COVID19 Death rate estimates: 0.2% – 0.5%

by George Avery, PhD. MPA (Epidemiologist) – (Epidemiology is the study and analysis of the distribution (who, when, and where), patterns and determinants of health and disease conditions in defined populations.)

We are seeing a panic reaction towards the newly emerged SARS-COVID-2 [Wuhan] epidemic, marked by panic buying of items including the much-joked about toilet paper, drastic action by political figures that often impinges on basic civil rights, and potentially devastating lasting economic impact. Much of this has been fueled by naïve and sensationalist reporting of fatality rates, such as a March 10, 2020 report by the Bloomberg news service that implies that 3.4 – 3.5% of infected individuals die (https://www.bloomberg.com/news/articles/2020-03-09/travel-companies-pull-forecasts-italy-extends-ban-virus-update ). This has caused comparisons to the 1919 Influenza A:H1N1 pandemic and its 2.5% case fatality rate, which would qualify as a level 5 event on the CDC’s Pandemic Severity Index (PSI) and has led to a panicked overreaction worldwide. This case fatality rate, however, to a trained epidemiologist is obviously a significant overestimation of the actual fatality rate from the disease.

Ascertainment bias is a systematic error in statistical estimation of a population parameter resulting from errors in measurement – usually, in under measurement of a parameter. In this case, we are underestimating the actual number of cases in the population, which is the denominator in the calculation of the estimated case fatality rate. We are accurately estimating deaths, but to get the case fatality rate, we divide deaths by our estimate of the number of cases. Because that it too low due to measurement error, the estimate of the case fatality rate is too high.

For example, for a hypothetical disease if we have three deaths and observed ten cases, then the case fatality rate is 30% (3/10=0.3 or 30%). If, however, there were actually 300 cases, and only 10 were observed and reported, ascertainment bias has led us to underestimate the cases and overestimate the case fatality rate, which is actually 1% (3/300=0.01 or 1%).

In this case, in the absence of population-based screening to more actually estimate the total number of cases, we are only counting cases who are sick enough to seek health care — almost all disease reports are made by healthcare professionals. We are missing people who have no more than a cold or who are infected but show no symptoms, individuals who almost certainly make up the overwhelming majority of actual cases. Thus, as in my hypothetical example, we are overestimating the case fatality rate for the disease.

There is, however, data available on SARS-COVID-2 [Wuhan] that allows us to get a better grasp on the actual case fatality rates for the virus.

One case is that of the cruise ship Diamond Princess, which achieved some notoriety from the well-publicized outbreak among its 3711 passengers and crew in January and February of 2006. Held aboard in constricted quarters, the population was subject to 3068 polymerase chain reaction (pcr) tests, which identified 634 individuals (17%) as infected, with over half of these infections (328) producing no symptoms. Seven infected passengers died, all of them over the age of 70. Adjusting the data for age, researchers at the London Institute of Tropical Medicine have estimated a fatality rate per infection (IFR) for the epidemic in China of 0.5% (95% CI: 0.2-1.2%) during the same period. This is far below the earlier estimates of 3.4% or greater that were promoting panic over the epidemic. See Russell et al, Estimating the infection and case fatality ratio for COVID-19 using age-adjusted data from the outbreak on the Diamond Princess cruise ship, MedRXIV 2020 at https://www.medrxiv.org/content/10.1101/2020.03.05.20031773v2.full.pdf .

South Korea has also implemented far wider population-based screening than the US, expanding their screening past suspected cases to voluntary population screening in geographies frequented by identified cases. As of March 15, as Stanford University economist Richard Epstein has noted, they performed over 235,000 tests and identified 8, 162 infections with 75 deaths (CFR=0.91%). Again, only about 10% of the deaths were in the population under the age of 60. See https://www.hoover.org/research/coronavirus-isnt-pandemic .

While their population screening efforts were far better than that of the United States, this was still not a broad-based screening effort (such as was used on the Diamond Princess), being biased because while it looked at a broader population, it still was enriched with cases by looking only at a segment of the population with a higher risk. Still, the case fatality rate is significantly below the 3.4% rate that caused the public panic.

What we are likely seeing, in my estimation, is an epidemic with a real case fatality rate between 0.2 and 0.5%, which is similar to the 1957 Asian Influenza A:H2N2 or 1968 Hong Kong Influenza A:H3N2 pandemics, which were also essentially virgin field respiratory epidemics. These pandemics rate, not as PSI5 events, but as PSI2 events on the CDC scale. They are certainly atypical and more severe than a PSI1 event (such as a routine seasonal flu epidemic), but not a shattering event like the 1919 influenza A:H1N1 pandemic. These earlier pandemics essentially tripled the number of deaths due to influenza experienced annually, and were posed little long-term economic or other damage to the population despite being handled without the extreme measures that are currently being adopted or proposed by political figures. Like those pandemic events, SARS-COVID-2 [Wuhan] has its most significant impact on elderly or otherwise compromised individuals, with few fatalities observed in the population under the age of 60. From what we have observed, half of those infected show no symptoms, 40% show mild symptoms such as a cold, and only about 2% advance to serious or critical illness. What is needed now is for politicians and the population to pause, take a deep breath, and address the epidemic with rational measures, such as social distancing of the older population, ring screening around identified cases, quarantine of identified infected individuals, and adequate hospital triage systems to protect other patients and health care staff from infection in order to preserve our ability to treat the most severe cases. This is a strategy identified by myself and colleagues at Purdue in 2007 to ensure adequate capacity to deal with another true influenza pandemic, and it applies to this one as well.


George Avery, PhD. MPA

Dr. Avery has a PhD in Health Services Research from the University of Minnesota School of Public Health, and has conducted significant research in the area of public health emergency preparedness, including five journal articles and two book chapters on the topic. He has served on several CDC advisory boards, including a panel on preparedness and emergency response centers, and consulted for the Defense Department on Medical Civic Action program doctrine. He has edited a special issue of the research journal Bioterrorism and Biodefense and served as a reviewer for the Journal of Homeland Security and Emergency Management as well as Disaster Medicine and Public Health. He is a health services researcher with a medical analytics firm in the Midwest, and has formerly been a professor with the public health program at Purdue and worked from 1990-2000 with the Arkansas Department of Health’s Division of Public Health Laboratories.


Note by Jason Hommel.

I found George Avery because he commented on the following article: https://www.thecollegefix.com/stanford-epidemiologist-warns-that-coronavirus-crackdown-is-based-on-bad-data/

Another Doctor said that article was very important, and so was George Avery’s comment. This other doctor said I should try to find and reach out to George Avery for further comment. George had written:

George Avery 

I am an epidemiologist and health services researcher, one with particular expertise and experience in public health emergency preparedness. I have been saying the same thing as John – I spoke for about 45 minutes last week with a reporter from ProPublica, trying to explain the concept of ascertainment bias and why the case fatality rates being tossed about were horribly exaggerated. Frankly, the real impact from a health standpoint in the US was likely to be no worse than the 1956 or 1968 influenza epidemics, even without the extreme measures. In fact, we are reaching a point where the long-term damage from the panic-driven response may well be worse than the impact of the disease.

12 replies on “COVID19 Death rate estimates: 0.2% – 0.5%”

  1. Trump announced on TV about 2 hours ago that the mortality rates are under 1%, and so no longer a threat like it would be if it was 5%.

  2. Germany’s low coronavirus mortality rate intrigues experts
    Some query data methodology while others say high testing rates are giving more accurate picture

    This means Germany currently has the lowest mortality rate of the 10 countries most severely hit by the pandemic: 0.3% compared with 9% in Italy and 4.6% in the UK.

    https://www.theguardian.com/world/2020/mar/22/germany-low-coronavirus-mortality-rate-puzzles-experts

    Right. The more “non deathly ill” people you test, and with a test that gives a lot of false positives, you have a lower death rate. The virus is not spreading, they are simply detecting more false positives among the generally healthy population.

  3. The CDC is engaged in selection bias, as is evidenced at their own page, with their guidelines to only test the sick.

    “Should I be testing all patients for COVID-19?

    Clinicians should base their decisions on whether a patient should be tested for COVID-19 on:

    Signs and symptoms,
    Local epidemiology, and
    If the patient has had close contact with a confirmed COVID-19 patient or a history of travel from an area with sustained transmission within 14 days of symptom onset.”
    https://www.cdc.gov/coronavirus/2019-ncov/lab/tool-virus-requests.html

  4. As said at the link above, comorbidities, or previous chronic conditions, will cause a falsely increased “death rate”.

    “There may be increased rates of smoking or comorbidities amongst the fatalities.”
    https://www.cebm.net/global-covid-19-case-fatality-rates/

    Here are two articles that show that 99% of Italy’s COVID19 cases suffered from old age, and other co morbid chronic conditions. They were both old and very sick.

    Italy just announced that only 2 out of 100 people died “from coronavirus” with no other co morbidity problems (even if we could trust the test kits, which we can not).

    Rome, 13 Mar 19:12 – (Agenzia Nova) – There may be only two people who died from coronavirus in Italy, who did not present other pathologies. This is what emerges from the medical records examined so far by the Higher Institute of Health, according to what was reported by the President of the Institute, Silvio Brusaferro, during the press conference held today at the Civil Protection in Rome. “Positive deceased patients have an average of over 80 years – 80.3 to be exact – and are essentially predominantly male,” said Brusaferro. “Women are 25.8 percent. The average age of the deceased is significantly higher than the other positive ones. The age groups over 70, with a peak between 80 and 89 years. The majority of these people are carriers of chronic diseases. Only two people were not presently carriers of diseases “, but even in these two cases, the examination of the files is not concluded and therefore, causes of death different from Covid-19 could emerge. The president of the ISS has specified that “little more than a hundred medical records” have so far come from hospitals throughout Italy.

    These are the first minimum detailed data provided so far by the Civil Protection on the causes of death of coronavirus patients. At present, in fact, the authorities are unable to distinguish those who died from the virus, from those who, on the other hand, are communicated daily to the public, but who were mostly carriers of other serious diseases and who, therefore, would not have died from Covid-19. In response to a question from “Agenzia Nova”, in fact, Brusaferro was unable to indicate the exact number of coronavirus deaths. However, the professor clarified that, according to the data analyzed, the great majority of the victims “had serious pathologies and in some cases the onset of an infection of the respiratory tract can lead more easily to death. To clarify this point , and provide real data, “as we acquire the folders we will go further. However, the populations most at risk are fragile, carriers of multiple diseases “. (Rin) © Agenzia Nova – Reproduction reserved

    https://translate.google.com/translate?hl=en&sl=auto&tl=en&u=https%3A%2F%2Fwww.agenzianova.com%2Fa%2F5e6bcf1da7fbe3.23491954%2F2851060%2F2020-03-13%2Fcoronavirus-iss-in-italia-i-decessi-accertati-finora-per-causa-del-covid-19-sono-solo-due

    —–AND—-

    Bloomberg confirms the story: https://www.bloomberg.com/news/articles/2020-03-18/99-of-those-who-died-from-virus-had-other-illness-italy-says?utm_campaign=pol&utm_medium=bd&utm_source=applenews&fbclid=IwAR0tcRdVnhFZ0EIHCiVWFj9yLL8e6HBEgxe4FV5s6aYVSXpiBGx-vwpcwk8

    “More than 99% of Italy’s coronavirus fatalities were people who suffered from previous medical conditions, according to a study by the country’s national health authority.”

    “The Rome-based institute has examined medical records of about 18% of the country’s coronavirus fatalities, finding that just three victims, or 0.8% of the total, had no previous pathology. Almost half of the victims suffered from at least three prior illnesses and about a fourth had either one or two previous conditions.

    More than 75% had high blood pressure, about 35% had diabetes and a third suffered from heart disease.”

    —–AND—–
    The overall death rate is not increasing, even with 800 deaths in a day and 650 deaths the next day. But this should increase the death rate if this is a new disease.

    “Important reference values include the number of annual flu deaths, which is up to 8,000 in Italy and up to 60,000 in the US; normal overall mortality, which in Italy is up to 2,000 deaths per day; and the average number of pneumonia cases per year, which in Italy is over 120,000.

    Current all-cause mortality in Europe and in Italy is still normal or even below-average. ” Source: https://swprs.org/a-swiss-doctor-on-covid-19/

    1. And if the overall death rate is not increasing, and if 99% of COVID19 deaths are people suffering from comorbid conditions, then it appears as if the death rate is even lower than that estimated in the headline of this article. It is likely that 99% of the COVID19 deaths are simply re-classifications, and not true COVID19 deaths at all.

  5. Dr. Fauci now says the death rate may actually be 0.1%!!!

    Covid-19 — Navigating the Uncharted
    List of authors.
    Anthony S. Fauci, M.D.
    https://www.nejm.org/doi/full/10.1056/NEJMe2002387

    “If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively”

  6. By assuming COVID19 death, it’s overclassifying deaths as from COVID19, and they are deliberately attempting to artificially increase the death rate.

    Reportedly, this is guidance from the CDC, and it’s like this in every state, not just Hawaii. This is from Hawaii:

    ” It is important to emphasize that Coronavirus Disease 2019 or COVID-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death.”
    https://health.hawaii.gov/vitalrecords/guidance-for-certifying-covid-19-deaths/

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