{"id":10089,"date":"2020-03-28T05:21:23","date_gmt":"2020-03-28T09:21:23","guid":{"rendered":"http:\/\/stateofthenation.co\/?p=10089"},"modified":"2020-03-28T06:44:54","modified_gmt":"2020-03-28T10:44:54","slug":"current-data-confirms-covid-19-much-less-fatal-than-reported-over-60-with-comorbid-conditions-deaths-skews-mortality-rate-worldwide","status":"publish","type":"post","link":"http:\/\/stateofthenation.co\/?p=10089","title":{"rendered":"CURRENT DATA CONFIRMS: <b>COVID-19 much less fatal than reported, Death victims over 60 with comorbid conditions significantly skew mortality rates worldwide<\/b>"},"content":{"rendered":"<h1 style=\"text-align: center;\"><strong>Global Covid-19 Case Fatality Rates<\/strong><\/h1>\n<p><!--more--><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-10090\" src=\"http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/COVID-Banner.png\" alt=\"\" width=\"977\" height=\"210\" srcset=\"http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/COVID-Banner.png 977w, http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/COVID-Banner-300x64.png 300w, http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/COVID-Banner-768x165.png 768w\" sizes=\"auto, (max-width: 977px) 100vw, 977px\" \/><\/p>\n<p>Jason Oke, Carl Heneghan<br \/>\nUpdated 27th March<\/p>\n<p><a href=\"https:\/\/www.healthwatch-uk.org\/2-uncategorised\/185-covid-19-1.html\">Lay Summary by Mandy Payne, Health Watch<\/a><\/p>\n<hr \/>\n<p>This page is updated daily as new information emerges. It sets out the current Case Fatality Rate (CFR) estimates, the country-specific issues affecting the CFR, and provides a current best estimate of the CFR, and more importantly, the Infection Fatality Rate (IFR).<\/p>\n<p>The IFR estimates the fatality rate in all those with infection: the detected disease (cases) and those with an undetected disease (asymptomatic and not tested group).<\/p>\n<hr \/>\n<p><strong>Case Fatality Rates<\/strong><\/p>\n<p>The total number of cases and the total number of deaths from COVID-19 outbreak data was drawn down (scraped) from\u00a0<a href=\"https:\/\/www.worldometers.info\/coronavirus\/\">https:\/\/www.worldometers.info\/coronavirus\/<\/a>.<\/p>\n<p>The proportion of deaths to the total numbers of cases was meta-analysed using the R function\u00a0<em>metaprop<\/em>, using fixed-effect inverse-variance weighting. Estimates from the cruise ship \u2018Diamond Princess\u2019 as well as countries with three or fewer deaths to date recorded were excluded from the analysis. Country-level case fatality is presented as a percentage along with 95% confidence intervals in a forest plot. Estimates of heterogeneity and a 95% prediction interval are presented, but a pooled overall estimate is suppressed due to heterogeneity. (<a href=\"https:\/\/blogs.plos.org\/absolutely-maybe\/2017\/07\/03\/5-tips-for-understanding-data-in-meta-analyses\/\">understanding data in meta-analysis)<\/a><\/p>\n<p>*case fatality rate is the number of reported deaths per number of reported cases (Updated 25th March)<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-10103\" src=\"http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/CFR_analysis2020-03-27part2-924x1024-1.png\" alt=\"\" width=\"924\" height=\"1024\" srcset=\"http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/CFR_analysis2020-03-27part2-924x1024-1.png 924w, http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/CFR_analysis2020-03-27part2-924x1024-1-271x300.png 271w, http:\/\/stateofthenation.co\/wp-content\/uploads\/2020\/03\/CFR_analysis2020-03-27part2-924x1024-1-768x851.png 768w\" sizes=\"auto, (max-width: 924px) 100vw, 924px\" \/><\/p>\n<p>Between countries, case Fatality rates vary significantly, and over time, which suggests considerable uncertainty over the exact case fatality rates. see: <a href=\"https:\/\/www.cebm.net\/wp-content\/uploads\/2020\/03\/PIplot2020-03-27.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Prediction intervals for CFR overtime pdf<\/a><\/p>\n<p><strong>What is affecting the case fatality rate?<\/strong><\/p>\n<ul>\n<li>The number of cases detected by testing will\u00a0 vary considerably by country;<\/li>\n<li><a href=\"https:\/\/catalogofbias.org\/biases\/selection-bias\/\">Selection bias<\/a>\u00a0can mean those with severe disease are preferentially tested;<\/li>\n<li>There may be delays between symptoms onset and deaths \u00a0which\u00a0 can lead to underestimation of the CFR;<\/li>\n<li>There may be factors that account for increased death rates such\u00a0 as coinfection,\u00a0 poorer healthcare, patient demographics (i.e., older patients might be more prevalent in countries such as Italy);<\/li>\n<li>There may be increased rates of smoking or comorbidities amongst the fatalities.<\/li>\n<li>Differences in how deaths are attributed to Coronavirus: dying with the disease (association) is not the same as dying from the disease (causation).<\/li>\n<\/ul>\n<p><strong>China:<\/strong><\/p>\n<p>In China,\u00a0 CFR was\u00a0<a href=\"https:\/\/www.worldometers.info\/coronavirus\/coronavirus-death-rate\/#ref-12\" target=\"_blank\" rel=\"noopener noreferrer\">higher in the early stages of the outbreak<\/a>\u00a0(17% for cases from 1 to 10 January) and reduced to 0.7% for patients with symptom onset after 1 February.<\/p>\n<p><strong>UPDATE 21st March:\u00a0<\/strong><\/p>\n<p><a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2762130?guestAccessKey=bdcca6fa-a48c-4028-8406-7f3d04a3e932&amp;utm_source=For_The_Media&amp;utm_medium=referral&amp;utm_campaign=ftm_links&amp;utm_content=tfl&amp;utm_term=022420&amp;mod=article_inline\">Summary of a Report of 72\u202f314 Cases From the Chinese Center for Disease Control and Prevention.\u00a0<\/a>The data is also reported in the Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) \u2014 China, 2020 (<a href=\"http:\/\/weekly.chinacdc.cn\/en\/article\/id\/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51\">China CDC weekly<\/a>).<\/p>\n<p>The epidemic curve of onset of symptoms peaked around January 23rd to 26th, then began to decline up to February 11th. Most cases were aged 30 to 79 years of age (87%), 1% aged \u2264 9 years, 1% aged 10 to 19 years, and 3% 80 years or older.<\/p>\n<p>The CFR was 2.3% (1023 deaths\/44\u202f672 confirmed cases).<\/p>\n<p>Reported CFRs by age were<\/p>\n<table>\n<tbody>\n<tr>\n<td><strong>Age (deaths\/cases)<\/strong><\/td>\n<td><strong>CFR (95% CI)<\/strong><\/td>\n<\/tr>\n<tr>\n<td>\u2264 9 years\u00a0 \u00a0(0\/416)<\/td>\n<td>0%<\/td>\n<\/tr>\n<tr>\n<td>10 to 19 years (1\/549)<\/td>\n<td>0.18%\u00a0 \u00a0(0.03 to 1.02%)<\/td>\n<\/tr>\n<tr>\n<td>20 to 49\u00a0 years (63\/19790)<\/td>\n<td>0.32% (0.25% to 0.41%)<\/td>\n<\/tr>\n<tr>\n<td>50 to 59 years (130\/10,008)<\/td>\n<td>1.3%\u00a0 (1.1% to 1.5%)<\/td>\n<\/tr>\n<tr>\n<td>60 to 69. years (309\/8583)<\/td>\n<td>3.6% (3.2% to 4.0%)<\/td>\n<\/tr>\n<tr>\n<td>70 to 79 years (312\/3918)<\/td>\n<td>8.0% (7.2% to 8.9%)<\/td>\n<\/tr>\n<tr>\n<td>\u226580 years (208\/1408)<\/td>\n<td>\u00a0 14.8% (13.0% to 16.7%)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Patients with comorbid conditions had much higher CFR rates:<\/p>\n<table>\n<tbody>\n<tr>\n<td><strong>Condition*<\/strong><\/td>\n<td><strong>CFR<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Cardiovascular disease<\/td>\n<td>10.5%<\/td>\n<\/tr>\n<tr>\n<td>Diabetes<\/td>\n<td>7.3%<\/td>\n<\/tr>\n<tr>\n<td>Chronic respiratory disease<\/td>\n<td>6.3%<\/td>\n<\/tr>\n<tr>\n<td>Hypertension<\/td>\n<td>6.0%<\/td>\n<\/tr>\n<tr>\n<td>Cancer<\/td>\n<td>5.6%<\/td>\n<\/tr>\n<tr>\n<td>No comorbidities<\/td>\n<td>0.9%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>*Critical cases had a\u00a0 CFR of 49.0%, no deaths occurred among those with mild or even severe symptoms.<\/p>\n<ul>\n<li>Critical cases were classified as those that exhibited respiratory failure, septic shock, and\/or multiple organ dysfunction\/failure.<\/li>\n<li>Severe characterised by dyspnea, respiratory rate \u226530\/minute, oxygen saturation \u226493%, PaO<sub>2<\/sub>\/FiO<sub>2<\/sub>\u00a0ratio &lt;300, and\/or lung infiltrates &gt;50% within 24\u201348 hours<\/li>\n<\/ul>\n<p><a href=\"http:\/\/weekly.chinacdc.cn\/en\/article\/id\/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51\">1716 case were health workers<\/a>\u00a0(3.8%), \u00a0254 cases (14.8%)\u00a0 were classified as severe or critical, and five health workers\u00a0 (0.3%) died.<\/p>\n<p><strong>Limitation:<\/strong>\u00a0some variables of interest (i.e.,\u00a0 comorbid condition, and case severity) are not required fields in the Chinese CDC Infectious Disease Information System, and some records have missing data.<\/p>\n<p><strong>Why is cardiovascular disease (CVD) so prevalent in those who died with COVID-19?<\/strong><\/p>\n<p>Most acute viral infections have three short-term effects on the CVD\u00a0 system:<\/p>\n<ul>\n<li class=\"bulletfix\">Increase the risk of acute coronary syndromes due to the inflammatory response,<\/li>\n<li class=\"bulletfix\">Depression of the myocardium leading to worsening heart failure,<\/li>\n<li class=\"bulletfix\">The inflammatory process can unmask heart arrhythmias.<\/li>\n<\/ul>\n<p>Seasonal influenza infections have been shown to contribute to an increase in CVD deaths significantly. Community-level rises in Influenza-like illness\u00a0 (ILI) were associated with and predictive of CVD mortality:\u00a0 deaths from ischaemic heart disease rose from 2.3% to 6.3% when emergency department visits with ILI rose from the 25th to the 75th centile.<\/p>\n<p><a href=\"https:\/\/www.nature.com\/articles\/s41591-020-0822-7\">Nature Medicine: Estimating the clinical severity of COVID-19<\/a>\u00a0from the transmission dynamics in Wuhan, China~:<\/p>\n<ul>\n<li>in those with coronavirus symptoms in Wuhan, China, had a 1.4%\u00a0 (95% CI, 0.9% to 23.1% chance of dying,<\/li>\n<li>As of 29th February, the crude CFR case risk, outside Hubei was 0.85%,<\/li>\n<li>Risk of symptomatic infection increases with age, but this may be preferential ascertainment of older and more severe cases. \u2018One largely unknown factor at present is the number of asymptomatic, undiagnosed infections.<\/li>\n<\/ul>\n<p>Because Wuhan prioritized the admission of more severe cases, the sCFR will be substantially lower than the HFR*<\/p>\n<p>*sCFR (s for symptomatic) defines a case as someone who is infected and shows certain symptoms;\u00a0HFR (hospitalized)\u00a0defines a case as someone who is infected and hospitalized.<\/p>\n<p><strong>Italy:<\/strong><\/p>\n<p>In Italy, there are several reasons why the. CFR might be higher. The age structure of the Italian population (2nd oldest in the world); highest rates of antibiotic resistance deaths in Europe (Italy tops the EU\u00a0 for antibiotic-resistance deaths,\u00a0<a href=\"http:\/\/www.ansa.it\/english\/news\/science_tecnology\/2019\/11\/19\/italy-top-in-eu-in-antibiotic-resistance_369e0123-0107-445e-8c17-f11932c9d27c.html\" target=\"_blank\" rel=\"noopener noreferrer\">with nearly 1\/3rd\u00a0 of the deaths<\/a>\u00a0in the EU). Smoking also seems to be a factor associated with poor survival \u2013\u00a0 in Italy, 24% smoke, 28% men. In the UK, for instance, 15% are current smokers.<\/p>\n<p><a href=\"https:\/\/www.stuff.co.nz\/national\/health\/coronavirus\/120443722\/coronavirus-is-covid19-really-the-cause-of-all-the-fatalities-in-italy\"><strong>UPDATE 20 March:<\/strong>\u00a0Coronavirus: Is Covid-19 the cause of all the fatalities in Italy?<\/a><\/p>\n<p class=\"sics-component__html-injector sics-component__story__paragraph\">Sarah Newy reports\u00a0 Italy\u2019s death rate might be higher because of how fatalities are recorded.\u00a0 In Italy, all those who die in hospitals with Coronavirus will be included in the death numbers.\u00a0\u00a0In this\u00a0<a href=\"https:\/\/www.stuff.co.nz\/national\/health\/coronavirus\/120443722\/coronavirus-is-covid19-really-the-cause-of-all-the-fatalities-in-italy\">article<\/a>, Professor Walter Ricciardi,\u00a0 Scientific Adviser to, Italy\u2019s Minister of Health, reports,\u00a0 \u201cOn re-evaluation by the National Institute of Health, only 12 per cent of death certificates have shown a direct causality from coronavirus, while 88% patients who have died have at least one pre-morbidity \u2013 many had two or three.\u201d<\/p>\n<p class=\"sics-component__html-injector sics-component__story__paragraph\">Recording the numbers of those who die\u00a0<strong>with<\/strong>\u00a0Coronavirus will inflate the CFR as opposed to those that died\u00a0<strong>from<\/strong>\u00a0Coronavirus, which will reduce the CFR.<\/p>\n<p><strong>17th March 2020:<\/strong>\u00a0<a href=\"https:\/\/www.epicentro.iss.it\/coronavirus\/bollettino\/Report-COVID-2019_17_marzo-v2.pdf\">Report from the Italian National Institute of Health: a<\/a>nalysed 355\u00a0 fatalities and found only three patients (0.8%)\u00a0 had no prior medical conditions. See Table 1 in the paper; (99% who died had one pre-existing health condition):<\/p>\n<ul>\n<li>49%\u00a0 had three or\u00a0 more health conditions,<\/li>\n<li>26% had two other \u2018pathologies\u2019,<\/li>\n<li>25% had one.<\/li>\n<\/ul>\n<p class=\"mol-para-with-font\">The most common problems in the 355 who died were:<\/p>\n<ul>\n<li class=\"mol-para-with-font\">\u00a076% high blood pressure,<\/li>\n<li class=\"mol-para-with-font\">\u00a036%\u00a0 diabetes,<\/li>\n<li class=\"mol-para-with-font\">\u00a033%\u00a0 ischemic heart disease.<\/li>\n<\/ul>\n<p id=\"tw-target-text\" class=\"tw-data-text tw-text-large tw-ta\" dir=\"ltr\" data-placeholder=\"Translation\"><span lang=\"en\">The average age of deceased and COVID-19 positive patients was 79.5 years (median 80.5, range 31-103, InterQuartile \u2013 IQR 74.3-85.9). The median age of the patients who died was &gt; 15 years higher than that of patients who contracted the infection (median age: patients who died 80.5 years \u2013 patients with infection 63 years).\u00a0<\/span><span lang=\"en\">Women who died after contracting COVID-19 were older than men (median ages: women 83.7 \u2013 men 79.5).<\/span><\/p>\n<p><strong>UPDATE: 27TH MARCH Iceland:<\/strong><\/p>\n<p>Iceland is presenting many interesting pointers for estimating the CFR.\u00a0<a href=\"https:\/\/nordiclifescience.org\/covid-19-first-results-of-the-voluntary-screening-on-iceland\/\">Iceland has tested a higher proportion<\/a>\u00a0of people than any other country (9,768 individuals), equivalent to\u00a0 26,762 per million inhabitants the highest in the world (as a\u00a0 comparison, South Korea has teated\u00a0 6,343 individuals).<\/p>\n<div>The results of screenings have suggested 0.5% are infected;\u00a0 the true figure is likely higher due to asymptomatic and as a result of many not seeking testing:\u00a0<a href=\"https:\/\/nordiclifescience.org\/covid-19-first-results-of-the-voluntary-screening-on-iceland\/\">estimates suggest the real number infected is 1%<\/a>. Iceland is currently reporting two deaths in 737 patients, CFR. 0.27%; if 1% of the population (364,000) is infected, then the corresponding IFR would be 0.05%.\u00a0 \u00a0 However, they have limited infections in the elderly as their test and quarantine measures have seemingly shielded this group, and the deaths will lag by about two weeks after the infection. Iceland\u2019s higher rates of testing, the smaller population, and their ability to ascertain all those with Sars-CoV-2\u00a0 means they will likely provide an accurate estimate of the CFR and the IFR.\u00a0 Current data from Iceland suggests the IFR is somewhere between 0.05% and 0.14%.<\/div>\n<div><\/div>\n<div><strong>United Kingdom:<\/strong><\/div>\n<div>Assessment:\u00a0<a href=\"https:\/\/spiral.imperial.ac.uk:8443\/handle\/10044\/1\/77482\">Impact assessment of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand<\/a><\/div>\n<p>Neil Ferguson\u2019s team at Imperial College, London, modelled the impact of COVID-19, interventions to reduce the spread and their effects on case fatality.<\/p>\n<p>See the summary of their assumptions:\u00a0<a href=\"https:\/\/www.cebm.net\/wp-content\/uploads\/2020\/03\/Impact-assessment-of-non-pharmaceutical-interventions-NPIs-to-reduce-COVID-19-mortality-and-healthcare-demand-.pdf\">Impact assessment of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand pdf<\/a><\/p>\n<p>Their Infection Fatality Rate estimates were based on\u00a0<a href=\"https:\/\/www.medrxiv.org\/content\/10.1101\/2020.03.09.20033357v1\">from Verity et al.\u00a0<\/a>and adjusted to account for a non-uniform attack rate giving an overall IFR of 0.9% (95% credible interval 0.4%-1.4%).<\/p>\n<p><a href=\"https:\/\/www.medrxiv.org\/content\/10.1101\/2020.03.09.20033357v1\">Published in \u00a0MedRxiv<\/a>\u00a0(<a href=\"https:\/\/www.medrxiv.org\/content\/what-unrefereed-preprint\">preprint and not been peer-reviewed)\u00a0<\/a>Verity obtained age-stratified CFR estimates from cumulative death data in China, and from individual data on 1,334 cases identified outside of mainland China.\u00a0\u00a0<a href=\"https:\/\/www.medrxiv.org\/content\/10.1101\/2020.03.09.20033357v1\">Verity et al.<\/a>estimated an overall IFR for China of 0.66% (0.39%,1.33%), that increased with age.<\/p>\n<p><strong>Comparison with Swine Flu<\/strong><\/p>\n<p>The overall\u00a0<a href=\"https:\/\/www.eurosurveillance.org\/content\/10.2807\/ese.14.33.19309-en\" target=\"_blank\" rel=\"noopener noreferrer\">case fatality rate as of 16 July 2009\u00a0<\/a>\u00a0(10 weeks after the first international alert) with pandemic H1N1 influenza varied from 0.1% to 5.1% depending on the country.\u00a0 The WHO reported in 2019 that swine flu ended up with a\u00a0<a href=\"https:\/\/www.reuters.com\/article\/us-health-flu-who\/world-must-prepare-for-inevitable-next-flu-pandemic-who-says-idUSKBN1QS1EP\" target=\"_blank\" rel=\"noopener noreferrer\" data-analytics-post-depth=\"60\" data-analytics-module=\"body_link\">fatality rate of 0.02%<\/a>. Evaluating CFR during a pandemic is a hazardous exercise, and high-end estimates end be treated with caution as the H1N1 pandemic highlights that original estimates were out by a factor greater than 10.<\/p>\n<p><strong>Effect of concurrent infections<\/strong><\/p>\n<p><a href=\"https:\/\/academic.oup.com\/jpubhealth\/article\/30\/1\/91\/1577196\" target=\"_blank\" rel=\"noopener noreferrer\">Highest peak rate ratios for admissions<\/a> are in those years where the confirmed simultaneous circulation of Influenza-Like Illness (ILI)\u00a0 and acute bronchitis occur. Between\u00a0 1990\u201391 to 2004\u201305 respiratory admissions of\u00a0 \u226565 years in England and Wales were analysed. The\u00a0 ILI peaked was highly variable: the earliest during mid-November (week 46, 1993\u201394) and the latest, late February\/early March (week 7, 1997\u201398).<\/p>\n<p><strong>Diamond Princess Cruise Ship<\/strong><\/p>\n<p>On the\u00a0<em>Diamond Princess<\/em>, six deaths occurred out of 705 who tested positive constituting a CFR\u00a0 of 0.85%. All six deaths six occurred in patients &gt; 70. No one under 70 died.<\/p>\n<p><a href=\"https:\/\/www.medrxiv.org\/content\/10.1101\/2020.03.05.20031773v2\">Estimating the infection and case fatality ratio for COVID-19<\/a>\u00a0using age-adjusted data from the outbreak on the Diamond Princess cruise ship. Comparing deaths onboard with expected deaths based on naive CFR estimates using China data, they estimated: CFR 1.1% (95% CI: 0.3-2.4%); IFR 0.5% (95% CI: 0.2-1.2%).<\/p>\n<p><strong>UPDATE 27th. March:<br \/>\n<\/strong>Nature published on\u00a0<a href=\"https:\/\/www.nature.com\/articles\/d41586-020-00885-w\">what the cruise-ship outbreaks reveal about COVID-19<\/a>Japanese officials performed more than<\/p>\n<ul>\n<li>3,000 tests on the\u00a0<i>Diamond Princess<\/i>, starting with older passengers and those with symptoms<\/li>\n<li>20th February, 18% of all infected people had no symptoms<\/li>\n<li>After people were confined to their rooms, the R0 &lt;1<\/li>\n<\/ul>\n<p id=\"page-title\" class=\"highwire-cite-title\"><a href=\"https:\/\/www.medrxiv.org\/content\/10.1101\/2020.03.05.20031773v2\">Estimating the infection and CFR\u00a0 for COVID-19<\/a>\u00a0using age-adjusted data from the outbreak on the Diamond Princess cruise ship using the age structure of the onboard population and modelled that on naive CFR estimates using China data.\u00a0 They report:<\/p>\n<ul>\n<li>Onboard CFR as 2.3% (0.75%-5.3%),<\/li>\n<li>Onboard IFR. as 1.2% (0.38-2.7%),<\/li>\n<li>Estimated China CFR as 1.1% (95% CI: 0.3-2.4%); and the IFR to be 0.5% (95% CI: 0.2-1.2%).<\/li>\n<\/ul>\n<p><strong>UPDATE: 26th March: Estimating COVID-19 Case Fatality\u00a0 Rates (CFR) and Infection Rate Fatality (IFR)<\/strong><\/p>\n<p>Our current best assumption, as of the 22nd March, is the IFR\u00a0 is approximately CFR 0.57% (95% CI, 0.50% to 0.65%). We used the estimate from Germany\u2019s current data 22nd March (93 deaths 2312 cases).<\/p>\n<p>In the elderly, comorbidities have a significant impact on the CFR: those with \u2265 3 comorbidities are at much higher risk, particularly those with cardiovascular conditions. Modelling the data on the prevalence of comorbidities is essential to understand the CFR and IFR by age. In those without pre-existing health conditions, and over 70, the data is reassuring that the CFR will likely not be above 1%. The prevalence of comorbidities is highly age-dependent and is higher in the\u00a0<a href=\"https:\/\/www.thelancet.com\/journals\/lancet\/article\/PIIS0140-6736(12)60240-2\/fulltext\">socially deprived<\/a>.<\/p>\n<p><strong>UPDATE. 27TH MARCH: estimated IFR figure?\u00a0<\/strong><\/p>\n<p>The current COVID outbreak seems to be following previous pandemics in that initial CFRs start high and then trend downwards. For example, In Wuhan, for instance, the CFR\u00a0 has gone down from 17% in the initial phase to near 1% in the late stage. It is increasingly clear that current testing strategies are not capturing everybody.\u00a0 In South Korea, considerable numbers who tested positive were also asymptomatics.\u00a0 Asymptomatic people and mild cases are l<a href=\"https:\/\/www.wbay.com\/content\/news\/Asymptomatic-people-may-be-driving-spread-of-coronavirus-568831221.html\">ikely driving the rapid worldwide spread.<\/a><\/p>\n<p>The number of asymptomatics is highly uncertain: estimates put it at least a half are asymptomatic; the proportion not coming\u00a0 forward for testing is also highly uncertain (i.e. you are symptomatic, but you do not present for testing)<\/p>\n<ul>\n<li>Early CFR rates are subject to selection bias as more severe cases are tested \u2013 generally those in the hospital settings or those with more severe symptoms.<\/li>\n<li>Mortality in children seems to be near zero (unlike flu) which will drive down the IFR significantly.<\/li>\n<\/ul>\n<p>Therefore we can estimate that the IFR is 0.29% (95% CI, 0.25% to 0.33%); at least half that of the CFR of Germany<\/p>\n<ul>\n<li>In Swine flu, the IFR was fivefold less than the lowest estimate in the 1st ten weeks (0.1%)<\/li>\n<\/ul>\n<p>We could also estimate the IFR as 0.26, based on halving the lowest boundary of the CFR prediction interval. There is still considerable uncertainty over how many people actually have the disease. (Update on this issue due tomorrow 28th March).<\/p>\n<p>Our assumptions, however, do not account for some exceptional cases. As in Italy, where the population is older, smoking rates, comorbidities higher, and antibiotic resistance are higher, which all can act to increase the CFR and the IFR. It is also currently not clear what the excess mortality is in this group.<\/p>\n<p>It is essential to understand whether the elderly are dying with or from the disease (see the\u00a0<a href=\"https:\/\/www.stuff.co.nz\/national\/health\/coronavirus\/120443722\/coronavirus-is-covid19-really-the-cause-of-all-the-fatalities-in-italy\">Sarah Newy report<\/a>). It is also not clear if the presence of other circulating influenza illnesses acts to increase the CFR (testing for co-pathogens is not occurring), and whether certain populations (e.g., those with heart conditions) are more at risk. Understanding this issue is now critical. If, for instance, 80% of those over 80 died with the disease (20% from it) then the CFR\u00a0 in &gt;80s would be near 3% as opposed to 15%. This would then lower the overall CFR (and IFR) substantially.<\/p>\n<p>What matters is now is how many people get infected in a short space of time: to what extent this overwhelms healthcare services and whether they can manage. The impact of measures to reduce spread are crucial in the upward phase of a pandemic that can affect a significant number of people at any one time.<\/p>\n<hr \/>\n<p>*Estimating CFR and IFR in the early stage of outbreaks is subject to considerable uncertainties, the estimates are likely to change as more data emerges. The current prediction interval based on the available has a wide-ranging estimate of the CFR from 0.60 to 7.19. the corresponding IFR estimate based on this data would be 0.30 to 3.60.<\/p>\n<p><a href=\"https:\/\/www.thelancet.com\/journals\/laninf\/article\/PIIS1473-3099(20)30195-X\/fulltext?fbclid=IwAR0z2mTiZ4D4itGAzVM9WhiNgSYuYlH48MDlYIWXqXqGLn1XdbIwcsk2wM4\"><strong>See Lancet report:\u00a0<\/strong><\/a>\u00a0CFRs on mortality rate estimates can be misleading if the CFR is based on the number of deaths per number of confirmed cases at the same time.\u00a0 Using the denominator of the mortality rate as the total number of patients infected at the same time as those who died would lead to much higher CFRs. However, they report the full denominator remains unknown as asymptomatic with mild symptoms might not be tested and will not be identified, particularly in the early stages of an outbreak.<\/p>\n<p><strong>Acknowledgements:<\/strong><\/p>\n<p>Thanks to David Bernstein (George Mason University) for posing the question of how we arrived at the CFR estimates.<\/p>\n<p>We welcome more critiques\/questions on this article, and we are keeping the CFR under daily review.<\/p>\n<p><strong>Disclaimer:<\/strong>\u00a0 the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice.<\/p>\n<p>Estimating Case fatality rates in the early stage of outbreaks is subject to considerable uncertainties, the estimates are likely to change as more data emerges.<\/p>\n<p>___<br \/>\n<a href=\"https:\/\/www.cebm.net\/covid-19\/global-covid-19-case-fatality-rates\/\">https:\/\/www.cebm.net\/covid-19\/global-covid-19-case-fatality-rates\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Global Covid-19 Case Fatality Rates<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-10089","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"http:\/\/stateofthenation.co\/index.php?rest_route=\/wp\/v2\/posts\/10089","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/stateofthenation.co\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/stateofthenation.co\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/stateofthenation.co\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/stateofthenation.co\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=10089"}],"version-history":[{"count":0,"href":"http:\/\/stateofthenation.co\/index.php?rest_route=\/wp\/v2\/posts\/10089\/revisions"}],"wp:attachment":[{"href":"http:\/\/stateofthenation.co\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=10089"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/stateofthenation.co\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=10089"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/stateofthenation.co\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=10089"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}