Estimation of SARS-CoV-2 mortality during the early stages of an epidemic: a modeling study in Hubei, China, and six regions in Europe
Authors: Hauser Anthony , Counotte Michel J. , Margossian Charles C. , Konstantinoudis Garyfallos , Low Nicola , Althaus Christian L. , Riou Julien 
Published: March 2020

AbstractBackgroundAs of 16 May 2020, more than 4.5 million cases and more than 300,000 deaths from disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported. Reliable estimates of mortality from SARS-CoV-2 infection are essential to understand clinical prognosis, plan health care capacity and for epidemic forecasting. The case fatality ratio (CFR), calculated from total numbers of reported cases and reported deaths, is the most commonly reported metric, but can be a misleading measure of overall mortality. The objectives of this study were to: 1) simulate the transmission dynamics of SARS-CoV-2 using publicly available surveillance data; 2) infer estimates of SARS-CoV-2 mortality adjusted for biases and examine the CFR, the symptomatic case fatality ratio (sCFR) and the infection fatality ratio (IFR) in different geographic locations.Method and FindingsWe developed an age-stratified susceptible-exposed-infected-removed (SEIR) compartmental model describing the dynamics of transmission and mortality during the SARS-CoV-2 epidemic. Our model accounts for two biases: preferential ascertainment of severe cases and right-censoring of mortality. We fitted the transmission model to surveillance data from Hubei province, China and applied the same model to six regions in Europe: Austria, Bavaria (Germany), Baden-Württemberg (Germany), Lombardy (Italy), Spain and Switzerland. In Hubei, the baseline estimates were: CFR 2.4% (95% credible interval [CrI]: 2.1-2.8%), sCFR 3.7% (3.2-4.2%) and IFR 2.9% (2.4-3.5%). Estimated measures of mortality changed over time. Across the six locations in Europe estimates of CFR varied widely. Estimates of sCFR and IFR, adjusted for bias, were more similar to each other but still showed some degree of heterogeneity. Estimates of IFR ranged from 0.5% (95% CrI 0.4-0.6%) in Switzerland to 1.4% (1.1-1.6%) in Lombardy, Italy. In all locations, mortality increased with age. Among 80+ year olds, estimates of the IFR suggest that the proportion of all those infected with SARS-CoV-2 who will die ranges from 20% (95% CrI: 16-26%) in Switzerland to 34% (95% CrI: 28-40%) in Spain. A limitation of the model is that count data by date of onset are required and these are not available in all countries.ConclusionsWe propose a comprehensive solution to the estimation of SARS-Cov-2 mortality from surveillance data during outbreaks. The CFR is not a good predictor of overall mortality from SARS-CoV-2 and should not be used for evaluation of policy or comparison across settings. Geographic differences in IFR suggest that a single IFR should not be applied to all settings to estimate the total size of the SARS-CoV-2 epidemic in different countries. The sCFR and IFR, adjusted for right-censoring and preferential ascertainment of severe cases, are measures that can be used to improve and monitor clinical and public health strategies to reduce the deaths from SARS-CoV-2 infection.Author summaryWhy was this study done?Reliable estimates of measures of mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are needed to understand clinical prognosis, plan health care capacity and for epidemic forecasting.The case fatality ratio (CFR), the number of reported deaths divided by the number of reported cases at a specific time point, is the most commonly used metric, but is a biased measure of mortality from SARS-CoV-2 infection.The symptomatic case fatality ratio (sCFR) and overall infection fatality ratio (IFR) are alternative measures of mortality with clinical and public health relevance, which should be investigated further in different geographic locations.What did the researchers do and find?We developed a mathematical model that describes infection transmission and death during a SARS-CoV-2 epidemic. The model takes into account the delay between infection and death and preferential ascertainment of disease in people with severe symptoms, both of which affect the assessment of mortality.We applied the model to data from Hubei province in China, which was the first place affected by SARS-CoV-2, and to six locations in Europe: Austria, Bavaria (Germany), Baden-Württemberg (Germany), Lombardy (Italy), Spain and Switzerland, to estimate the CFR, the sCFR and the IFR.Estimates of sCFR and IFR, adjusted for bias, were similar to each other and varied less geographically than the CFR. IFR was lowest in Switzerland (0.5%) and highest in Hubei province (2.9%). The IFR increased with age; among 80+ year olds, estimates ranged from 20% in Switzerland to 34% in Spain.What do these findings mean?The CFR does not predict overall mortality from SARS-CoV-2 infection well and should not be used for the evaluation of policy or for making comparisons between geographic locations.There are geographic differences in the IFR of SARS-CoV-2, which could result from differences in factors including emergency preparedness and response, and health service capacity.SARS-CoV-2 infection results in substantial mortality. Further studies should investigate ways to reduce death from SARS-CoV-2 in older people and to understand the causes of the differences between countries.