Current estimates about the Covid-19 fatality rate may be too high by orders of magnitude.
By Eran Bendavid and Jay Bhattacharya, WSJ
March 24, 2020 6:21 pm ET
A line at an emergency room in Brooklyn, N.Y., March 19.
If it’s true that the novel coronavirus would kill millions without shelter-in-place orders and quarantines, then the extraordinary measures being carried out in cities and states around the country are surely justified. But there’s little evidence to confirm that premise—and projections of the death toll could plausibly be orders of magnitude too high.
Fear of Covid-19 is based on its high estimated case fatality rate—2% to 4% of people with confirmed Covid-19 have died, according to the World Health Organization and others. So if 100 million Americans ultimately get the disease, two million to four million could die. We believe that estimate is deeply flawed. The true fatality rate is the portion of those infected who die, not the deaths from identified positive cases.
The latter rate is misleading because of selection bias in testing. The degree of bias is uncertain because available data are limited. But it could make the difference between an epidemic that kills 20,000 and one that kills two million. If the number of actual infections is much larger than the number of cases—orders of magnitude larger—then the true fatality rate is much lower as well. That’s not only plausible but likely based on what we know so far.
Population samples from China, Italy, Iceland and the U.S. provide relevant evidence. On or around Jan. 31, countries sent planes to evacuate citizens from Wuhan, China. When those planes landed, the passengers were tested for Covid-19 and quarantined. After 14 days, the percentage who tested positive was 0.9%. If this was the prevalence in the greater Wuhan area on Jan. 31, then, with a population of about 20 million, greater Wuhan had 178,000 infections, about 30-fold more than the number of reported cases. The fatality rate, then, would be at least 10-fold lower than estimates based on reported cases.
Next, the northeastern Italian town of Vò, near the provincial capital of Padua. On March 6, all 3,300 people of Vò were tested, and 90 were positive, a prevalence of 2.7%. Applying that prevalence to the whole province (population 955,000), which had 198 reported cases, suggests there were actually 26,000 infections at that time. That’s more than 130-fold the number of actual reported cases. Since Italy’s case fatality rate of 8% is estimated using the confirmed cases, the real fatality rate could in fact be closer to 0.06%.
In Iceland, deCode Genetics is working with the government to perform widespread testing. In a sample of nearly 2,000 entirely asymptomatic people, researchers estimated disease prevalence of just over 1%. Iceland’s first case was reported on Feb. 28, weeks behind the U.S. It’s plausible that the proportion of the U.S. population that has been infected is double, triple or even 10 times as high as the estimates from Iceland. That also implies a dramatically lower fatality rate.
The best (albeit very weak) evidence in the U.S. comes from the National Basketball Association. Between March 11 and 19, a substantial number of NBA players and teams received testing. By March 19, 10 out of 450 rostered players were positive. Since not everyone was tested, that represents a lower bound on the prevalence of 2.2%. The NBA isn’t a representative population, and contact among players might have facilitated transmission. But if we extend that lower-bound assumption to cities with NBA teams (population 45 million), we get at least 990,000 infections in the U.S. The number of cases reported on March 19 in the U.S. was 13,677, more than 72-fold lower. These numbers imply a fatality rate from Covid-19 orders of magnitude smaller than it appears.
How can we reconcile these estimates with the epidemiological models? First, the test used to identify cases doesn’t catch people who were infected and recovered. Second, testing rates were woefully low for a long time and typically reserved for the severely ill. Together, these facts imply that the confirmed cases are likely orders of magnitude less than the true number of infections. Epidemiological modelers haven’t adequately adapted their estimates to account for these factors.
The epidemic started in China sometime in November or December. The first confirmed U.S. cases included a person who traveled from Wuhan on Jan. 15, and it is likely that the virus entered before that: Tens of thousands of people traveled from Wuhan to the U.S. in December. Existing evidence suggests that the virus is highly transmissible and that the number of infections doubles roughly every three days. An epidemic seed on Jan. 1 implies that by March 9 about six million people in the U.S. would have been infected. As of March 23, according to the Centers for Disease Control and Prevention, there were 499 Covid-19 deaths in the U.S. If our surmise of six million cases is accurate, that’s a mortality rate of 0.01%, assuming a two week lag between infection and death. This is one-tenth of the flu mortality rate of 0.1%. Such a low death rate would be cause for optimism.
This does not make Covid-19 a nonissue. The daily reports from Italy and across the U.S. show real struggles and overwhelmed health systems. But a 20,000- or 40,000-death epidemic is a far less severe problem than one that kills two million. Given the enormous consequences of decisions around Covid-19 response, getting clear data to guide decisions now is critical. We don’t know the true infection rate in the U.S. Antibody testing of representative samples to measure disease prevalence (including the recovered) is crucial. Nearly every day a new lab gets approval for antibody testing, so population testing using this technology is now feasible.
If we’re right about the limited scale of the epidemic, then measures focused on older populations and hospitals are sensible. Elective procedures will need to be rescheduled. Hospital resources will need to be reallocated to care for critically ill patients. Triage will need to improve. And policy makers will need to focus on reducing risks for older adults and people with underlying medical conditions.
A universal quarantine may not be worth the costs it imposes on the economy, community and individual mental and physical health. We should undertake immediate steps to evaluate the empirical basis of the current lockdowns.
Dr. Bendavid and Dr. Bhattacharya are professors of medicine at Stanford. Neeraj Sood contributed to this article.
@ Michael S:
“Hi reader. We did not shut down over the flu, because:”
I will answer you point-by-point:
“1. Most people, including my wife and I are immunized against it”
– Less than 50% of the people got flu immunizations in the US in 2017-2018 (the latest data) instead of the government-recommended 70%;
– you cannot be immunized “against it” because the original viruses constantly mutate and the vaccine is not a guarantee. Also, both of you are very lucky to have had no complications from it (I know someone who did and was even hospitalized for it). Most people who get the flu have symptoms because they have not yet developed immunity to this particular virus. I know (older) people who never get immunized “against it” and never catch it (or once every 7-10 years).
“2. Those who do need hospitalization don’t need the intensive care that COVID-19 people do.”
– You don’t know that. The ~70% of the elderly flu cases who die from it most likely do.
“3. COVID-19 is EXTREMELY infectious, and infection is spread by completely healthy-looking individuals for a long time before symptoms appear.”
– CDC: 38,000,000 – 54,000,000 flu illnesses in 2020 – this seems pretty damn infectious to me .
– The flu is spread the same way also, at most after the the 1st 12 hours of the infection, except the flu might have a shorter incubation period (when the infected person still feels and looks healthy).
“You said it yourself: The flu DOES NOT shut down the economy. COVID-19 can destroy health care systems and economies.”
There is a difference between possible and probable.
Right now COVID-19’s ability to do that all by itself seems improbable.
You can argue that this is so because of the heroic efforts of our government to stem the tide of the pandemic.
I can answer that if the politicians were to writhe in hysterics about the annual flu epidemics like they do about this virus with locking up the high-risk cases like lepers, the stats on the flu cases might resemble the stats for the coronavirus, i.e. TENS of THOUSANDS instead of TENS of MILLIONS.
“Don’t play with the numbers.”
– I don’t. All I did was to display the valid stats on the flu and the coronavirus side-by-side
“I won’t argue with you about them.”
– You can’t because I didn’t make them up.
“My best friend is very ill and may soon die from what is likely COVID-19.”
– Maybe, maybe not.
“He doesn’t want to call the doctor, and I am not able to go see him because of the quarantine.”
– You have our dear politicians to thank for this one. I am not that old but I wouldn’t call the doctor either if I didn’t feel it was a dire emergency because I wouldn’t want to be taken away, isolated, quarantined, treated like a lab animal, etc.
At your friend’s age, he doesn’t want this to happen to him, either.
“This is not a math quiz in the funnies paper.”
– Again, I wasn’t doing any math, it was a straight comparison.
– I don’t want to belittle the real fear of the infection and the possible complications – I have it myself (the fear).
– However, I still believe that there is a political agenda this time, and if there is not – GREAT.
However, if there is, I pray that anyone’s evil designs (if they exist) will come to naught.
“Unemployment rate reaches 20.4% – 39,000 people applied for benefits in the last 24 hours.” From today’s jerusalem Post. So pathetic. My beloved country desroyed by a “pandemic” that doesn’t even exist, and panic fostered by deluded politicians and doctors both abroard and at home. I knew Israel was in trouble because of its numerous well-armed and hate-crazed enemies, the hatred of the entire “international community,” the huge number of treasonous enemy sympathizers in positions of great power and influence within the country, etc. But I never imagined that a mass panic about a nonexistent illness would bring Israel down. But that’s what’s happened.
@ Reader: All excellent points and highly relevant numbers, Reader.
@ Edgar G.:
In “History of the World Part I”, Mel Brooks (Jewish) portrayed a “stand-up philosopher”, which seemed to mean a “comedian”. He was a good one — played Caesar’s Palace!
https://www.liveleak.com/view?t=9e2Is_1567969003
@ Reader:
Hi reader. We did not shut down over the flu, because:
1. Most people, including my wife and I are immunized against it
2. Those who do need hospitalization don’t need the intensive care that COVID-19 people do.
3. COVID-19 is EXTREMELY infectious, and infection is spread by completely healthy-looking individuals for a long time before symptoms appear.
You said it yourself: The flu DOES NOT shut down the economy. COVID-19 can destroy health care systems and economies.
Don’t play with the numbers. I won’t argue with you about them. My best friend is very ill and may soon die from what is likely COVID-19. He doesn’t want to call the doctor, and I am not able to go see him because of the quarantine. This is not a math quiz in the funnies paper.
I just posted some very interesting statistics comparing 2019-20 flu and the 2020 coronavirus in the US.
It’s “awaiting moderation”.
Read the statistics and judge for yourselves:
https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm
“CDC estimates that, from October 1, 2019, through March 14, 2020, there have been:
38,000,000 – 54,000,000 flu illnesses
17,000,000 – 25,000,000 flu medical visits
390,000 – 710,000 flu hospitalizations
HOW COME THE HEALTH SYSTEM DIDN’T CRASH?!
23,000 – 59,000 flu deaths” NO HYSTERIA.
23,000:5.5mos = ~4182 deaths from the flu/mo (AVG)
This wasn’t the worst flu season.
https://www.cdc.gov/flu/highrisk/65over.htm
“In recent years, for example, it’s estimated that between about 70 percent and 85 percent of seasonal flu-related deaths have occurred in people 65 years and older, and between 50 percent and 70 percent of seasonal flu-related hospitalizations have occurred among people in this age group.” NO HYSTERIA.
https://www.worldometers.info/coronavirus/country/us/
“Coronavirus Cases: 68,203” (03-25-20 9:35pm CST)
Deaths: 1,027 EXTREME HYSTERIA, SHUTDOWN OF THE ECONOMY.
1027:~2mos = ~513 deaths/mo (AVG) EXTREME HYSTERIA.
I assumed the time period from Feb. 1, 2020 March 25, 2020
@ Michael S:
We seem to have completed the circle (on this site) by arriving back to the opinion of the ancient Greeks, who, when they first encountered the Jews, said we were a :Nation of Philosophers”……..
@ Reader:
“This will only happen IF they KEEP doubling for 55 days.”
Yes. We’ll know on 7/15. Here is the graph, showing trajectory inflection over time by country:
https://www.visualcapitalist.com/infection-trajectory-flattening-the-covid19-curve/
According to the graph, the US caseload (not death count) has been doubling every 2-1/2 days, keeping company with Italy, Spain and Germany (and China in the early days of the pandemic). China stopped the doubling spree through ham-fisted lockdowns and quarantines, and we are trying to emulate them.
Deaths lag behind case confirmations, in most cases, by several weeks: a shorter time, if little testing is done, and a longer time (or never) if early testing detects the virus. Unfortunately, as a country’s health system gets overloaded by the heavy caseload, it has fewer human and material resources available for testing.
I wish these were just numbers. One of my best friends may have COVID-19, but he doesn’t want to call it in. He’s 91.
Perhaps he-or I- is getting mixed up between the confirmed, and “estimated” infected. This seems to be flaw in the reasoning, because the estimated infected have not progressed enough to report in, to be tested as positive Many of his “estimated” may never be tested, having no symptoms, indeed may not have the virus at all..
It’s obvious that by enlarging the base figure massively, by including the “estimated” the ratio will go down. Otherwise one must face that there will be catastrophic numbers of deaths.
Now I’m the one getting mixed up, so I’d better stop here. Likely I have read over it too quickly and don’t grasp the points being made. Perhaps, sub-consciously, I don’t want to….!!
@ deanblake:
“Trump’s Easter ‘resurrection day’ work release date”
Trump is not dumb, he thinks everyone else is. His ‘work release date” simply means that this coronavirus is not the plague, that the whole “pandemic” was a fake (just another annual flu virus mutation).
It would be interesting if they get their 20% unemployment rate, ruin thousands of small businesses, bring the manufacturing back from China (MAGA!), give the manufacturers the 4 trillion $$ bailout, and Americans, instead of rushing to grab those factory jobs, will refuse this kind of work.
OOPS!!!
@ Michael S:
“Expected deaths in 55 days: 20 million (10 doublings)”
This will only happen IF they KEEP doubling for 55 days.
@ adamdalgliesh:
Actually as usual you are wrong my mind is not made up on this topic. I am listening to multiple medical and scientific professional sources. You the non-scientist (English Teacher) are not objective and are pitching a point of view. You are interested in only with what agrees with your viewpoint. So I am not interested in your viewpoint, as I told to you.
Some of your commentary (when I still read it) bordered on the emotionally hysterical and other commentary as usual was very much in your Chicken Little pattern of outburst. Sometimes it was combined!
I happen to have insight via my physician friend of a network of physicians and scientists who are studying Covid-19. They are discussing and debating the issue plus have provided me access to data of interest. I know you believe Rush Limbaugh is an expert on this subject because he has cancer and this makes him an expert in your worldview. Like I said you saying something is inaccurate is not of interest to me because you have no credibility.
Hi, Dean
I don’t think President Trump considers himself immune to the coronavirus. He is a positive thinker (a la Norman Vincent Peale, the pastor of his youth), but also a realist (He washes his hands like a germophobe).
Statistics can be manipulated to stretch the truth; but as you say, when friends and loved ones die, they are no longer statistics. This is a real crisis. Dalgliesh is still in denial, Laura has already been through anger, and others are working through bargaining, depression and acceptance (the five stages of grieving).
What’s important, is that we come through the grieving without much damage. I’ve said before, that the best way to deal with this virus is to treat it like a war — specifically, like WWII, which we actually won.
Author George Orwell (aka Eric Blair) worked for the BBC during the war, if I’m not mistaken, which at that time was part of Britain’s propaganda ministry. It was there, that Orwell realized that a government can do practically anything it wants during a war, which is why his book “1984” was set in an environment of continual warfare – with, essentially, the US, Russia and China as arch-enemies who formed alliances with one another as need required. There was even a mandatory “Two Minute Hate” session for government employees, wherein they spewed out venom against the current “enemy”.
Now that the whole world is effectively under martial law, things don’t bode well for human liberties. Neither did they, of course, during WWII. Nevertheless, World War II was a real war, wherein people really died, and the current crisis is indeed a real crisis.
I pray. Half my family is in China; and my wife and I here in Oregon are under mandatory quarantine. We’re all on the front lines; and on the front lines, soldiers pray.
God bless and keep you and yours.
@ Bear Klein: My replies to your inaccurate and alarmist reports are not intended for your benefit, Bear, but for those of our readers who still have an open mind. I am attempting to explain to these readers why your alarmist statistics are without any factual basis. I realize that you have got this information from mainstream media sources, who in turn get them from governments and disease-control organizations, both public and private. But unlike you, I don’t take it for granted that these sources are correct. I believe that we all need to do a bit of critical thinking and question authority.
Having known you as a commenter for several years now, I know that you do not have an open mind and that you accept without question what you are told by authority figures. And you never change your mind once it is made up.So I am not writing for your benefit, but for those of our readers who have an open mind and are capable of critical thinking.
Statistics are meaningless if you catch the infection and die as you will be 100% dead. Trump’s Easter ‘resurrection day’ work release date will defeat and nullify prior efforts with its economic losses and only ensure the perpetuation this infection in the population until an effective vaccine is created.
At age 71 I suspect Trump and his cronies being rich think that they are immune from infection and would like to Dispose of my generation for economic reasons ; less SSI taxes and fewer ‘useless mouths’ to feed. We saw this in Ronald Reagan re HIV and 3d World infection. S Africa is 40% Black infected, thousand of orphaned children and a very ruined economy. Only when his friend Rock Hudson was infected did he act. Trump is the same as he forgets his old pal Roy Cohen did of infection.
This article is scientificly premature and morally Bankrupt.
Current deaths, worldwide 20,000
Doubles every 5-6 days
Expected deaths in 55 days: 20 million (10 doublings)
15% of closed cases resulted in death
https://www.worldometers.info/coronavirus/
Death rate is calculated from graph.
@ adamdalgliesh:
“They both refute the accuracy of these statistics.”
They seem to imply that total lockdowns are unjustified while STILL claiming that the measures to “protect” the elderly are sensible.
I think this is intellectually dishonest and cowardly if not worse.
Are the elderly subhuman that they are allowed to be treated like lepers?
Nobody thinks of “protecting” the older people (starting at what age?) against the common flu, and if this coronavirus is no more dangerous, then there is no justification in treating the elderly worse than animals.
BTW, if someone is capable of STANDING in line for EMERGENCY care, are they experiencing a true emergency?
@ adamdalgliesh:
Adam as I told you before I am not interested in your opinion on this topic. No need to address any comments to me as I am not reading your posts.
@ Bear Klein: See my reply to Michael, and read Drs. Ben-David and Battacharya’s articlle more carefully. They both refute the accuracy of these statistics.
@ Michael S: Totally illogical. In fact, there is no scientific evidence that there is a “coronavirus disease” that is separate and distinct from other diseases. COVID-19is a virus, not a disease. The symptoms of “coronavirus “are identical to, and typical of, those of influenza, bronchitis or pneumonia.
The fact that a particular virus is in one’s system is not proof or even evidence that that is what is making you sick. Dr. Shiva Ayyadurai points out that millions, even billions, of different viruses are present in our bodies at any one time. Also, an equally large number of bacteria. That means that even if COVID-19 is present in one’s body, there are numerous other microbes that could be causing one to become sick. In order to determine whether “coronvirus victims” have been made sick by COVID-19 or other microbes, one would have to test not only for COVID-19 but for other known pathogens in the bodies of sick people, and then make a comparative study of which microbe or microbes are in the systems of the largest number of people who are sick.
In other words, one would have to check for possible other possible causes before concluding that it is the coronavirus that is making people sick. No one has done this. Without a thorough comparative study,the reported coronavirus death rate, and even the the alleged number of coronavirus “cases,” are without any factual or evidentiary basis.
And for these meaningless statistics we are shutting down our country and locking up tens of millions of people? Madness.
The coronavirus has primarily struck in four places:
1. Europe
2. China
3. Iran
4. the US, in that order
Worldwide, on average, them number of deaths doubles every 6 days. Of the cases that have been “resolved”, 85% result in recovery and 15% in death.
19,600 have died as I write this. That should double to ~40,000 in six days, and double five thimes to 640,000 in a month. If the pandemic keeps on at the current rate for six weeks, that will increase to about 3 million dead.
Hot and humid places like Africa and India have not been hit very hard so far, so it may be that the virus will abate when hot, humid weather arrives — as, in fact, happens with most viral infections. Even so, it’s safe to predict that millions will die from COVID-19.
A few observations that might help:
1. The crude death rate for the world, from all causes, is about 8% per year, or about 2% per quarter. X 8 billion people, that comes to 160 million. Obviously, only a fraction of these will die from coronavirus in the next few months.
2. Even though death is always near us, most Westerners are not accustomed to “kill-offs” of this magnitude. The 2014-2016 Ebola outbreak caused only 11,000 deaths, mostly in three African countries. The Rwanda genocide killed 500,000 to a million. The Cambodia genocide killed 1.5 million to 2 million. COVID-19 may very well kill more than this.
3. World War II killed some 70-85 million people, over six years. It was brought under control by a herculean effort by people applying themselves and not panicking. That is probably the most practical way to approach the current crisis.
4. Plagues are sent from God, on purpose, for good reasons. It was by recognizing this fact, and acting upon it, that King David was able to stay a rapidly growing plague in Israel. 70,000 died then. The story is in 2 Samuel 24:15.
The numbers are just starting to grow rapidly in the US. Starting in various hot spots like NY City were they hospital system can no longer function normally.
United States
Coronavirus Cases:
54,941
Deaths:
784
Recovered:
379
The death curve is rising steeply by the day. 50 per day 4 days ago (march 20) and now up to over 225 per day (march 24)
See full stats in US per state and total at plus graphs showing steep rise in deaths.
https://www.worldometers.info/coronavirus/country/us/