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Long-term care connection accounts for high mortality rate in county

Chart shows Covid-19 cases and number of deaths in North Carolina counties with at least 100 cases. [HENDERSONVILLE LIGHTNING GRAPHIC]

By Bill Moss, Published: April 20, 2020

Henderson County has the highest Covid-19 mortality rate among North Carolina counties with at least 100 cases, based on the reported death toll of 12 as of Saturday, primarily because of its older population and the fact that every fatality so far has been associated with a long-term care facility.

A review of state- and county-reported data showed that the mortality rate here, at 9.75 percent, was higher than the rates in other counties with at least 100 Covid-19 cases. The Hendersonville Lightning reviewed the state Department of Health and Human Services statistics on positive cases and the number of deaths for all 100 counties. The newspaper focused on counties with at least 100 cases to compare death rates (see chart). (The county's totals climbed to 129 cases and 13 deaths after Sunday's update. Figures in this report are based on totals through Saturday.)

Henderson County has been reporting the number of positive cases and Covid-19-related deaths daily since the outbreak started. The number has been going up gradually since the first reported death on April 2. Based on the county's 123 cases and 12 deaths, Henderson County's death rate comes out to 9.75 percent, the highest among the 15 counties with 100 or more cases.

Johnston County, with 118 cases and nine deaths, had the second highest fatality rate, at 7.6 percent. Guilford County, with 162 cases and 12 deaths, had the third highest rate, at 7.4 percent. In Rowan County, which has a general hospital and a V.A. Medical Center, the death rate was 5.5 percent. No other county had a death rate higher than 5 percent. Statewide, there are 6,140 laboratory-confirmed Covid-19 cases and 164 deaths, for a death rate of 2.67 percent.

"The mortality rate today for Henderson County is skewed because over half of testing today has been singularly dedicated to populations in long-term care facilities," Steve Smith, Henderson County's public health director, said Sunday in an email response to questions the Lightning submitted. "When our number of cases was at 99, I recall that 70 of those were long-term care facility residents."

Smith cited a CDC report on a study of Covid-19 deaths that "estimated a mortality rate of 10 percent to 27 percent for those ages 85 and over, 3 percent to 11 percent for those ages 65 to 84, 1 percent to 3 percent for those ages 55 to 64 and less than 1 percent for those ages 20 to 54."

"Our experience would appear to be consistent with these estimates," he said, with a "15.7 percent mortality rate for those 70" patients in long-term care facilities. "All deaths to date have been associated with that setting." A higher mortality rate would be expected because "age ranges in long-term care facilities certainly extend into the 80s and even 90s. The long-term care facility is also not representative of the general population for those age groups with almost everyone having additional underlying health conditions or some degree of compromised immune system.

"The other takeaway here," he added, "is that we have not yet experienced a death from the general population."

Smith, other county officials and health care providers have emphasized in briefings that the number of elderly people in congregant living facilities gives Henderson County a more vulnerable population than most counties. (The Henderson County Nursing/Adult Care Home Community Advisory Committee monitors 38 long-term care facilities that house about 670 residents or patients.)

A discrepancy in the state's count of Henderson County's fatalities, at 6, and the total of 12 reported Saturday by the Henderson County Public Health Department is likely just a time-lapse issue, Smith said.

"There will always be a lag time between the time we report a Covid-19 death and the time when the state reflects that same death report," Smith said. "The state is reliant on our input into the North Carolina Electronic Disease Surveillance System and a thorough and subsequent review of medical information related to the case. In some limited cases, the State may not recognize a particular submission as a Covid-19 death if there were other contributing factors. That determination also includes a review of the death certificate which might list Covid-19 as a primary cause of death or just a contributing factor. Given the numbers of deaths statewide, that is always going to take more time for the State to review and finalize. Our model for now is that if a confirmed Covid-19 case dies (Henderson County resident), we’ll report it as a death as our best near-term representation of mortality."

23 cases at Cherry Springs

The number of Covid-19 cases in the county nearly doubled, to 51, when the health department reported on April 5 that 23 cases had been confirmed at the Cherry Springs Village assisted living center on Clear Creek Road. Responding to a question at a news conference the next day about the high number of cases here — 20 more than Buncombe County's total at that point — Smith said the county's public health surveillance team had focused on the places where cases were most likely to be found.

“I know it’s unnerving for some people to have the higher case count in Henderson County but I think that is true today because we’ve been looking,” Smith said at the time. “We’ve been going out to find these cases. Honestly, I’m concerned about the status of these kinds of facilities statewide. I think they’re very susceptible and of course the people that rely on them for care are very susceptible.”

The 26th most populous county in the state, Henderson County has the 10th highest number of Covid-19 cases and second highest number of deaths (along with Rowan and Guilford counties) after Mecklenburg County, which has 24.

County withholds location, age of Covid fatalities

One impediment to more fully understanding the death rate here is the county's decision to withhold information on the location, circumstances, gender and age of the fatalities. The county's Department of Public Health and its two hospitals, Pardee UNC Health and Advent Health, have said that for patient privacy reasons they would not report Covid-19 deaths after the first one, an older patient who lived at Carolina Village, on April 2. Nor are the Public Health Department and the hospitals publicly reporting the number of Covid-19 patients in their facilities.

When a retired physician, William Vine, asked Smith in an email how many Covid-19 patients were hospitalized, the public health director said not many.

"These have been very small numbers to date (single digits or even just one patient at times)," Smith responded. "(Neither) public health (officials) nor the hospitals anticipate reporting this for a small jurisdiction since it might lead to identification of an individual. That position has been reviewed with the UNC School of Government and the County Attorney."

Public reporting on the age, gender, location and circumstances of Covid-19-related deaths varies widely from county to county, the Lightning's review of 15 counties with more than 100 cases found.

The Granville-Vance Public Health agency, for instance, reported more detail on Covid-19 deaths than many counties.

"A 72-year old male from Vance County died yesterday, April 12," the agency said in a news release on Monday, April 13. "He was hospitalized and had multiple pre-existing health conditions that worsened as a result of COVID-19. In Granville County, the Bureau of Prisons reported four deaths (at the federal prison in Butner) to Granville Vance Public Health today. On April 11, an 81-year-old male died, on April 12, a 57-year-old male and a 78-year-old male died, and on April 13, a 46-year-old male died, all from complications related to COVID-19. All individuals were also hospitalized and experienced underlying health conditions."

Cabarrus County's Covid-19 dashboard breaks down the county's cases by race, zip code and four different age groups. Wake County breaks down cases by gender and 12 age groups. Rowan County's website reports positive tests, negative tests, number hospitalized and number recovered and breaks down the total positive cases by race, gender and zip code.

Mecklenburg County Public Health announced Friday that it would begin identifying long-term care facilities that report an outbreak of COVID-19, which the Centers for Disease Control and Prevention defines as two or more positive cases. The agency listed seven facilities with outbreaks.

The state DHHS website reports that Henderson County has outbreaks in three nursing homes and one residential care facility.

Henderson County is not identifying long-term care centers with outbreaks, for what Smith described as privacy reasons. Outbreaks that have been made public, he said, were "self-disclosed" by Cherry Springs, which is a residential care facility, and the Brian Center and the Laurels, both nursing homes. "We won’t be providing case and death counts by facilities or locations going forward for the same reasons cited above (it could lead to identification of specific individuals)," Smith said in his email response to Dr. Vine.

Asked by the Lightning whether he could provide the ages of the 12 Covid-19 fatalities, Smith said: "No, but we do anticipate qualifying future cases and deaths in age ranges in the future so that the public can see the general distribution."