The Great Pneumonia Epidemic

While the world was panicking over COVID-19, a more deadly but common disease was being left untreated, resulting in thousands of deaths

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.

Swiss Data

Pharmaceutical data from Switzerland also shows a decrease in antibiotic prescriptions in 2020, particularly for respiratory infections.

The decrease in prescriptions could be due to a number of reasons. Switzerland, along with other European countries, has made it a priority to lower antibiotic usage due to concerns over antibiotic resistance. I unfortunately was not able to find data for 2018, but in 2017 there were over 1,000 prescriptions for pneumonia per 100,000 Swiss inhabitants, even though pneumonia deaths were roughly the same as in 2019. This implies that doctors have been increasingly trying to administer other remedies before using antibiotics as a last resort. One could argue that this at least partially explains the large decrease in antibiotic prescriptions in 2020.

We would also expect antibiotic prescriptions to decrease if there were fewer serious cases of pneumonia. This is where the data looks worrying. In 2020, Swiss hospitals recorded a 50% increase in hospital patients with pneumonia. Even if doctors were actively striving to lower antibiotic prescriptions, a 50% increase in serious cases of pneumonia should not result in an approximately 50% decrease in antibiotic prescriptions to treat pneumonia.

Data retrieved from the Swiss BAG (German, French, or Italian only)

Deaths attributed solely to pneumonia decreased in 2020, but around 40% of all COVID deaths listed pneumonia as a comorbidity¹. That meant that in Switzerland, there were approximately 4,000 deaths associated with pneumonia, a six fold increase from the previous year.

Is it possible to determine how many of these people could have died due to the lack of antibiotic prescriptions? Unfortunately, with the data available, there are too many unknowns in order to come up with an accurate estimation. I was not able to find data for antibiotic usage in hospitals, though I would assume Swiss doctors used antibiotics on a significant portion of COVID patients. Switzerland also did not have a spike in pneumonia only deaths like what we saw in the United States. Maybe doctors were only giving medication to the patients that desperately needed it and lowered outpatients prescriptions for less severe cases.

Again, it’s impossible to know for sure. The only thing we do know for sure is that antibiotic usage decreased significantly in Switzerland, and deaths associated with pneumonia increased.

Denmark and Germany

A few Danish scientists recognized that in Denmark, antibiotic prescriptions fell by 18.5% in the first pandemic year. The authors gave two possible reasons to explain this trend. First, the “stop the spread” measures were likely contributing to diminishing infections. Second, there was evidence that many patients were being underdiagnosed or undertreated.

Given what we know about the rise in pneumonia cases in Switzerland and the United States, the second explanation seems much more likely than the first. Unfortunately, I did not come by much official pneumonia mortality data from Denmark. The Danes group all respiratory deaths together, so the pneumonia situation in Denmark is a bit shrouded in mystery.

German mortality and hospital data, on the other hand, is quite detailed. According to government data from the Statistisches Bundesamt, hospitals in Germany reported over a 50% increase in pneumonia deaths in 2020, followed by another significant increase in 2021. The rise in deaths stands in stark contrast to the relatively stable mortality numbers from 2017-2019.

Hospital deaths due to respiratory illness (top row), flu and pneumonia and its subcategories (rows 2-9), and total hospital deaths (last row).

Perhaps the most concerning number listed in the table above is the deaths from “Viral pneumonia, elsewhere not classified” (Viruspneumonie, anderenorts nicht klassifizert). In 2020, there were over 20,000 more deaths in this category as in 2019. These deaths also match fairly closely with the difference in “flu and pneumonia” deaths between 2019 and 2020.

The increase in viral pneumonia diagnoses could at least partially explain why antibiotic prescriptions in Germany fell in 2020 (shown below).

Source: Statista

This tells us one of two things. Either cases of viral pneumonia increased significantly. Or, there was serious misdiagnosing and undertreatment.

Though it is of course entirely possible for viral pneumonia cases to increase significantly in the course of a year, I find it hard to believe that the COVID pandemic somehow caused viral pneumonia deaths to increase by a factor of one hundred. Misdiagnosing or undertreatment seems much more likely. It’s also not unreasonable to assume that this was going on in other countries as well.

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Based on the pneumonia and antibiotic usage data, a couple things are certain. Antibiotic prescriptions decreased significantly in 2020. Deaths from pneumonia increased, though many of these deaths were accompanied by COVID-19.

The relationship between these two facts is more difficult to establish. While it is possible that the shock from the COVID-19 disease led to the sudden rise in pneumonia deaths, it is unlikely to account for all of it. More likely, the increase in deaths was due to misdiagnosing, underdiagnosing, and undertreatment.

The potential causes of underdiagnosing and undertreatment are many. Doctors were focusing on COVID. Labs were devoting resources to PCR tests instead of pneumonia tests. Many COVID patients were told to stay home for two weeks if they tested positive, thus discouraging people to get proper medications before it was too late. During lockdowns, people did not seek the medical attention they needed. Lockdowns disrupted supply chains that may have affected how diagnoses were carried out.

Whatever the reason, it is clear that the worrisome aberration in pneumonia deaths and antibiotic usage was not just happening in one country. This was a problem in multiple countries where panic was a key component of the pandemic response. The lesson we can learn is that in the face of a pandemic, it is important to take all health considerations into account, not just the disease getting all the media attention. Doing so can ensure that people are getting the proper healthcare they need, and could be the key in saving thousands of lives.

1. Data retrieved from the Swiss Federal Statistic Office, Begleiterkrankungen aller Sterbefälle mit COVID-19 als Haupttodesursache, nach Monat, Geschlecht. Published Oct. 6, 2022.