, no, because we treat them with a lot of respect anyway.
“But understanding its potential is important.”
It’s important, Muldoon said, so the medical community and government leaders can better prepare for the next outbreak.
“We’ll want to get it right the next time,” he said, “so we can geographically target testing, tracing and treating. And we want to send those resources to the places that they’re needed in proportion to the number of COVID deaths they have.”
It’s also important in the context of what has become a politically charged and intensely divisive debate over the restrictions and requirements that governors have ordered in the name of slowing the spread of the virus.
Protests across the country, including in Kentucky, have given voice to people who say the virus is not as dangerous as it’s been made out to be — that the only people who are dying are people who were old and sick.
They say the number of cases and deaths have been overreported (Kentucky’s public health commissioner, Dr. Steven Stack, recently said there is no evidence to suggest it was happening), or that the government is unnecessarily destroying the economy and infringing on personal liberties.
“People are going to die and suffer one way or another,” Muldoon said. “They’re either going to die from COVID while the economy is perking along, or they’re going to suffer and theoretically die from a stagnated economy in the name of saving the lives.
“So, the real debate is, how many deaths do you want to spend to help the masses in the economic machine?”
‘For those who were like my father’
To Sara Westerman, it’s important to know how many lives this outbreak has taken, “for those who were like my father and experienced pneumonia so suddenly.”
She may never know if the coronavirus killed her dad. Even if it didn’t, like so many other Kentuckians, it stole her chance to properly say goodbye to him.
“You can’t really celebrate his life,” she said. “That’s part of the hard part, feeling the closure. That’s extremely difficult.”
Jim Haswell was a retired special education teacher with Jefferson County Public Schools, a skilled gardener, a loyal friend and an avid bicyclist who, after beating throat cancer, bought an electric bicycle to help him get back to enjoying one of his favorite activities.
“He lived life to the fullest,” his daughter said. “He knew he lived longer than he ever thought he would.”
Jonathan Bullington is an investigative reporter. Reach him at: 502-582-4241; [email protected]; Twitter: @jrbullington. Support strong local journalism by subscribing today: courier-journal.com/subscribe.
