CFR, IFR, and You: What is the true COVID-19 death rate?
Approximately 6 months off from the official start of the COVID-19 outbreak in China (although the actual start of the outbreak is debated) and over 3 months from the initial nationwide shutdown in the United States, there is much uncertainty as to the true mortality rate of the disease. It is first important to define terms, as there are different types of “mortality” or “fatality” rates.
Defining Case Fatality Rate vs. Infection Fatality Rate
As shown in Figure 1, the reported number of COVID-19 cases does not necessarily represent the true number of infected individuals. The confirmed number of cases (positive tests for active infection) is smaller than the number of probable infected (sick patients believed to be infected based on symptoms and likely exposure but who never received a diagnostic test), which is smaller than the actual number of total infected individuals.
A case fatality rate (CFR) is the proportion of deaths from a disease compared to the total number of people diagnosed.
An infection fatality rate (IFR) is the proportion of deaths among all infected individuals, in other words the true fatality rate. While related to the CFR, an IFR attempts to estimate the mortality rate including non-diagnosed cases (e.g. not tested, asymptomatic). An IFR should be lower than the CFR, since the denominator would be expected to be larger.
Visually, these can be represented as shown in Figure 2 below, based on the relative differences in confirmed vs. total cases as shown in Figure 1. Note that deaths can be scored as either confirmed deaths or probable deaths. As testing becomes more widespread, the difference between “confirmed” and “total” infected shrinks, as does the difference between CFR and IFR.
There is variability in reported mortality rates
Reporting of fatality rate (or mortality rate) often does not distinguish between CFR and IFR, which contributes to the uncertainty. Initial data from the outbreak in China suggested a mortality rate of 2% which was later updated to 3.4% as of March. It is likely that there will not ever be a fully accurate IFR because the reported mortality rates vary greatly across demographics, age groups, and countries. It is well-understood that like many diseases, including influenza, the fatality rate increases exponentially with age. Original data from China reported IFR ranging from 0.2% in 10 to 39 year olds to 14.8% for those over 80, as shown in Figure 3.
Data from New York City in May shows that 49% of deaths are from individuals 75 and older, with 22% of deaths coming from 45–64 year-olds and 25% from 65–75 year-olds. Only 4.5% of deaths were under 45, and interestingly both the China and NYC data show that mortality is almost completely absent for young children. 75% of COVID-19 deaths in NYC were associated with a known relevant underlying condition.
What has especially made pinning down the COVID-19 fatality rate has been the extremely large variance across the world in CFR. Data from May 9th shows that CFR varied from a minuscule 0.1% in Singapore to 6% in the U.S. to a staggering 16.3% in Belgium. It is likely that at least a significant contributor to the differences in CFR across countries (or across states in the U.S.) is incomplete testing. Several studies show the rate of asymptomatic cases between ~40% and 80%, implying that the number cases could be undercounted by 2–5x (and therefore the IFR could be substantially lower than the CFR). Even that adjustment may be an underestimate, since many people with only mild to moderate symptoms are also likely to not have been tested, especially earlier in the crisis when accessibility to testing was more restricted, at least in the U.S. On the other hand, limited access to testing could also result in undercounting of deaths, since it is likely that many sick individuals have died without ever receiving formal COVID -19 diagnoses.
Antibody Testing Results Must Be Interpreted With Caution
A potential answer to solving the “IFR gap” is the promise of widespread antibody testing. Unlike the nasal swab for active coronavirus infection, antibody blood tests can identify past infections, as indicated by the presence of active antibodies against the virus (and at least plausible medium-to-long-term immunity). With widespread, accurate antibody testing it may be possible to obtain the true infection rate and therefore better estimate the IFR (for a given population). Until recently however, antibody testing has been of poor quality with little to no regulation. The accuracy of any diagnostic test is determined by the sensitivity (or absence of false negatives) and specificity (absence of false positives). For active coronavirus tests a high sensitivity is very important, because it would be dangerous for tested individuals to believe they are uninfected while they were in fact a risk to others. In contrast, for antibody tests the specificity rate is more important, because a false positive would infer a faulty sense of immunity. Due to a quirk of statistics, the true accuracy of a test result is not only dependent on the test itself but also the prevalence in the population. While the false positive/negative rate is inherent to the test, the relative likelihood that a test result is correct is directly related to the population prevalence (how widespread the disease actually is).
As an example (shown in Figure 4): If a test has a specificity of 95% (meaning a 5% false positive rate), if only 5% of the population was truly infected then there is actually over a 50% chance that a positive antibody result will be incorrect. This is because out of a population of 100 people, if only 5 actually had COVID-19 and 95 did not, then even though only approximately 5 out of 95 will receive a false positive test, the individuals cannot possibly know if they are one of the 5 true positives or the 5 false positives. If prevalence is higher, the relative population of true negatives is smaller and therefore a positive test is more likely to be correct (Figure 5).
This can lead to some circular reasoning when attempting to use antibody tests to measure population prevalence, since the percentage of true tests is high only if the true prevalence rate is high (which is unknown). New York State released results from widespread antibody data on May 2nd showing that 12% of the statewide population and 20% of NYC was positive for COVID-19 antibodies. However, at that time many of the tests on the market had a 5% or higher false positive rate. Therefore, at a 5% false positive rate the true prevalence in New York State was likely only 6–7% while at a 10% false positive rate the true prevalence was likely under 4%. Luckily, FDA has since improved oversight of antibody testing and two newer tests from Abbott and Roche claim close to a 0% false positive rate. Nevertheless, results from earlier prevalence studies should be questioned.
COVID-19 is Much More Dangerous Than Flu… By Any Metric
Many critics of the public health response to COVID-19 have cited these antibody studies to claim that the true IFR is over an order of magnitude lower than reported and is therefore similar to influenza. As shown in Figure 6, the COVID-19 mortality rate is 5–12x more deadly across different lifestages compared to the flu based off CDC data from late March (presumably these figures represent CFR, at least for COVID-19). Based on IFR, the relationship still holds, with many COVID-19 IFR estimates (based on the potentially flawed antibody testing data cited above) of 0.5% and up, compared to 0.02% — 0.05% for flu.
Another important comparison often absent from the discussion is the relative hospitalization rates. As an indirect measure, population hospitalization rates over 6 weeks of the COVID-19 pandemic compared to 6 weeks during a flu season suggests that COVID-19 hospitalization rates are 20-times higher. Among confirmed COVID-19 cases, data from late April showed a staggering 13% hospitalization rate, although that number is likely inflated due to reduced testing at the time (only severe cases were able to get tested). In comparison, the previous 3 flu seasons average to a hospitalization rate of 1.6%, almost 10-fold less and mirroring the differences in fatality rate.
What is the actual COVID-19 IFR?
Given all these factors, it may be impossible to pin down a single IFR value that applies to everyone and is consistent across time. Worldometers.info, which is among the best resources for daily tracking of COVID-19 cases across the world and the U.S., attempted to calculate an IFR using NYC antibody data to estimate the amount infected and NYC excess deaths to determine the true deaths from the disease. I already addressed the possibility of antibody data estimating the prevalence of infection, but there are potential issues with the use of excess death as well. Excess death compares the number of deaths above seasonal baseline levels as an indirect measure of deaths from a unique cause. This method was used to estimate excess deaths in Puerto Rico following Hurricane Maria in 2017. The issue with excess deaths is that they are “all-cause”. In other words, they may not represent only deaths directly related to the disease but also indirect mortality. For example, it is possible that a substantial percentage of excess deaths may be due to patients not being admitted to the hospital for unrelated conditions. Therefore these deaths may be attributed to the pandemic, but not to the disease itself.
Worldometers.info combined confirmed deaths, probable deaths (no confirmed positive lab test for the virus, but symptoms and likely exposure suggests COVID-19 was the cause), and excess deaths and compared the sum to the extrapolated estimate of infected NYC residents from antibody data. The result was an estimated IFR of 1.4% (data as of May 1st). A recent publication from early June (not yet peer-reviewed) estimated a median of only 0.25% IFR (with a wide variance) across all age groups with a median of 0.05% for those below 70 years old. The CDC provides a “best estimate” CFR of 0.4% and a calculated IFR of 0.26% (based off assumption of 35% asymptomatic cases) as of late April, very similar to the cited study. On the higher end of the spectrum, a great review article published mid-June in the academic journal Nature covering many of the issues discussed here suggests that most studies appear to converge around an IFR of 0.5–1%, meanwhile a brand new study posted online in mid-June (also not yet peer-reviewed) derived an IFR of 0.64% based on data from Switzerland. That study also derived age-specific (but not risk factor-adjusted) IFRs of 5.6% for adults over 65, 0.14% for those 50–64, and only 0.0092% for ages 20–49.
Conclusions and Long-Term Health Concerns
While there is certainly much remaining uncertainty, the available studies so far (as of the time of publication in late June, 2020) indicate that the COVID-19 IFR is likely ~ 0.25–0.75%. As testing has increased greatly in the past few months, the CFR appears to be approaching the IFR. The U.S. showed a CFR of approximately 6% in early May, while despite a recent surge in cases the daily CFR is now approximately 1% (as of June 22, 2020) and the overall CFR is down to 2.7%. In addition to increased testing, it is also possible that the initial rapid wave of the virus targeted highly susceptible groups especially hard, and therefore they may have been overrepresented in early mortality data. The continuous discovery of somewhat effective treatments for COVID-19 such as remdesavir and dexamethosone also contribute to the decreasing mortality rate over time.
The good news is that it appears COVID-19 may be much less deadly than initially feared. It is still important to note however that both the mortality rate and hospitalization rate appear to be in the range of 10x higher compared to the flu. While influenza is primarily a respiratory disease and patients who recover are back to normal relatively quickly, there is evidence of sustained long-term damage following “recovery” from COVID-19. An additional concern from infection is the potential for “hidden effects” that may not present until years or decades later. SARS-CoC-2 (the virus behind COVID-19) attacks the body through the binding of a receptor called ACE2, which is broadly expressed throughout the body. ACE2 is especially highly expressed in kidney and testis, indicating that otherwise mild or asymptomatic infection could plausibly lead to kidney disease or infertility later in life.
The whole world is going through this crisis together, and we can all help each other by trying to be responsible citizens. Even if we are not a high risk, we may be carriers for others who are. Data suggests that consistent mask-wearing may have a stronger mitigating effect than even originally believed. When combined with social distancing and minimizing crowded indoor interactions, the global effects of COVID-19 can be reduced and we can survive the pandemic as safely as possible.