﻿ Coronavirus Mortality Rate (COVID-19)

TRANSLATE

# Coronavirus (COVID-19) Mortality Rate

### Introduction

When calculating the mortality rate, we need:

1. The number of actual cases. We need to know the number of actual cases (not merely the reported ones, which are typically only a small portion of the actual ones) that have already had an outcome (positive or negative: recovery or death), not the current cases that still have to resolve (the case sample shall contain zero active cases and include only "closed" cases).
2. The number of actual deaths related to the closed cases examined above.

Considering that a large number of cases are asymptomatic (or present with very mild symptoms) and that testing has not been performed on the entire population, only a fraction of the SARS-CoV-2 infected population is detected, confirmed through a laboratory test, and officially reported as a COVID-19 case. The number of actual cases is therefore estimated to be at several multiples above the number of reported cases. The number of deaths also tends to be underestimated, as some patients are not hospitalized and not tested.

If we base our calculation (deaths / cases) on the number of reported cases (rather than on the actual ones), we will greatly overestimate the fatality rate.

### Fatality Rate based on New York City Actual Cases and Deaths

We has analyzed the data provided by New York City, the New York State antibody study, and the excess deaths analysis by the CDC. Combining these 3 sources together we can derive the most accurate estimate to date on the mortality rate for COVID-19, as well as the mortality rate by age group and underlying condition. These findings can be valid for New York City and not necessarily for other places (suburban or rural areas, other countries, etc.), but they represent the best estimates to date given the co-occurrence of these 3 studies.

### Actual Cases (1.7 million: 10 times the number of confirmed cases)

New York State conducted an antibody testing study [source], showing that 12.3% of the population in the state had COVID-19 antibodies as of May 1, 2020. The survey developed a baseline infection rate by testing 15,103 people at grocery stores and community centers across the state over the preceding two weeks. The study provides a breakdown by county, race (White 7%, Asian 11.1%, multi/none/other 14.4%, Black 17.4%, Latino/Hispanic 25.4%), and age, among other variables. 19.9% of the population of New York City had COVID-19 antibodies. With a population of 8,398,748 people in NYC [source], this percentage would indicate that 1,671,351 people had been infected with SARS-CoV-2 and had recovered as of May 1 in New York City. The number of confirmed cases reported as of May 1 by New York City was 166,883 [source], more than 10 times less.

### Actual Deaths (23,000: almost twice the number of confirmed deaths)

As of May 1, New York City reported 13,156 confirmed deaths and 5,126 probable deaths (deaths with COVID-19 on the death certificate but no laboratory test performed), for a total of 18,282 deaths [source]. The CDC on May 11 released its "Preliminary Estimate of Excess Mortality During the COVID-19 Outbreak — New York City, March 11–May 2, 2020" [source] in which it calculated an estimate of actual COVID-19 deaths in NYC by analyzing the "excess deaths" (defined as "the number of deaths above expected seasonal baseline levels, regardless of the reported cause of death") and found that, in addition to the confirmed and probable deaths reported by the city, there were an estimated 5,293 more deaths to be attributed. After adjusting for the previous day (May 1), we get 5,148 additional deaths, for a total of actual deaths of 13,156 confirmed + 5,126 probable + 5,148 additional excess deaths calculated by CDC = 23,430 actual COVID-19 deaths as of May 1, 2020 in New York City.

### Infection Fatality Rate (23k / 1.7M = 1.4% IFR)

Actual Cases with an outcome as of May 1 = estimated actual recovered (1,671,351) + estimated actual deaths (23,430) = 1,694,781.

Infection Fatality Rate (IFR) = Deaths / Cases = 23,430 / 1,694,781 = 1.4% (1.4% of people infected with SARS-CoV-2 have a fatal outcome, while 98.6% recover).

### Mortality Rate (23k / 8.4M = 0.28% CMR to date) and Probability of Dying

As of May 1, 23,430 people are estimated to have died out of a total population of 8,398,748 in New York City. This corresponds to a 0.28% crude mortality rate to date, or 279 deaths per 100,000 population, or 1 death every 358 people. Note that the Crude Mortality Rate will continue to increase as more infections and deaths occur (see notes under the paragraph "Herd Immunity" below for details).

### Mortality Rate by Age

When analyzing the breakdown of deaths by age and condition [source], we can observe how, out of 15,230 confirmed deaths in New York City up to May 12, only 690 (4.5% of all deaths) occurred in patients under the age of 65 who did not have an underlying medical condition (or for which it is unknown whether they had or did not have an underlying condition).

Underlying illnesses include Diabetes, Lung Disease, Cancer, Immunodeficiency, Heart Disease, Hypertension, Asthma, Kidney Disease, GI/Liver Disease, and Obesity [source]

#### Under 65-year-old (0.09% CMR to date)

85.9% of the population (7,214,525 people out of 8,398,748) in New York City is under 65 years old according to the US Census Bureau, which indicates the percent of persons 65 years old and over in New York City as being 14.1% [source].

We don’t know what percentage of the population in this age group has an underlying condition, so at this time we are not able to accurately estimate the fatality rate for the under 65 years old and healthy.

But we can calculate it for the entire population under 65 years old (both healthy and unhealthy): with 6,188 deaths (26% of the total deaths in all age groups) occurring in this age group, of which 5,498 deaths (89%) in patients with a known underlying condition, the crude mortality rate to date will correspond to 6,188 / 7,214,525 = 0.09% CMR, or 86 deaths per 100,000 population (compared to 0.28% and 279 deaths per 100,000 for the general population).

So far there has been 1 death every 1,166 people under 65 years old (compared to 1 death every 358 people in the general population). And 89% of the times, the person who died had one or more underlying medical conditions.

NOTE: We are gathering and analyzing additional data in order to provide more estimates by age group.

### Herd Immunity and final Crude Mortality Rate

Crude mortality rate is not really applicable during an ongoing epidemic.

And to reach herd immunity for COVID-19 and effectively end the epidemic, approximately two thirds (67%) of the population would need to be infected. As of May 1, New York City is at 20%, based on the antibody study findings.

Therefore, the crude mortality rate has the potential to more than triple from our current estimate, reaching close to 1,000 deaths per 100,000 population (1% CMR), and close to 300 per 100,000 (0.3% CMR) in the population under 65 years old, with 89% of these deaths (267 out of 300) occurring in people with a known underlying medical condition (including obesity).

### 3.4% Mortality Rate estimate by the World Health Organization (WHO) as of March 3

In his opening remarks at the March 3 media briefing on Covid-19, WHO Director-General Dr Tedros Adhanom Ghebreyesus stated:

"Globally, about 3.4% of reported COVID-19 cases have died. By comparison, seasonal flu generally kills far fewer than 1% of those infected."

#### Initial estimate was 2%

Initially, the World Health Organization (WHO) had mentioned 2% as a mortality rate estimate in a press conference on Wednesday, January 29 and again on February 10. However, on January 29 WHO specified that this was a very early and provisional estimate that might have changed. Surveillance was increasing, within China but also globally, but at the time it was said that:

• 1. We don’t know how many were infected ("When you look at how many people have died, you need to look at how many people where infected, and right now we don’t know that number. So it is early to put a percentage on that.").
• 2. The only number currently known is how many people have died out of those who have been reported to the WHO.
• 3. It is therefore very early to make any conclusive statements about what the overall mortality rate will be for the novel coronavirus, according to the World Health Organization.

### Mortality Rate as of Feb. 20 in China (findings from the Report of the WHO-China Joint Mission)

The Report of the WHO-China Joint Mission published on Feb. 28 by WHO is based on 55,924 laboratory confirmed cases. The report notes that "The Joint Mission acknowledges the known challenges and biases of reporting crude CFR early in an epidemic" (see also our discussion on: How to calculate the mortality rate during an outbreak). Here are its findings on Case Fatality Ratio, or CFR (the mortality rate):

"As of 20 February, 2,114 of the 55,924 laboratory confirmed cases have died (crude fatality ratio [CFR: 3.8%) (note: at least some of whom were identified using a case definition that included pulmonary disease).

The overall CFR varies by location and intensity of transmission (i.e. 5.8% in Wuhan vs. 0.7% in other areas in China).

In China, the overall CFR was higher in the early stages of the outbreak (17.3% for cases with symptom onset from 1-10 January) and has reduced over time to 0.7% for patients with symptom onset after 1 February."

The Joint Mission noted that the standard of care has evolved over the course of the outbreak.

### Mortality Rate, as discussed by the National Health Commission (NHC) of China on Feb. 4

Asked at a press conference on February 4 what the current mortality rate (or case fatality rate, CFR) is, an official with China NHC said that:

• The formula they are using is: cumulative current total deaths / current confirmed cases. Therefore, as of 24:00 on Feb. 3, the formula used was 425/20,438.
• Based on this figure, the national mortality rate to date was 2.1% of confirmed cases.
• There might be mild cases and other cases not reported.
• 97% of the country’s total deaths (414) were in the Hubei Province.
• Mortality rate in Wuhan was 4.9%.
• Mortality rate in the Hubei Province was 3.1%.
• Mortality rate nationwide was 2.1%.
• Fatality rate in other provinces was 0.16%.
• Deaths in Wuhan were 313, accounting for 74% of China’s total.
• Most of the cases were still mild cases, therefore there was no need to panic.
• Asked why Wuhan was so much higher than the national level, the NHC official replied that it was for lack of resources, citing as an example that there were only 110 critical care beds in the three designated hospitals where most of the cases were sent.
• National mortality rate was basically stable, as of Feb. 4 at 2.1%, and it was 2.3% at the beginning of the epidemic, which can be seen as a slight decline.
• Front the analysis of death cases, it emerged that the demographic profile was mainly male, accounting for 2/3, females accounting for 1/3, and is mainly elderly, more than 80% are elderly over 60 years old, and more than 75% had underlying diseases present such as cardiovascular and cardiovascular diseases, diabetes and, in some cases, tumor.
• Elderly people with basic diseases, as long as they have pneumonia, were clinically a high-risk factor regardless of whether it is a coronavirus or not, and the case fatality rate was also very high, so it is not that the case fatality rate of pneumonia is high because of the infection with the new coronavirus. "This point must be explained to everyone," concluded the NHC official.

### Preliminary study providing a tentative 3% estimate for case fatality rate

A preliminary study published on The Lancet on January 24 provided an early estimation of 3% for the overall case fatality rate. Below we show an extract (highlights added for the relevant data and observations):

Of the 41 patients in this cohort, 22 (55%) developed severe dyspnoea and 13 (32%) required admission to an intensive care unit, and six died.

Hence, the case-fatality proportion in this cohort is approximately 14.6%, and the overall case fatality proportion appears to be closer to 3%.

However, both of these estimates should be treated with great caution because not all patients have concluded their illness (ie, recovered or died) and the true number of infections and full disease spectrum are unknown.

Importantly, in emerging viral infection outbreaks the case-fatality ratio is often overestimated in the early stages because case detection is highly biased towards the more severe cases.

As further data on the spectrum of mild or asymptomatic infection becomes available, one case of which was documented by Chan and colleagues, the case-fatality ratio is likely to decrease.

Nevertheless, the 1918 influenza pandemic is estimated to have had a case-fatality ratio of less than 5% but had an enormous impact due to widespread transmission, so there is no room for complacency.

A novel coronavirus outbreak of global health concern - Chen Wang et al., The Lancet. January 24, 2020

Fatality rate can also change as a virus can mutate, according to epidemiologists.

### Death rate among patients admitted to hospital

A study on 138 hospitalized patients with 2019-nCoV infection, published on February 7 on JAMA, found that 26% of patients required admission to the intensive care unit (ICU) and 4.3% died, but a number of patients were still hospitalized at the time.

A previous study had found that, out of 41 admitted hospital patients, 13 (32%) patients were admitted to an ICU and six (15%) died.

### Days from first symptom to death

The Wang et al. February 7 study published on JAMA found that the median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days.

Previously. the China National Health Commission reported the details of the first 17 deaths up to 24 pm 22 Jan 2020. A study of these cases found that the median days from first symptom to death were 14 (range 6-41) days, and tended to be shorter among people of 70 year old or above (11.5 [range 6-19] days) than those with ages below 70 year old (20 [range 10-41] days.

#### Median Hospital Stay

The JANA study found that, among those discharged alive, the median hospital stay was 10 days.

### Comparison with other viruses

For comparison, the case fatality rate with seasonal flu in the United States is less than 0.1% (1 death per every 1,000 cases).

Mortality rate for SARS was 10%, and for MERS 34%.

 Virus Death Rate Wuhan Novel Coronavirus (2019-nCoV) 2%* SARS 9.6% MERS 34% Swine Flu 0.02%
*estimate

### How to calculate the mortality rate during an outbreak

At present, it is tempting to estimate the case fatality rate by dividing the number of known deaths by the number of confirmed cases. The resulting number, however, does not represent the true case fatality rate and might be off by orders of magnitude [...]

A precise estimate of the case fatality rate is therefore impossible at present.
2019-Novel Coronavirus (2019-nCoV): estimating the case fatality rate – a word of caution - Battegay Manue et al., Swiss Med Wkly, February 7, 2020

The case fatality rate (CFR) represents the proportion of cases who eventually die from a disease.

Once an epidemic has ended, it is calculated with the formula: deaths / cases.

But while an epidemic is still ongoing, as it is the case with the current novel coronavirus outbreak, this formula is, at the very least, "naïve" and can be "misleading if, at the time of analysis, the outcome is unknown for a non negligible proportion of patients."

In other words, current deaths belong to a total case figure of the past, not to the current case figure in which the outcome (recovery or death) of a proportion (the most recent cases) hasn’t yet been determined.

The correct formula, therefore, would appear to be:

CFR = deaths at day.x / cases at day.x-{T}
(where T = average time period from case confirmation to death)

This would constitute a fair attempt to use values for cases and deaths belonging to the same group of patients.

One issue can be that of determining whether there is enough data to estimate T with any precision, but it is certainly not T = 0 (what is implicitly used when applying the formula current deaths / current cases to determine CFR during an ongoing outbreak).

Let’s take, for example, the data at the end of February 8, 2020: 813 deaths (cumulative total) and 37,552 cases (cumulative total) worldwide.

If we use the formula (deaths / cases) we get:

813 / 37,552 = 2.2% CFR (flawed formula).

With a conservative estimate of T = 7 days as the average period from case confirmation to death, we would correct the above formula by using February 1 cumulative cases, which were 14,381, in the denominator:

Feb. 8 deaths / Feb. 1 cases = 813 / 14,381 = 5.7% CFR (correct formula, and estimating T=7).

T could be estimated by simply looking at the value of (current total deaths + current total recovered) and pair it with a case total in the past that has the same value. For the above formula, the matching dates would be January 26/27, providing an estimate for T of 12 to 13 days. This method of estimating T uses the same logic of the following method, and therefore will yield the same result.

An alternative method, which has the advantage of not having to estimate a variable, and that is mentioned in the American Journal of Epidemiology study cited previously as a simple method that nevertheless could work reasonably well if the hazards of death and recovery at any time t measured from admission to the hospital, conditional on an event occurring at time t, are proportional, would be to use the formula:

CFR = deaths / (deaths + recovered)

which, with the latest data available, would be equal to:

11,419 / (11,419 + 91,981) = 11% CFR (worldwide)

If we now exclude cases in mainland China, using current data on deaths and recovered cases, we get:

8,164 / (8,164 + 20,241) = 28.7% CFR (outside of mainland China)

The sample size above is limited, and the data could be inaccurate (for example, the number of recoveries in countries outside of China could be lagging in our collection of data from numerous sources, whereas the number of cases and deaths is more readily available and therefore generally more up to par).

There was a discrepancy in mortality rates (with a much higher mortality rate in China) which however is not being confirmed as the sample of cases outside of China is growing in size. On the contrary, it is now higher outside of China than within.

That initial discrepancy was generally explained with a higher case detection rate outside of China especially with respect to Wuhan, where priority had to be initially placed on severe and critical cases, given the ongoing emergency.

Unreported cases would have the effect of decreasing the denominator and inflating the CFR above its real value. For example, assuming 10,000 total unreported cases in Wuhan and adding them back to the formula, we would get a CFR of 10.1% (quite different from the CFR of 11% based strictly on confirmed cases).

Neil Ferguson, a public health expert at Imperial College in the UK, said his “best guess” was that there were 100,000 affected by the virus even though there were only 2,000 confirmed cases at the time.

Without going that far, the possibility of a non negligible number of unreported cases in the initial stages of the crisis should be taken into account when trying to calculate the case fatally rate.

As the days go by and the city organized its efforts and built the infrastructure, the ability to detect and confirm cases improved. As of February 3, for example, the novel coronavirus nucleic acid testing capability of Wuhan had increased to 4,196 samples per day from an initial 200 samples.

A significant discrepancy in case mortality rate can also be observed when comparing mortality rates as calculated and reported by China NHC: a CFR of 3.1% in the Hubei province (where Wuhan, with the vast majority of deaths is situated), and a CFR of 0.16% in other provinces (19 times less).

Finally, we shall remember that while the 2003 SARS epidemic was still ongoing, the World Health Organization (WHO) reported a fatality rate of 4% (or as low as 3%), whereas the final case fatality rate ended up being 9.6%.