New York City, already a world epicenter of the coronavirus outbreak, sharply increased its death toll by more than 3,700 victims on Tuesday, after officials said they were now including people who had never tested positive for the virus but were presumed to have died of it.

The new figures, released by the city’s Health Department, drove up the number of people killed in New York City to more than 10,000, and appeared to increase the overall United States death count by 17 percent to more than 26,000.

WASHINGTON/NEW YORK (Reuters) - New York City, the hardest hit U.S. city in the coronavirus pandemic, revised its official COVID-19 death toll sharply higher to more than 10,000 on Tuesday, to include victims presumed to have perished from the lung disease but never tested.

The new cumulative figure for “confirmed and probable COVID-19 deaths” released by the New York City Health Department marked a staggering increase of over 3,700 deaths formally attributed to the highly contagious illness since March 11.

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U.S. public health authorities have generally only attributed deaths to COVID-19, the respiratory disease caused by the novel coronavirus, when patients tested positive for the virus.

New York City’s Health Department said it will now also count any fatality deemed a “probable” coronavirus death, defined as a victim whose “death certificate lists as a cause of death ‘COVID-19’ or an equivalent.”

March 11 was used as the starting pointbecause that was the date of the first confirmed coronavirus death, the city said.

As coronavirus has swept through the United States, finding the true number of people who have been infected has been stymied due to lack of testing. Now, official counts of coronavirus deaths are being challenged, too.

In Colorado, for example, a Republican state legislator has accused the state’s public health department of falsely inflating COVID-19 deaths; in Florida, local media have objected to the State Department of Health’s refusal to release medical examiner data to the public, alleging that the state may be underreporting deaths.

The reality is that assigning a cause of death is not always straightforward, even pre-pandemic, and a patchwork of local rules and regulations makes getting valid national data challenging. However, data on excess deaths in the United States over the past several months suggest that COVID-19 deaths are probably being undercounted rather than overcounted.

CAUSE OF DEATH
Death certificates can be signed by a physician who was responsible for a patient who died in a hospital, which accounts for many COVID-19 deaths. They can also be signed by medical examiners or coroners, who are independent officials who work for individual counties or cities. Many COVID-19 death certificates are being handled by physicians unless the death occurred outside of the hospital, in which case a medical examiner or coroner would step in, said Dr. Sally Aiken, the president of the National Association of Medical Examiners (NAME). In some jurisdictions, including cities such as Chicago and Milwaukee, medical examiners are involved in determining the cause of death for every suspected COVID-19 case. In those jurisdictions, medical examiners review medical records even of patients who die in hospitals to ensure that the symptoms and any testing indicate that the patient did indeed die of COVID-19.

Having medical examiners confirm COVID-19 deaths can create more uniformity and clearer documentation, Aiken told Live Science. On a death certificate, there are spaces to list an immediate cause of death, as well as the chain of events that led to that final disease or incident. There are also spaces for adding contributing factors.

For COVID-19, the immediate cause of death might be listed as respiratory distress, with the second line reading “due to COVID-19.” Contributing factors such as heart disease, diabetes or high blood pressure would then be listed further down. This has led to some confusion by people arguing that the “real” cause of death was heart disease or diabetes, Aiken said, but that’s not the case.

“Without the COVID19 being the last straw or the thing that led to the chain of events that led to death, they probably wouldn’t have died,” she said.

DETECTING COVID-19
How hard it is to accurately determine whether COVID-19 was truly that last straw depends on the situation. Most COVID-19 deaths seen at Mount Sinai Health System in New York are in people who have comorbid (or co-occurring) conditions such as coronary artery disease or kidney disease, said Dr. Mary Fowkes, the chief of autopsy services at Mount Sinai. But it’s not typically difficult to tell what killed them.

“Most of the cases are pretty straightforward,” Fowkes told Live Science. “The lungs are usually so severely involved with pathology, so they are two to three times or more the normal weight of a normal lung.”

(The excess weight is due to fluid and cell detritus from damaged lung tissues.)

In some cases, particularly those where someone dies at home or quickly perishes after entering an emergency room, the determination can be a little more fuzzy, said Dr. Jeremy Faust, an emergency physician at Brigham and Women’s Hospital in Massachusetts.

Autopsies can help answer that question, but autopsy rates were low even pre-pandemic, Fowkes said. Even at Mount Sinai, a rare medical system that offers every family a chance to have their loved one autopsied for free, the rate of autopsy was only about 20% prior to the pandemic. According to NAME, there is an ongoing shortage of forensic pathologists working in the United States, with about 500 currently employed and a need for 1,200. Autopsies for COVID-19 can also be dangerous due to the infectious nature of the disease and ongoing shortages of personal protective equipment for pathologists.

Another complication for assigning a cause of death for COVID-19 is that some younger people have died of strokes and heart attacks and then tested positive for COVID-19 without any history of respiratory symptoms. The virus is now known to cause blood clots, suggesting that COVID-19 was the killer in these cases, too. Fowkes and her colleagues conducted a microscopic inspection of the brains of 20 COVID-19 victims in her hospital system and found that six of them contained tiny blood clots that had caused small strokes before death.

“We’re seeing it in younger patients than you would expect, and we’re seeing it in a distribution that you wouldn’t expect, so we think it’s related to the COVID,” Fowkes said.

The Centers for Disease Control and Prevention (CDC) has issued guidelines for how to attribute a death to COVID-19. The guidelines urge using information from COVID-19 testing, where possible, but also allow for deaths to be listed as “presumed” or “probable” COVID-19 based on symptoms and the best clinical judgment of the person filling out the death certificate. A medical examiner trying to determine a cause of death in the absence of testing would comb medical records and query family and loved ones about the person’s symptoms before they died, Aiken said. Postmortem COVID-19 tests may be possible, depending on the jurisdiction.

UNDERREPORTING OR OVERREPORTING?
All of the inconsistencies of cause-of-death reporting precede the COVID-19 pandemic, says Jay Wolfson, a professor of public health at the University of South Florida (USF). But getting good data about deaths is now extremely pressing, he told Live Science. Death certificates are often used by epidemiologists and public health officials to detect strange clusters of deaths or to link certain risk factors to certain causes of death. But because different states and localities have different rules about recording and reporting causes of death, the cumulative data is always messy.

“I think some states are reluctant to open their databases up, knowing they have validity problems or knowing the data might be misused,” Wolfson said. But public health officials need access, he said, and they need to figure out ways to dig into the data and standardize them. Wolfson and other researchers at USF are already working with state officials to see what kind of data the state can legally release, he said.

Meanwhile, as the political debate over the response to the virus heats up, some have argued that death reports are being deliberately skewed. Aiken rejected the notion of a vast conspiracy by medical examiners; medical examiners are designed to be independent entities, she said, and they run the political gamut from conservative to liberal.

“It always cracks me up,” she said. “Medical examiners and coroners aren’t organized enough to have a conspiracy.”

In Colorado, the discrepancy over people dying with COVID-19 versus of COVID-19 is due to federal reporting guidelines requiring the health department to report any COVID-positive death to the CDC, even if COVID-19 wasn’t thought to cause the death, Gov. Jared Polis said in a news conference Friday (May 15). The health department has been instructed not to report those deaths as being caused by COVID-19 to the public, Polis said.

In Florida, state law prevents the release of death certificate data, Wolfson said, but it may be possible to get public release of death certificates with identifying information removed, or of cumulative datasets.

Both undercounts and overcounts of COVID-19 deaths are possible, Wolfson said, but it’s not yet clear which is more likely, or whether they might simply balance each other out. Fowkes said that based on her experience, it’s more likely that COVID-19 deaths are being missed than overcounted. That’s because New York is among several cities that show spikes in deaths at home, and these anomalous spikes could be due to untested, untreated COVID-19.

Perhaps, the best clue as to whether COVID-19 deaths have been undercounted or overcounted is excess mortality data. Excess mortality is deaths above and beyond what would normally be expected in a given population in a given year. CDC data shows a spike of excess mortality in early 2020, adding up to tens of thousands of deaths.

Some argue that many of these excess deaths are related to COVID-19 lockdowns, not COVID-19 themselves, Faust said, because people fear catching the disease if they go to the hospital for other reasons. A study in the Journal of the American College of Cardiology did find that nine major hospitals saw a 38% drop in emergency visits for a particular kind of heart attack in March. That suggests that people really are delaying or avoiding medical care, which could mean that some of them die of preventable causes.

But non-COVID conditions probably don’t explain most excess deaths, Faust said. Only a portion of heart attack visits would have represented lives saved, he said, because doctors must treat perhaps 10 patients to save one life. And other causes of death—such as motor vehicle accidents—are down.

This could change with time, Faust cautioned. For example, if cancer patients forego their treatments for a year, rather than a few months, the impact on their death rates is much more likely to be noticeable in the population-wide data. But for now, he said, “it’s unlikely that the coronavirus deaths are being overcounted by a magnitude that explains our observation that something very unusual is going on.”

Za něj si od moderátora televizní debaty Václava Moravce vysloužil ostrý výrok: „Bagatelizace a zpochybňování statistik z vás může činit dezinformátora.“ Blatný se korektně, ale důrazně ohradil.

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Teprve v „pomalých“ datech o příčinách úmrtí se zohlední takzvaná základní příčina úmrtí.

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Při vytváření těchto dat se má uplatnit expertní komise pod vedením náměstka ministra zdravotnictví Vladimíra Černého, kterou opakovaně zmiňuje ministr Blatný. Podrobně vytváření obou datových sad – „rychlé“ i „pomalé“ – popisuje prezentace Šárky Daňkové z ÚZIS, která se věnuje agendě příčin úmrtí.

"220 XXII. Kódy pro speciální účely"
Pozn. Kapitola XXII. představuje úmrtnost na COVID–19 (U07.1–U07.2)

- U07.1 COVID-19, virus identifikován

- U07.2 COVID-19, virus neidentifikován
POZNÁMKA
Klinicky a epidemiologicky diagnostikovaný COVID-19; Pravděpodobný COVID-19; Suspektní COVID-19

BALTIC SEA – A significant focus of BALTOPS every year is the demonstration of NATO mine hunting capabilities, and this year the U.S. Navy continues to use the exercise as an opportunity to test emerging technology.
In support of BALTOPS, U.S. Navy Sixth Fleet partnered with U.S. Navy research and warfare centers to bring the latest advancements in Unmanned Underwater Vehicle (UUV) mine hunting technology to the Baltic Sea to demonstrate the vehicle’s effectiveness in operational scenarios.

Experimentation was conducted off the coast of Bornholm, Denmark

European security officials on Monday and Tuesday observed Russian Navy support ships in the vicinity of leaks in the Nord Stream pipelines likely caused by underwater explosions, according two Western intelligence officials and one other source familiar with the matter.

It’s unclear whether the ships had anything to do with those explosions, these sources and others said – but it’s one of the many factors that investigators will be looking into.

Western troops, policemen, and civilians are largely to blame for the rapid growth of the sex slavery industry in Kosovo over the past five years, a mushrooming trade in which hundreds of women, many of them under-age girls, are tortured, raped, abused and then criminalised, Amnesty International said yesterday.

In a report on the Mb, Amnesty said Nato soldiers, UN police, and western aid workers operated with near impunity in exploiting the victims of the sex traffickers.

As a result of the influx of thousands of Nato-led peacekeepers, "Kosovo soon became a major destination country for women trafficked into forced prostitution. A small-scale local market for prostitution was transformed into a large-scale industry based on trafficking, predominantly run by criminal networks."

The international presence in Kosovo continues to generate 80% of the income for the pimps, brothel-owners, and mafiosi who abduct local girls or traffic women mainly from Moldova, Romania, Ukraine, and Russia to Kosovo via Serbia, the report said, although the international "client base" for the sex trade has fallen to 20% last year from 80% four years ago.

Up to 2,000 women are estimated to have been coerced into sex slavery in Kosovo, which had seen "an unprecedented escalation in trafficking" in recent years. The number of premises in Kosovo listed by a special UN police unit as being involved in the rackets has swollen from 18 in 1999 to 200 this year.

A few weeks ago the UN's department of peacekeeping in New York acknowledged that "peacekeepers have come to be seen as part of the problem in trafficking rather than the solution".

The sex slavery in Kosovo parallels similar phenomena next door in Bosnia, where the arrival of thousands of Nato peacekeepers in 1995 fuelled a thriving forced prostitution industry.

International personnel in Kosovo enjoy immunity from prosecution unless this is waived by the UN in New York for UN employees or by national military chiefs for Nato-led troops.

One police officer last year and another the year before had their immunity waived, enabling criminal prosecutions.

"Amnesty International has been unable to find any evidence of any criminal proceedings related to trafficking against any military personnel in their home countries," the 80-page report said.

The report said that US, French, German and Italian soldiers were known to have been involved in the rackets.

Criticism of the international troops in Kosovo follows a recent broader indictment of the Kosovo mission by the International Crisis Group thinktank, which called for the mission to be overhauled.

Women were bought and sold for up to £2,000 and then kept in appalling conditions as slaves by their "owners", Amnesty said. They were routinely raped "as a means of control and coercion", beaten, held at gunpoint, robbed, and kept in darkened rooms unable to go out.

Apart from women trafficked into Kosovo, there is a worsening problem with girls abducted locally. A Kosovo support group working with victims reported that a third of these locals were under 14, and 80% were under 18.

The UN admission in March that its peacekeepers were part of the problem was welcome, said Amnesty.

September 23, 2017
BUNIA, Congo (AP) — She had been orphaned by a brutal conflict, but the 14-year-old Congolese girl found refuge in a camp protected by United Nations peacekeepers.

The camp should have been safe the day she was raped. A delegation from the U.N. was paying a visit, and her grandmother had left her in charge of her siblings. That was the day, the girl says, that a Pakistani peacekeeper slipped inside their home and assaulted her in front of the other children.

But that was not the end of her story. Even though she reported the rape, the girl never got any help from the U.N. She did become pregnant, however, and had a baby.

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The raped teenager’s experience is grimly emblematic of the underbelly of U.N. peacekeeping, and the organization as a whole. During a yearlong investigation, the AP found that despite promising reform for more than a decade, the U.N. failed to meet many of its pledges to stop the abuse or help victims, some of whom have been lost to a sprawling bureaucracy. Cases have disappeared or been handed off to the peacekeepers’ home countries — which often do nothing with them.

The attack on the 14-year-old was so brazen it still haunts the U.N.’s top human rights official more than a decade after hearing the girl’s story.

“What on earth would it take for this soldier not to do it — to have all the heads of the U.N. together, and he still does it?” asked Zeid Ra’ad al Hussein, a member of the delegation that heard the girl’s testimony in 2004. One year later, he helped write a landmark report intended to curb sexual abuse and exploitation within the U.N. system.

With rare exceptions, victims interviewed by the AP received no help. Instead, many were banished from their families for having mixed-race children, who also are shunned, becoming a second generation of victims.

The AP even found a girl who was raped by two peacekeepers; she gave birth to two babies by the time she was 14.

To this day, the sexual violence by U.N. peacekeepers and personnel continues: Congo already accounts for nearly one-third of the 43 allegations made worldwide in 2017.

William L. Swing was in charge of the Congo mission between May 2003 and January 2008, a period when abuse allegations swelled in a country that has been torn by dictatorship, civil war and unrest for the last half-century.

“I take full responsibility for what happened,” Swing told the AP. “I knew at the time the buck stopped with me.”

Swing said the U.N. at times made it clear he should be relieved of his duties. Instead, he was named the head of the U.N.’s International Organization for Migration. Now, he sits on a new task force appointed to tackle the problem yet again. Swing insists the mistakes made during the early years of the Congo mission provided lessons that could shape new reforms.

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Women were bought and sold for up to £2,000 and then kept in appalling conditions as slaves by their "owners", Amnesty said. They were routinely raped "as a means of control and coercion", beaten, held at gunpoint, robbed, and kept in darkened rooms unable to go out.