A systematic review and meta-analysis of published research data on COVID-19 infection-fatality rates

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Highlights

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COVID-19 infection-fatality rate (IFR) is an important statistic for policy about the disease.
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Published estimates vary, with a ‘true’ fatality rate hard to calculate.
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Systematically reviewing the literature and meta-analyzing the results shows an IFR of 0.68% (0.53-0.82%).
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This rate was variable from place to place, with a lower range of 0.17% and a highest estimate of 1.7%.
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Serology studies with a lower risk of bias appeared to demonstrate a higher IFR than those at a higher risk of bias.

Abstract

An important unknown during the COVID-19 pandemic has been the infection-fatality rate (IFR). This differs from the case-fatality rate (CFR) as an estimate of the number of deaths as a proportion of the total number of cases, including those who are mild and asymptomatic. While the CFR is extremely valuable for experts, IFR is increasingly being called for by policy-makers and the lay public as an estimate of the overall mortality from COVID-19.

Methods

Pubmed, Medline, SSRN, and Medrxiv were searched using a set of terms and Boolean operators on 25/04/2020 and re-searched 14/05/2020, 21/05/2020, and 16/06/2020. Articles were screened for inclusion by both authors. Meta-analysis was performed in Stata 15.1 using the metan command, based on IFR and confidence intervals extracted from each study. Google/Google Scholar was used to assess the grey literature relating to government reports.

Results

After exclusions, there were 24 estimates of IFR included in the final meta-analysis, from a wide range of countries, published between February and June 2020.

The meta-analysis demonstrated a point-estimate of IFR of 0.68% (0.53-0.82%) with high heterogeneity (p < 0.001).

Conclusion

Based on a systematic review and meta-analysis of published evidence on COVID-19 until July, 2020, the IFR of the disease across populations is 0.68% (0.53-0.82%). However, due to very high heterogeneity in the meta-analysis, it is difficult to know if this represents a wholly unbiased point estimate. It is likely that, due to age and perhaps underlying comorbidities in the population, different places will experience different IFRs due to the disease. Given issues with mortality recording, it is also likely that this represents an underestimate of the true IFR figure. More research looking at age-stratified IFR is urgently needed to inform policy-making on this front.

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Most cited references 54

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An interactive web-based dashboard to track COVID-19 in real time

Ensheng Dong, Hongru Du, Lauren Gardner (2020)

In December, 2019, a local outbreak of pneumonia of initially unknown cause was detected in Wuhan (Hubei, China), and was quickly determined to be caused by a novel coronavirus, 1 namely severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The outbreak has since spread to every province of mainland China as well as 27 other countries and regions, with more than 70 000 confirmed cases as of Feb 17, 2020. 2 In response to this ongoing public health emergency, we developed an online interactive dashboard, hosted by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, Baltimore, MD, USA, to visualise and track reported cases of coronavirus disease 2019 (COVID-19) in real time. The dashboard, first shared publicly on Jan 22, illustrates the location and number of confirmed COVID-19 cases, deaths, and recoveries for all affected countries. It was developed to provide researchers, public health authorities, and the general public with a user-friendly tool to track the outbreak as it unfolds. All data collected and displayed are made freely available, initially through Google Sheets and now through a GitHub repository, along with the feature layers of the dashboard, which are now included in the Esri Living Atlas. The dashboard reports cases at the province level in China; at the city level in the USA, Australia, and Canada; and at the country level otherwise. During Jan 22–31, all data collection and processing were done manually, and updates were typically done twice a day, morning and night (US Eastern Time). As the outbreak evolved, the manual reporting process became unsustainable; therefore, on Feb 1, we adopted a semi-automated living data stream strategy. Our primary data source is DXY, an online platform run by members of the Chinese medical community, which aggregates local media and government reports to provide cumulative totals of COVID-19 cases in near real time at the province level in China and at the country level otherwise. Every 15 min, the cumulative case counts are updated from DXY for all provinces in China and for other affected countries and regions. For countries and regions outside mainland China (including Hong Kong, Macau, and Taiwan), we found DXY cumulative case counts to frequently lag behind other sources; we therefore manually update these case numbers throughout the day when new cases are identified. To identify new cases, we monitor various Twitter feeds, online news services, and direct communication sent through the dashboard. Before manually updating the dashboard, we confirm the case numbers with regional and local health departments, including the respective centres for disease control and prevention (CDC) of China, Taiwan, and Europe, the Hong Kong Department of Health, the Macau Government, and WHO, as well as city-level and state-level health authorities. For city-level case reports in the USA, Australia, and Canada, which we began reporting on Feb 1, we rely on the US CDC, the government of Canada, the Australian Government Department of Health, and various state or territory health authorities. All manual updates (for countries and regions outside mainland China) are coordinated by a team at Johns Hopkins University. The case data reported on the dashboard aligns with the daily Chinese CDC 3 and WHO situation reports 2 for within and outside of mainland China, respectively (figure ). Furthermore, the dashboard is particularly effective at capturing the timing of the first reported case of COVID-19 in new countries or regions (appendix). With the exception of Australia, Hong Kong, and Italy, the CSSE at Johns Hopkins University has reported newly infected countries ahead of WHO, with Hong Kong and Italy reported within hours of the corresponding WHO situation report. Figure Comparison of COVID-19 case reporting from different sources Daily cumulative case numbers (starting Jan 22, 2020) reported by the Johns Hopkins University Center for Systems Science and Engineering (CSSE), WHO situation reports, and the Chinese Center for Disease Control and Prevention (Chinese CDC) for within (A) and outside (B) mainland China. Given the popularity and impact of the dashboard to date, we plan to continue hosting and managing the tool throughout the entirety of the COVID-19 outbreak and to build out its capabilities to establish a standing tool to monitor and report on future outbreaks. We believe our efforts are crucial to help inform modelling efforts and control measures during the earliest stages of the outbreak.

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The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

Hussin A Rothan, Siddappa Byrareddy (2020)

Coronavirus disease (COVID-19) is caused by SARS-COV2 and represents the causative agent of a potentially fatal disease that is of great global public health concern. Based on the large number of infected people that were exposed to the wet animal market in Wuhan City, China, it is suggested that this is likely the zoonotic origin of COVID-19. Person-to-person transmission of COVID-19 infection led to the isolation of patients that were subsequently administered a variety of treatments. Extensive measures to reduce person-to-person transmission of COVID-19 have been implemented to control the current outbreak. Special attention and efforts to protect or reduce transmission should be applied in susceptible populations including children, health care providers, and elderly people. In this review, we highlights the symptoms, epidemiology, transmission, pathogenesis, phylogenetic analysis and future directions to control the spread of this fatal disease.

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Presumed Asymptomatic Carrier Transmission of COVID-19

Yan Bai, Lingsheng Yao, Tao Wei … (2020)

This study describes possible transmission of novel coronavirus disease 2019 (COVID-19) from an asymptomatic Wuhan resident to 5 family members in Anyang, a Chinese city in the neighboring province of Hubei.

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Author and article information

Journal

Journal ID (nlm-ta): Int J Infect Dis

Journal ID (iso-abbrev): Int. J. Infect. Dis

Title: International Journal of Infectious Diseases

Publisher: Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

ISSN (Print): 1201-9712

ISSN (Electronic): 1878-3511

Publication date PMC-release: 29 September 2020

Publication date (Electronic): 29 September 2020

Affiliations

[a ]Western Sydney Local Health District, United States

[b ]University of Wollongong, United States

[c ]James Cook University, United States

[d ]Tropical Public Health Service, Cairns, United States

Author notes

[* ]Corresponding author at: Western Sydney Local Health District, United States.

Article

Publisher Item ID: S1201-9712(20)32180-9

DOI: 10.1016/j.ijid.2020.09.1464

PMC ID: 7524446

PubMed ID: 33007452

SO-VID: ea50be84-1fcd-4458-be28-b982b685ef3b

License:

Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

History

Date received : 8 July 2020

Date revision received : 20 September 2020

Date accepted : 24 September 2020

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A systematic review and meta-analysis of published research data on COVID-19 infection-fatality rates

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Highlights

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Novel Coronavirus Disease COVID-19

Most cited references 54

An interactive web-based dashboard to track COVID-19 in real time

The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

Presumed Asymptomatic Carrier Transmission of COVID-19

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Cited by 174

Most referenced authors 1,396