COVID Still Deadlier Than the Flu — But the Gap Is Narrowing

Patients hospitalized with COVID-19 were more likely to die than those hospitalized with influenza during the fall and winter of 2023-2024, according to an analysis of Veterans Affairs data.

Among over 11,000 patients hospitalized for either illness during this past fall and winter, 5.7% of patients with COVID-19 died within 30 days of admission versus 4.24% of patients with influenza, reported Ziyad Al-Aly, MD, of the VA St. Louis Health Care System, and colleagues.

After adjusting for variables, the risk of death in people hospitalized for COVID-19 was 35% higher (adjusted HR 1.35, 95% CI 1.10-1.66), the authors detailed in a research letter in JAMA.

Al-Aly told MedPage Today that his group was actually surprised by the results. “We pretty much bought into the public narrative and drank the Kool-Aid like everybody, thinking that COVID is no longer [more deadly than the flu], although … there was no data,” he said. “But the verdict is out now, because we’ve analyzed the data from the 2023-2024 COVID season and clearly COVID mortality is still higher than the flu.”

Moreover, the authors pointed out that the results of the study should be considered in light of the fact that there were nearly twice as many hospitalizations for COVID-19 compared with the flu for the 2023-2024 season, according to CDC surveillance data. In the study population, over three times the number of people were hospitalized for COVID-19 than for the flu.

However, the results did reveal that the risk of mortality in patients hospitalized with COVID-19 had fallen when compared to the previous 2022-2023 season. In their 2023 study, using the same database and methods, Al-Aly’s group found that in the fall and winter of 2022-2023, COVID was about 60% more deadly than the flu in patients hospitalized for the illnesses.

“We should continue to take COVID seriously,” Al-Aly emphasized. “I know we’re all sick and tired of this pandemic and all of us have pandemic fatigue, but COVID is still more of a threat to health than the flu.”

Reassuringly, there appeared to be no significant difference in the risk of death among patients hospitalized for COVID-19 before and during the emergence of the JN.1 variant of SARS-CoV-2 (adjusted HR 1.07, 95% CI 0.89-1.28), suggesting that JN.1 may not be more severe than other recent variants, they posited. The JN.1 variant became predominant beginning in late December 2023.

The study looked at data from VA electronic health records across all 50 states. Researchers identified people admitted to the hospital with a diagnosis of COVID-19 or influenza between Oct. 1, 2023 and March 27, 2024, along with a positive test 2 days before or up to 10 days after admission. Patients with either illness who were hospitalized for another reason were excluded. The study’s cohort included 8,625 participants hospitalized for COVID-19 and 2,647 participants hospitalized for seasonal influenza.

After propensity score weighting, the mean age of the two cohorts was about 74 and 95% were male. About 19% were Black and 65% were white. Approximately 47% were infected before the JN.1 variant emerged. Also, of patients hospitalized for COVID-19, about 65% had received three or more shots of a COVID-19 vaccine, but approximately 15% had not received any COVID-19 vaccine. Approximately 44% of the study population had been vaccinated for influenza.

Only about 5.3% of people with COVID-19 had been treated with an outpatient antiviral, such as nirmatrelvir-ritonavir (Paxlovid), molnupiravir (Lagevrio), or remdesivir (Veklury). In contrast, 8% of patients hospitalized with the flu had received outpatient oseltamivir (Tamiflu).

The authors acknowledged that the VA study population was older and predominantly male, so the results may not be generalizable to other populations. Also, the causes of death were not examined.