Global COVID-19 fatality analysis reveals Hubei-like countries potentially with severe outbreaks
Authors: Boyan Lv, Zhongyan Li, Yajuan Chen, Cheng Long, Xinmiao Fu
Journal: Journal of Infection (2020)

•CFR in Iran in the early stage of the outbreak is highest among all the countries.•CFRs in the USA and Italy are similar to Hubei Province in the early stage.•CFRs in South Korea are similar to outside Hubei, indicating less severity.•Our findings highlight the severity of outbreaks globally, particular in the USA. The outbreak of 2019 novel coronavirus diseases (COVID-19) is ongoing in China,1Tang J.W. Tambyah P.A. Hui D.S.C. Emergence of a novel coronavirus causing respiratory illness from Wuhan, China.Journal of Infection. 2020; https://doi.org/10.1016/j.jinf.2020.01.014Abstract Full Text Full Text PDF Scopus (113) Google Scholar but appears to reach late stage and also just starts to devastate other countries.2WHO: Coronavirus disease (COVID-19) outbreak. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019.Google Scholar As of 13 March 2020, there have been 80991 confirmed COVID-19 cases and 3180 deaths in China, much higher than those outside China with 51767 confirmed cases and 1775 deaths.3WHO: Coronavirus disease (COVID-2019) situation reports, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/.Google Scholar However, the daily increase in COVID-19 cases outside China has greatly surpassed that inside China3WHO: Coronavirus disease (COVID-2019) situation reports, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/.Google Scholar (over 7000 verse 11 on 13 March), and therefore people raise deep concerns about the outbreaks outside China. Here we attempted to uncover their characteristics by comparative analysis on crude fatality ratios (CFRs). We collected data of the officially released cumulative numbers of confirmed cases and deaths (from 23 January to 13 March 2020) with respect to mainland China, epicenter of the outbreak (i.e., Hubei Province and Wuhan City), outside Hubei (in China) and outside Wuhan (in Hubei), as well as to typical countries reported with a substantial number of deaths including South Korea, Japan, Iran, Italy, USA, France and Spain (Fig. 1). CFRs in Hubei and Wuhan are significantly higher than those outside Hubei and outside Wuhan, and they are relatively higher in the early stage of outbreaks than in the late stage (Fig. 1A), in line with earlier comprehensive reports by China CDC and WHO.4Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf. 2020.Google Scholar,5The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020, http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51, in China CDC Weekly.Google Scholar The outbreaks outside China are overall lagging approximately one month behind China (Fig. 1B vs Fig. 1A). CFR in Iran in the early stage (from 21 February to late March) is extremely high while CFR in Korea is low and stable over time. Notably, CFR in Iran has significantly decreased since 2 March while CFR in Italy increased a lot in the past 10 days. Next, we performed comparative statistical analysis on CFRs in a period of 10 days in the early stage of outbreaks between outside China and China. In particular, two periods were set for Iran and Italy in order to fully cover their changing trends (for detail, refer to S1.xls file). Results displayed in Fig. 1C revealed i) CFRs in Iran, Italy and USA in the past ten days are not significantly different from Hubei (P being 0.24, 0.648 and 0.281, respectively); ii) CFR in USA is not significantly different from Wuhan to marginal degree (P being 0.0504); iii) CFR in Iran from 22 February to 2 March is significantly different from any regions of China (p<0.001; Table S1). In view of the detailed P values among all pairs (Table S1), we suppose the ranking for the severity of COVID-19 outbreaks in different countries/regions in terms of CFRs as follows: Iran>Wuhan>Hubei≈USA≈Italy>outside Wuhan ≈Spain≈Japan≈France>South Korea≈outside Hubei. As CFR is defined as the number of deaths (numerator) among the number of confirmed cases (denominator), both increase of numerator and decrease of denominator lead to higher CFR. In Hubei/Wuhan there were neither sufficient COVID-19 test kits for infection identification nor enough beds in hospitals for effective treatments of patients in the early stage of the outbreak.6Pu et al., Corona Virus Disease 2019, a growing threat to children? Journal of Infection, 2020, https://doi.org/10.1016/j.jinf.2020.02.024.Google Scholar These shortages led to numerous transmissions in households, reduced the apparent number of cumulative confirmed cases and caused mild patients without treatments to become severe/critical ones and even die, as implicated by earlier reports.4Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf. 2020.Google Scholar,7Ji Y. et al.Potential association between COVID-19 mortality and healthcare resource availability.Lancet Global Health. 2020; https://doi.org/10.1016/S2214-109X(20)30068-1Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar As such, CFRs in Hubei/Wuhan was relatively high in the early stage.5The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020, http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51, in China CDC Weekly.Google Scholar,7Ji Y. et al.Potential association between COVID-19 mortality and healthcare resource availability.Lancet Global Health. 2020; https://doi.org/10.1016/S2214-109X(20)30068-1Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar Similar CFRs between Hubei and USA/Italy, suggest that these countries may face similar situations at present as Hubei had experienced before. In support of this, recent news reports show that Italy is extremely short of medica resources (beds and acute care equipment) while USA has some problems in COVID-19 testing capacity.8CNN: The US is starting to look like Italy on coronavirus lockdown. It could learn a thing or two https://edition.cnn.com/2020/03/13/americas/coronavirus-us-italy-south-korea-lessons-intl/index.html.Google Scholar In Iran, these problems might be even more severe such that its CFR is extremely high. To fight against the COVDI-19 outbreaks in these Hubei/Wuhan-like countries, governments may need to implement control measures and timely supply medical resources as Hubei/Wuhan had done in the past month.2WHO: Coronavirus disease (COVID-19) outbreak. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019.Google Scholar,4Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf. 2020.Google Scholar This work is support by the National Natural Science Foundation of China (No. 31972918 and 31770830 to XF). Authors declare no conflict of interests. 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