H5N1

Worldometer: COVID-19 on Tuesday night (and the wisdom of Josef Stalin)

A screenshot: Coronavirus Update (Live): 858,669 Cases and 42,151 Deaths from COVID-19 Virus Outbreak.

That's an increase in 24 hours of 72,957 cases and 4,337 deaths.

 

As Josef Stalin famously observed, "One death is a tragedy. A million deaths are a statistic." As the case numbers grow, they become more abstract. I will try to pay less attention to the count and more to the response—to what people and governments are doing or not doing.

 

Future historians of this pandemic will have some crude estimate of the final toll, but it will be about as precise as those we read for the Spanish flu: 50 to 100 million, give or take a few million. Just statistics, like the 4,337 tragedies we have endured in the past 24 hours.

Covid-19 in the DRC: Bulletin 8, Tuesday 31 March 2020

CMR has published Covid-19 : Bulletin n°8 Mardi, le 31 mars 2020. Excerpt from the Google translation

COVID-19 EPIDEMIOLOGICAL SITUATION IN KINSHASA, ITURI, SOUTH AND NORTH KIVU AS AT 31 MARCH 2020  

Tuesday, 31 March 2020   

•  Since the start of the epidemic declared on March 10, 2020, the cumulative total is 109 confirmed cases. In total, there were 8 deaths. 

• 11 New confirmed cases, including: 

o 7  in Kinshasa; 

o 4 imported.   

Worldometer: COVID-19 on Tuesday afternoon

A screenshot: Coronavirus Update (Live): 856,851 Cases and 42,096 Deaths from COVID-19 Virus Outbreak:

Note that the US has more than doubled China's numbers and will likely triple them within 72 hours. Its overnight numbers almost match the UK's total cases since January 30. We will see a million cases worldwide well before the weekend.

 

Italy and Spain are collapsing, and Iran's numbers are actually beginning to look good by comparison. European countries with good healthcare systems like Belgium and the Netherlands have only triple-digit cases, but also triple-digit deaths.

 

Bear in mind that today's confirmed cases, everywhere in the world, were contracted in mid-March or a little later, and tested positive sometime later. However many people contracted COVID-19 today, we won't know until mid-April.

COVID-19 and the rebounding Chinese economy

Via Caixin Daily: a couple of news items and then a long comment:

China’s March factory outlook jumps as global threat looms  

Chinese manufacturing activity rebounded strongly in March, signaling that the world’s second-largest economy is restarting just as it faces a growing threat from slumping external demand.   

For manufacturing, the official purchasing managers’ index rose to 52.0 this month, according to data released by the National Bureau of Statistics on Tuesday. That’s up from a record low of 35.7 in February and above the 50 mark that signals improving conditions. The gauge covering services and construction was at 52.3. While the rise indicates better sentiment at Chinese factories, output remains a long way from normal.   

China should just give its people cash, experts say  

Chinese economists have called for the central government to provide direct cash transfers to low-income families as they find it difficult to make ends meet amid the Covid-19 pandemic.   

Since the novel coronavirus broke out in China at the end of last year, millions of people have lost their incomes as factories and stores were shut down to contain the virus. While businesses in the country are now gradually resuming work as the outbreak eases, employment is taking another hit as overseas demand plummets while the virus spreads abroad. 

Export backlogs grow for Chinese ventilator-makers 

The coronavirus pandemic sparked a global hunt for mechanical ventilators. Spurred by soaring global demand and with the local outbreak more or less under control, Chinese ventilator-makers are now shifting their focus from domestic use to the export market.   

In the 10 days starting March 19, China shipped around 1,700 mechanical ventilators to markets outside the country — about half that supplied to domestic hospitals this year, Ministry of Industry and Information Technology (MIIT) official Xu Kemin told a news briefing Monday in Beijing. As of Monday, China took orders for nearly 20,000 of the machines from overseas buyers, and a “large number” of other orders were under negotiation, according to Xu.

Imagine that: I have lived to see socialism advocated as the solution to the problems of communist China! What next, the overthrow of Czar Vladimir Putin and the installation of USSR 2.0?

The resurgence of the Chinese economy can be tracked by its CO2 emissions, as the climate site Carbon Brief has documented. But I can see another problem implicit in these news items: the ventilator gap is being treated by everyone as salvation technology, and if even North Korea could help meet global demand, it would find eager buyers around the world.

 

But what about routine Chinese manufacturing—the ordinary cheap consumer stuff that people line up for at Walmart (while keeping their distance, of course)? Unless global consumers have money in their pockets, China's renewed output will languish in containers on the Shanghai waterfront.

 

Even with oil making shipping costs effectively free, exports make no economic sense if buyers have neither the money nor the desire to spend more than they absolutely have to. Borrow more money to buy the kids Super Squirters and take them on holiday to Mexico? Don't even go there.

 

In the three short months since the first online rumours came out of Wuhan, COVID-19 has shaken the triumphant global economy into rubble. The collapse is ongoing, and the dust will not settle in any foreseeable future. I was born in 1941, when the US and Canada were barely emerging from the Great Depression, and unless COVID-19 picks me off I will live to see the start of the Greater Depression.

 

When advanced societies collapse, they don't go back to hunting and gathering. When the Mayan kings couldn't feed their people, the people overthrew them, deserted the great cities, and went back to village-level subsistence farming. Similarly, we will likely revert to (at a guess) 1920s-style industrial capitalism on a national scale, with tariff barriers and enough 20th-century-level weaponry to discourage foreign adventures against us.

 

That's assuming our reduced emissions ease climate change enough to let us survive foreseeable disasters for the next couple of decades: the wildfires, droughts, floods, and hurricanes...and the violence provoked by those disasters.

 

If the disasters persist regardless, we could be in real trouble. 

Investigating COVID-19: ICIJ African partners warn of looming threat

Via the International Consortium of Investigative Journalist: Investigating the coronavirus: ICIJ African partners warn of looming threat.

There are not enough masks, not enough ventilators, and in some hospitals, not enough healthy nurses and doctors.  

The coronavirus outbreak raging across Europe and North America has exposed planning failures and weaknesses of health systems generally considered the finest in the world. Across much of Africa, in countries with far fewer resources to begin with, the toll of the viral pandemic could be much, much worse, ICIJ partners on the continent say. 

“A patient tsunami would be fatal for Senegal,” said Momar Dieng, a reporter for Ouestaf in the West African nation. 

Dieng and two other ICIJ partners on the continent, Mohamed Kabba in Sierra Leone and Tatenda Prosper Chitagu in Zimbabwe, said their countries are ill equipped to handle a surge of patients needing intensive care – particularly the respiratory therapy the sickest COVID-19 patients require. 

As of Tuesday morning, Senegal had reported 162 coronavirus cases and Madagascar 46. Zimbabwe had recorded eight. Sierra Leone just reported its first case. 

Senegal, one of the most developed countries in West Africa, doesn’t have enough hospitals to begin with, Dieng said. Of those that do exist, only a handful, mostly clustered in Dakar, the capital, have the expertise to care for patients with severe coronavirus symptoms.

Dieng said that as cases mount, he and his colleagues have been limited to conducting interviews by phone or email. Reporting from the field, he said, “is almost impossible because the press is strictly prohibited from entering the centers where the patients are isolated.” 

Sierra Leone, another West African nation, still hasn’t recovered from the Ebola epidemic, which killed more than 3,500 people in 2014 and 2015. 

The government moved early to prevent a coronavirus outbreak, Kabba said. On Feb. 2, it began requiring travelers from any country with more than 50 coronavirus cases to quarantine on entering Sierra Leone, he said. It has since shut down most air travel.  

The health care system, Kabba said, is not prepared for a surge of cases. The Ebola treatment centers are closed and most hospitals can’t accommodate COVID-19 patients, he said. And there has been “no transparency” from the government about how much it is spending to prepare for the pandemic, he said. 

Zimbabwe is in worse shape, said Chitagu, a reporter with Newsday. “Our health system is in shambles,” he said. “The country’s first isolation center in [the capital] Harare, does not have a ventilator, oxygen, running water or even a working socket.”  

Nurses don’t have protective clothing, Chitagu said. Hospitals don’t have drugs. “If there are a lot of people diagnosed with the disease, our hospitals will be overwhelmed,” he said.

Many journalists also don’t have protective gear. “As such, many are keeping their distance, dealing a blow to the nation’s access to information on the disease,” Chitagu said. “For now, many have adopted the attitude of ‘no story worth dying for.’”  

Yet, tragically one has already died. The first officially recorded death caused by COVID-19 in Zimbabwe was Zororo Makamba, a 30-year-old radio and television host, and one of the country’s most prominent journalists.

New China COVID-19 data undercuts reassurances by our health officials

Sorry for the pause in blogging; I've been working on a Tyee piece based on the CMAJ article I linked to this morning. Its author, Dr. Peter Phillips, head of the infectious diseases division of the UBC School of Medicine, kindly cooperated. Here's my take: New China Data Undercuts Reassurances by Our Health Officials. Excerpt:

Every afternoon, B.C.’s Provincial Health Officer Dr. Bonnie Henry and Health Minister Adrian Dix offer a daily update on the COVID-19 situation across the province. Both offer solid performances, calm, frank, and reassuring even when the news is grim. 

But it’s not really news. Each day’s new cases and deaths reflect some fraction of those who were infected up to two long weeks ago. And some of those mid-March cases may have been caused by persons who showed no symptoms but still carried — and shed — the virus that causes COVID-19. 

Dr. Henry downplayed that possibility in a March 31 interview on CBC Radio’s Early Edition, saying a few such cases might exist and might be a “challenge,” but they were not enough to be concerned about.  

Events have already overtaken her reassurances. That same morning, China’s National Health Commission dropped a bombshell: as of Monday, the Chinese are aware of 1,541 asymptomatic COVID-19 carriers in the country, including 205 imported cases. What’s more, China will henceforth report these as active cases and quarantine them and their contacts just like symptomatic cases. 

Public health experts elsewhere in the world might be excused for swearing under their breath about Chinese secrecy; clearly, the National Health Commission has known about such cases for some time without publishing anything about them. But the new revelation helps to explain why everyone in China is wearing a mask, even when the World Health Organization says only symptomatic people should wear them. 

Our own B.C. C.D.C. says the same thing: “It may be less effective to wear a mask in the community when a person is not sick themselves. Masks may give a person a false sense of security and are likely to increase the number of times a person will touch their own face (e.g., to adjust the mask).” 

Big mistake: no masks  

And that also explains why Dr. George Gao, the head of China’s C.D.C., told Science magazine last week that the biggest mistake the West is making is our failure to make everyone wear a mask: “Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others.”  

These developments lend weight to an opinion piece published in CMAJ, the journal of the Canadian Medical Association, on Friday. Its author, Dr. Peter Phillips, is head of the infectious diseases division of the UBC School of Medicine. 

Dr. Phillips is blunt: “Canada’s response to the COVID-19 pandemic is not strong enough. Despite school closures, measures being taken at borders to minimize spread, and social distancing efforts, and despite the recent announcement of $82 billion to support the business community and the economy, more effort is urgently needed. New cases doubled over four days before reaching 1,426 on March 22, which was after a week of containment measures.”  

On March 31, Canada reported 7,474 cases.

Dr. Phillips continues: “Canada’s initial lack of a robust border policy or mandated supervised quarantine program for both incoming travellers and contacts of documented cases has impaired our ability to contain the epidemic here. If the main goal of our response is merely to try to flatten the epidemic curve in order to reduce the extent to which hospitals become overwhelmed, we will fail in Canada.”

Why Canada needs urgent revisions to its COVID-19 response strategy

Via CMAJ Journal, a March 27 opinion piece: Why Canada needs urgent revisions to its COVID-19 response strategy.

Canada’s response to the COVID-19 pandemic is not strong enough. Despite school closures, measures being taken at borders to minimize spread, and social distancing efforts, and despite the recent announcement of $82 billion to support the business community and the economy, more effort is urgently needed. New cases doubled over 4 days before reaching 1,426 on March 22nd, which was after a week of containment measures. Canada’s initial lack of a robust border policy or mandated supervised quarantine program for both incoming travellers and contacts of documented cases has impaired our ability to contain the epidemic here. 

If the main goal of our response is merely to try to flatten the epidemic curve in order to reduce the extent to which hospitals become overwhelmed, we will fail in Canada. Another very important goal must be to reduce the percentage of the population who will ultimately become infected, which has been estimated to between 10% and as high as 60% if there is inadequate containment, resulting in a massive death toll. Lessons from other countries and recent observations need to be urgently incorporated into our national strategy. 

Taiwan’s early and multifaceted response to COVID-19 successfully prevented uncontrolled spread in the community. It included a comprehensive border policy, mandated supervised quarantine utilizing a short text message service (“mHealth”), and rigorous case finding with contact tracing. Taiwan had previously been predicted to have the 2nd largest number of exported cases outside China, given its proximity and number of daily flights, yet only 252 cases have been reported in Taiwan to date (March 26th), putting it well down the league table of cases by country and illustrating the effectiveness of their public health policy. In contrast, Canada was predicted to have the 14th highest number of cases, but now we have 3,579 cases (March 26th) and are right where we were predicted to be. With a multipronged intervention like Taiwan’s it is difficult to determine which components were most important; however, their success so far challenges a popular view that early temporary travel restrictions (which included quarantine) have more negative consequences than benefits and should not be recommended. While Taiwan’s approach may be difficult to emulate in low resource settings, high resource countries like Canada should be able to follow their example. 

Two clear examples of successful responses to major COVID-19 outbreaks, so far, come from China and South Korea. China’s highly efficient response that included what might be considered “draconian measures” is unlikely to be replicated in Canada. However, democratic South Korea managed to largely control its epidemic with an aggressive approach, which has included extensive testing for case finding, extremely detailed contact tracing, plus mandatory supervised quarantine with fines for infractions of up to $2,500 USD. 

Convincing evidence is now emerging that cases may be contagious for days before they develop symptoms. Such evidence highlights a flaw in Canada’s previous program of allowing people returning from countries deemed to be ‘at risk’ (other than Hubei province and Iran) to self-monitor for symptoms, unsupervised and without self-isolation. That program was recently revised on March 12th to include instruction to returning travelers to self-isolate, but it remained neither mandatory nor supervised.  

Recently announced border control measures should help stem the flow of incoming infected travellers, but will do little to flatten the curve of our epidemic without the use of stronger mitigation strategies such as enforcement of social distancing measures, and supervised mandatory quarantine facilitated by the adoption of mobile phone short text message service. Quarantine has been shown to be more effective than self-monitoring for symptoms for infections where transmission can occur before patients become symptomatic. However, Canada’s Quarantine Service likely needs hundreds of additional staff across the country to accomplish this. 

Furthermore, we need to rapidly scale up diagnostic testing. This is already underway but obstacles include limited availability of testing kits from commercial suppliers, and also a shortage of swabs suitable for viral testing. Health messaging has been misleading regarding “who to test”. It should be clarified that although limited access to testing may make it impossible to test travellers with mild COVID-19 compatible symptoms right away, it is essential that such individuals be tested in the near future if we are to be successful in controlling further spread. Modification of the contact tracing protocol is needed to include testing of contacts of cases during the 2 days before the development of symptoms as recommended by the WHO. 

Canada also needs an increase in public health staffing to accommodate the burgeoning case load that greater requirements for testing will deliver. Increased funding targeted to public health and quarantine services will be needed if we are to follow South Korea’s response plan, over and above the $100M announced by the federal government last week, as well as creation of federally co-ordinated task forces and adequate funding (over and above the recently announced $500M) in order to lead efforts to secure adequate human resources, hospital and intensive care unit bed space, ventilators, personal protection equipment, swabs, facilities to house and support those who are infected but do not require hospitalization and whose housing is inadequate for home isolation.

Rapid scanning of global data could ensure that experience from other countries informs and regularly updates the Canadian response plan. Given the accomplishment of South Korea, which, at least so far, has managed to restrict spread to 0.0002% of their population, and which should be considered the gold standard of public health care, we in Canada should aim for nothing less. Even if this goal is ultimately unsuccessful, it will at least buy precious time which may allow for drug or vaccine development, and improving access to critical supplies.

Those who have strong concerns regarding the negative consequences for human rights due to such disruptive mitigation and containment measures should look more closely at the current situation in Italy, which has seen more than 700 deaths today (26th March) and over 600 per day for the past week. Surely the rights of Canadians who are at greatest risk of becoming seriously ill or dying also need to be considered. Our current epidemic curve suggests that we could end up in a similar situation as Italy in the next few weeks, unless major steps are taken to change the course.

The federal government’s reluctance to adopt disruptive measures until very recently reflects a serious underestimation of the gravity of this pandemic. The upfront costs and disruption to both society and the economy associated with a comprehensive containment strategy are considerably less than that related to an uncontrolled outbreak requiring mass community quarantine. The benefits from the important vaccine and drug treatment development initiatives are likely many months to years away. Canada’s government needs to do more and to do it now.

China to include symptom-free COVID-19 carriers in national figures

Just a few minutes ago I heard Dr. Bonnie Henry, BC's chief health officer, say on the radio that some asymptomatic COVID-19 cases might shed virus. This South China Morning Post report indicates the Chinese think otherwise: China to include symptom-free coronavirus carriers in national figures. Excerpt:

China will include asymptomatic coronavirus carriers in its daily figures from Wednesday, its National Health Commission said on Tuesday. 

Officials said the new measures would help to address growing public concerns about the risks of infection with Covid-19, the disease caused by the virus, brought about by these silent carriers. 

The commission added that it already required local health workers to report these cases through the central communicable disease report system. 

The commission also revealed for the first time that as of Monday, there were 1,541 asymptomatic carriers under medical observation in mainland China, including 205 imported cases. 

That compared with 2,161 Covid-19 patients who are still hospitalised and another 183 suspected cases. 

The announcement follows Monday’s meeting of the central government’s Covid-19 leading group chaired by Premier Li Keqiang, who instructed officials to be more proactive in investigating the extent of these silent carriers. 

Classified Chinese government data previously seen by the South China Morning Post suggested that the proportion of silent carriers could be as high as one-third of those who test positive.

The data suggested that by the end of February more than 43,000 people in mainland China had tested positive for Covid-19 but had no immediate symptoms. They were not included in the official tally of confirmed cases. 

Chang Jile, director of the commission’s Disease Prevention and Control Bureau, said on Tuesday that the government would step up screening and investigation of asymptomatic cases. 

“With effect from April 1, we will include reports of asymptomatic cases, any status change and how they are being handled, as part of our daily outbreak updates to address public concern,” Chang said. “We will strengthen our work in monitoring, surveillance, quarantine and the treatment of asymptomatic carriers, and do sampling in key areas to investigate and analyse these carriers.” 

Both symptom-free carriers and their close contacts would be placed under 14-day quarantine, he added. 

In a statement on its website, the commission confirmed that asymptomatic patients could be infectious. 

Without giving exact figures, the statement said there were instances in which close contacts of the silent carriers had become ill with Covid-19, in some cases resulting in a cluster of infections. 

“There are a small number of asymptomatic carriers whose respiratory tract swabs indicated a viral load that was no different from that of confirmed patients,” the commission said. “But some specialists said the asymptomatic carriers may be less infectious because they don’t cough or sneeze.” 

Officials and medical experts have said that droplets are a key transmission route for the coronavirus that has infected more than half a million and killed almost 40,000 people around the world. 

According to commission guidelines, asymptomatic carriers are people without identifiable clinical symptoms such as fever or a cough but who test positive for the new coronavirus. 

Some develop symptoms later while others remain symptom-free after 14 days of observation. 

Chinese hospitals and clinics have had to report asymptomatic cases to local centres for disease prevention and control within two hours of detection. Local CDCs then must investigate close contacts and report to the central surveillance system for communicable diseases within 24 hours.

No time for dilemma: Mass gatherings must be suspended

Via The Lancet: No time for dilemma: mass gatherings must be suspended. One of the authors is Ziad Memish, who used to be the Saudi deputy health minister early in the MERS outbreak. He has been called the "father of mass gathering medicine."

The coronavirus disease 2019 (COVID-19) pandemic places unprecedented pressure on societies and health-care systems around the world. This first pandemic of the 21st century demands internationally unified, cogent, and collective actions by individuals, communities, commercial bodies, institutional systems, and all governments in mitigating its escalating impact. Each day, more countries are closing their borders, repatriating their citizens, and discouraging tourism. Air travel between continents has been largely suspended. 

The main public health preventive advice focuses on hand hygiene and social distancing. The latter is impossible to enforce at mass gatherings. We found the Comment by Brian McCloskey and colleagues, advocating formal risk assessments with a view to permitting mass gatherings in the time of COVID-19, puzzling at the very least. As scientists, we are committed to unrestrained inquiry and dissenting opinion, but advocating a risk assessment for mass gatherings connotes an explicit approval for pending mass gathering activities at a time of an escalating global pandemic.

Advocating such a position is more than mere dissent. Mass gathering researchers have already categorically advocated for the suspension of Umrah and the potential suspension of the Hajj and the Olympic Games. Suggesting that pending mass gatherings such as the Olympics are worthy of risk assessment and could possibly take place at this time countervenes the public health preventive messages of hygiene and social distancing. It sends a misleading message to the public, to policy makers and to various powerful, heavily invested stakeholders. Shortly after writing this Correspondence, the Olympic Games were officially postponed to 2021. 

Certainly, if COVID-19 had remained contained in isolated pockets around the world, such recommendations would be legitimate, but the world is now subjugated by an uncontained pandemic with signs of further escalation. Allowing mass gatherings under these circumstances has the potential to endanger millions of attendees and upon return home also those who remained in their countries of origin. 

Evidence supporting the cancellation of mass gathering exists, as does evidence documenting the failure to contain mass gatherings at the time of pandemic. Saudi Arabia's suspension of the Umrah pilgrimage has been protective, whereas Iran's decision to permit mass gatherings in Mashhad and Qom has been detrimental. 

Additional considerations supporting the cancellation of mass gatherings include reports of significant morbidity among young people, survival of viral particles on innate surfaces, and repeat waves of infections. These considerations are crucial even for mass gatherings of which most attendees are young adults (eg, sports, music). At mass gatherings of mainly older and more vulnerable people with comorbidities (mainly religious), these considerations are even more relevant. Furthermore, the density of the typical mass gathering renders social distancing and continued disinfection of hard surfaces impossible. Outbreaks emanating from mass gatherings can also serve as potent seeds for successive waves of infection through international and regional travel. Finally, even with carefully thought-out mass gatherings, unless the viral evolutionary trajectory of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is determined, premature promotion of mass gatherings can only lead to re-ignition of the pandemic. Although the initial human response can be described as panic at times of crises, complacency quickly sets in. 

As public health leaders, we cannot be seen to permit even any tacit endorsement of a mass gathering during this unprecedented global event. When governments and societal and economic systems are unanimously intensifying efforts toward the economically and personally challenging concept of social distancing, any call to consider mass gatherings sends a diametrically opposing and confusing message to the public. 

Together we must commit all efforts to raise a cogent and unified call to fight the pandemic. Cancelling mass gatherings is traumatic for all stakeholders, but considering the nature of the SARS-CoV-2 virus, the risk of asymptomatic carriage and transmission, the global public health preventive advice of distancing and hand hygiene, and the many remaining unknowns, there is hardly any leeway for choice.

Estimates of the severity of COVID-19 disease: a model-based analysis

Via The Lancet Infectious Diseases: Estimates of the severity of coronavirus disease 2019: a model-based analysis. The summary:

Background 

In the face of rapidly changing data, a range of case fatality ratio estimates for coronavirus disease 2019 (COVID-19) have been produced that differ substantially in magnitude. We aimed to provide robust estimates, accounting for censoring and ascertainment biases. 

Methods 

We collected individual-case data for patients who died from COVID-19 in Hubei, mainland China (reported by national and provincial health commissions to Feb 8, 2020), and for cases outside of mainland China (from government or ministry of health websites and media reports for 37 countries, as well as Hong Kong and Macau, until Feb 25, 2020). These individual-case data were used to estimate the time between onset of symptoms and outcome (death or discharge from hospital). 

We next obtained age-stratified estimates of the case fatality ratio by relating the aggregate distribution of cases to the observed cumulative deaths in China, assuming a constant attack rate by age and adjusting for demography and age-based and location-based under-ascertainment. We also estimated the case fatality ratio from individual line-list data on 1334 cases identified outside of mainland China. Using data on the prevalence of PCR-confirmed cases in international residents repatriated from China, we obtained age-stratified estimates of the infection fatality ratio. Furthermore, data on age-stratified severity in a subset of 3665 cases from China were used to estimate the proportion of infected individuals who are likely to require hospitalisation. 

Findings 

Using data on 24 deaths that occurred in mainland China and 165 recoveries outside of China, we estimated the mean duration from onset of symptoms to death to be 17·8 days (95% credible interval [CrI] 16·9–19·2) and to hospital discharge to be 24·7 days (22·9–28·1). 

In all laboratory confirmed and clinically diagnosed cases from mainland China (n=70 117), we estimated a crude case fatality ratio (adjusted for censoring) of 3·67% (95% CrI 3·56–3·80). However, after further adjusting for demography and under-ascertainment, we obtained a best estimate of the case fatality ratio in China of 1·38% (1·23–1·53), with substantially higher ratios in older age groups (0·32% [0·27–0·38] in those aged <60 years vs 6·4% [5·7–7·2] in those aged ≥60 years), up to 13·4% (11·2–15·9) in those aged 80 years or older. 

Estimates of case fatality ratio from international cases stratified by age were consistent with those from China (parametric estimate 1·4% [0·4–3·5] in those aged <60 years [n=360] and 4·5% [1·8–11·1] in those aged ≥60 years [n=151]). Our estimated overall infection fatality ratio for China was 0·66% (0·39–1·33), with an increasing profile with age. Similarly, estimates of the proportion of infected individuals likely to be hospitalised increased with age up to a maximum of 18·4% (11·0–7·6) in those aged 80 years or older. 

Interpretation 

These early estimates give an indication of the fatality ratio across the spectrum of COVID-19 disease and show a strong age gradient in risk of death.