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HOME > Osong Public Health Res Perspect > Volume 11(2); 2020 > Article
Original Article Cross-Country Comparison of Case Fatality Rates of COVID-19/SARS-COV-2
Morteza Abdullatif Khafaie, Fakher Rahim
Osong Public Health and Research Perspectives 2020;11(2):74-80.
DOI: https://doi.org/10.24171/j.phrp.2020.11.2.03
Published online: March 31, 2020
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aSocial Determinants of Health Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

bHealth Research Institute, Research Center of Thalassemia and Hemoglobinopathies, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

• Received: March 13, 2020   • Revised: March 23, 2020   • Accepted: March 23, 2020

Copyright ©2020, Korea Centers for Disease Control and Prevention

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

  • Objectives
    Case fatality rates (CFR) and recovery rates are important readouts during epidemics and pandemics. In this article, an international analysis was performed on the ongoing coronavirus disease 2019 (COVID-19) pandemic.
  • Methods
    Data were retrieved from accurate databases according to the user’s guide of data sources for patient registries, CFR and recovery rates were calculated for each country. A comparison of CFR between countries with total cases ≥ 1,000 was observed for 12th and 23rd March.
  • Results
    Italy’s CFR was the highest of all countries studied for both time points (12th March, 6.22% versus 23rd March, 9.26%). The data showed that even though Italy was the only European country reported on 12rd March, Spain and France had the highest CFR of 6.16 and 4.21%, respectively, on 23rd March, which was strikingly higher than the overall CFR of 3.61%.
  • Conclusion
    Obtaining detailed and accurate medical history from COVID-19 patients, and analyzing CFR alongside the recovery rate, may enable the identification of the highest risk areas so that efficient medical care may be provided. This may lead to the development of point-of-care tools to help clinicians in stratifying patients based on possible requirements in the level of care, to increase the probabilities of survival from COVID-19 disease.
A novel coronavirus has spread through China, originating from the city of Wuhan and has caused many deaths so far. It is a highly contagious virus that has spread rapidly and efficiently. Coronavirus disease 2019 (COVID-19) is caused by a virus (SARS-CoV-2) from the same family as the lethal coronaviruses that caused severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS-CoV). COVID-19 is a relatively large virus (120 nm) and is enveloped, containing a positive-sense single-stranded RNA [1]. The virus is transmitted through direct contact with the infected person’s respiratory droplets (coughing and sneezing), as well as contact with infected surfaces. COVID-19 virus can survive for days on surfaces, but a simple disinfectant can eliminate this [2]. COVID-19 signs and symptoms include fever, cough, and shortness of breath. In more severe cases, infection can lead to pneumonia, serious respiratory problems and ultimately, fatalities. Thousands of people have been reported to have been infected with the virus so far [3]. Apart from China, other cases of the disease, also known as COVID-2, have been reported in several countries, including Thailand, South Korea, Japan, Taiwan, Australia, Iran, and the United States. According to the Worldometer, as of 10th March 2020, there are over 114,430 identified cases of COVID-19 worldwide in 115 countries and territories [1].
Of these 115 countries, South Korea and Iran (outside of China) have the largest epidemic of COVID-19 and Italy, France and Spain are the countries with a major epidemic of COVID-19 in Europe [2]. COVID-19 spreads mainly from person-to-person during the latency period before the symptoms appear [4]. There is much more to learn about the spread and severity of COVID-19. COVID-19 can cause mild flu-like symptoms, including fever, cough, dyspnea, myalgia, and fatigue, while more serious forms can cause severe pneumonia, acute respiratory distress syndrome, septic shock, and organ failure, which can lead to death [5]. Without a vaccine for COVID-19, transmission of the virus can be reduced with early detection and patient quarantine [6]. There is epidemiological and clinical evidence to suggest a number of novel compounds, as well as medicines licensed for other conditions, that appear to have potential efficacy against COVID-19 [7,8]. However, in the absence of a safe and effective vaccine or medicine, reducing viral transmission is the only strategy available where general education, and implementing the appropriate prevention and control is key. Precautions can help suppress the risk of infection, such as washing the hands frequently with soap and water or an alcohol-based disinfectant gel, coughing into the elbow or a folded napkin/tissue, avoiding close contact with those who have symptoms, and self-isolating, but medical help must be sought if difficulty in breathing is experienced [5].
COVID-19 can be diagnosed with diagnostic test kits [9] and imaging techniques such as chest X-ray and pulmonary CT scans that facilitate early diagnosis of pneumonia in patients with COVID-19 [1012].
The case fatality rate (CFR), is a measure of the ability of a pathogen or virus to infect or damage a host in infectious disease and is described as the proportion of deaths within a defined population of interest, i.e. the percentage of cases that result in death [13]. CFRs confers the extent of disease severity and CFR is necessary for setting priorities for public health in targeted interventions to reduce the severity of risk [14]. Initial studies reported an estimation of 3% for the global CFR of COVID-19 [15]. Estimating CFR from country-level data requires assessment of information about the delay between the report of the country-specific cases and death from COVID-19, as well as underestimating and under-reporting of death-related cases, which may not be known. Given the importance of CFR and recovery rate (RR), in this current study the CFR and RR of different countries during a COVID-19 ongoing pandemic was observed using up-to-date country-level data.
1. Source of data and procedure
The data were retrieved from accurate databases including Worldometer 2, WHO 3, the Center of Disease Control and Prevention [16], and the Morbidity and Mortality Weekly Report series (provided from Center of Disease Control and Prevention), according to the user’s guide of data sources for patient registries [17]. Due to the rapid increase in data, the analysis in this study was performed on the 12th and 23rd of March 2020.
Raw data was mapped according to countries and CFR and RR were compared for countries with ≥ 1,000 cases. All countries with < 1,000 cases are presented in supplementary Table 1. A comparison of CFR with different known viral diseases was performed.
2. Measuring the CFR and RR
The formulas below were used to measure CFR and RR.
CFR (%)=(Number of deaths due to COVID-19/Number ofclosed cases of COVID-19)×100RR (%)=(Number of cases recovered from COVID-19/Numberof closed cases of COVID-19)×100
The total number of confirmed cases of COVID-19 was highest in China, followed by Italy and Iran on 12th March, but on 23rd March 2020, total COVID-19 confirmed cases was the highest in China, followed by Italy, USA, and Spain (Table 1). However, Italy’s CFR was the highest on both time points (12th March, 6.22% versus 23rd March, 9.26%). The data showed that Italy was the only European country reported on 12th March, but by the 23rd March 2020, Spain and France had the highest CFR of 6.16 and 4.21%, respectively, which was strikingly higher than the overall CFR of 3.61%. The highest RR was observed in China, with RR values of 76.12% and 89.85% in both analysis time points, respectively, compared with the overall RR of 55.83% and 29.3% on the 12th and 23rd March 2020, respectively.
The highest CFR was observed in Italy, followed by China, Iran, and USA on 12th March, which changed to Italy, Spain, France, Iran, and China on 23rd March (Figure 1). Among European countries, Spain and France also faced an increasing rate of CFR. Although Morocco, Panama, and Iraq showed higher CFR values, there was only a small number of total cases, therefore the results of countries with highest outbreak and total cases of COVID-19 were preferentially reported.
China showed encouraging recovery rates from COVID-19 at both time points (76.12% and 89.85% on 12th and 23rd March 2020, respectively; Figure 2). Although the COVID-19 outbreak has led to high rates of death in other Asian countries such as Iran, the recovery rate may be considered acceptable (34%).
The comparison of CFR between different known infectious and viral diseases was shown in Figure 3. This revealed that the overall clinical concerns of COVID-19 may eventually be more like those of a severe seasonal flu (CFR of approximately 0.1%) or a pandemic flu, rather than SARS or MERS, which have had CFR of approximately 10% and 36%, correspondingly.
This study aimed to observe the CFR of different countries during an ongoing COVID-19 pandemic using recent country-level data, showing that alongside the outbreak of this virus, there is a frame-shift and transition from China (as the first country faced with the outbreak) to other countries in other continents.
The outbreak was declared a public health emergency of international concern on 30th January 2020 [18]. Confronting emerging diseases requires universal cooperation in identifying, controlling, and preventing these diseases. The Center for Disease Control obtained a number of factors to establish a geographic risk assessment for the spread of COVID-19 (Supplementary Figure 1). This may be used for international guidelines for public health decisions and travel-related exposure. For instance, China and Iran were categorized as countries where there was widespread ongoing transmission, with restrictions on entry.
The data from this study supports the fact that the CFR of the COVID-19 pandemic seems to be less than Bird flu, Ebola, SARS, and MERS, but public health concerns remain due to its highly infectious nature, since a large proportion of cases are asymptomatic or mild, which promotes the spread of the disease worldwide. In such situations, the media plays a crucial role in promoting health literacy and advocating limited spread of the disease [19]. Cross-country comparisons of CFR and RR as important indicators of disease characteristics are vital for national and international priority setting and recognizing health system performance. However, many factors can confound the current estimation for CFR and RR of COVID-19, namely, undetected cases or delayed case reporting, which can significantly affect the 2 indicators which are linked with a degree of preparedness and mitigation of both the general public and politicians.
Since the number of cases in the world is increasing in a heterogeneous form, to obtain a better picture for cross-country compression of medical care performance, we require a limiting denominator of CFR and RR to be applied to cases under official medical care with final disease outcome (death/ recovered or discharged).
Death and severity of COVID-19 are associated with age and comorbidities across the world. Especially in countries with the highest outbreaks, such as China, Italy, and Iran, strategies must be employed to ensure that high-risk groups, such as old people and those with other underlying diseases such as diabetes and cancer, received adequate protection from COVID-19. Therefore, early access to medical care when infected is vital for improving chances of survival. Improving medical supplies to countries such as Iran, which is significantly influenced by US punitive policies, can reduce the deterioration of this politically sensitive situation [20].
Furthermore, taking detailed and accurate medical history, and scoring CFR alongside RR, may highlight the highest risk areas, and more efficiently direct the intervention to decrease the spread of the virus globally. This may enable the development of point-of-care tools to help clinicians in stratifying patients, based on possible requirements in the level of care to improve probabilities of survival from COVID-19 disease.
Supplementary Figure 1
Geographic risk assessment for spread of COVID-19.
ophrp-11-74s1.tif
We acknowledge the contribution made by Dr. Asaad Sharhani, Department of Statistics and epidemiology at Ahvaz Jundishapur University of Medical Sciences, in data collection and data management.

Conflicts of Interest

The authors have no conflict of interest to declare.

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Figure 1
The cross-country comparison of case fatality rate (CFR) between different countries (n = 116). The circles showed the countries with highest outbreak and positive cases of COVID-19. Countries with CFR value zero has not been illustrated here.
ophrp-11-74f1.jpg
Figure 2
The cross-country comparison of recovery rate (RR) between different countries (n = 116). The circles showed the countries with highest outbreak and positive cases of COVID-19. Countries with RR value zero has not been illustrated here.
ophrp-11-74f2.jpg
Figure 3
The cross-country comparison of case fatality rate (CFR) between different known infectious and viral diseases (n = 116). The circles showed the estimated value and the reported range of CFR of COVID-19.
ophrp-11-74f3.jpg
Table 1
The comparison of case fatality rate (CFR) and recovery rate (RR) between different countries (n = 116). Only countries with total cases over 1,000 cases depicted (population in million and GDP in trillion USD; n = 116).
Country Population GDP ICU beds per capita Total cases Total deaths Total recovered Active cases Serious, critical Total cases/ 106 population Case fatality rate Recovery response
12th March 2020

China 1,386 12.24 3.6 80,783 3,158 61,493 16,132 4,492 56.1 3.91 76.12
Italy 60.48 1.935 12.5 10,149 631 1,004 8,514 877 167.9 6.22 9.89
Iran 81.16 0.4395 4.2 8,042 291 2,731 5,020 95.7 3.62 33.96
S. Korea 51.47 1.531 10.6 7,755 61 288 7,406 54 151.3 0.79 3.71
France 66.99 2.583 11.6 1,784 33 12 1,739 86 27.3 1.85 0.67
Spain 46.66 1.311 9.7 1,695 36 135 1,524 101 36.3 2.12 7.96
Germany 82.79 3.677 29.2 1,565 2 18 1,545 9 18.7 0.13 1.15
USA 327.2 19.39 34.7 1,010 31 15 964 10 3.1 3.07 1.49
All countries < 1,000 cases --- --- --- 6,442 56 872 5,514 118 --- --- ---
Total --- --- --- 119,225 4,299 66,568 48,358 5,747 15.3 3.61 55.83

23rd March 2020

China 1386 12.24 3.6 81,093 3,270 72,703 5,120 1,749 56 4/03 89/65
Italy 60.48 1.935 12.5 59,138 5,476 7,024 46,638 3,000 978 9/26 11/88
USA 327.2 19.39 34.7 33,563 420 178 32,965 795 101 1/25 0/53
Spain 46.66 1.311 9.7 28,768 1,772 2,575 24,421 1,785 615 6/16 8/95
Germany 82.79 3.677 29.2 24,873 94 266 24,513 23 297 0/38 1/07
Iran 81.16 0.4395 4.2 21,638 1,685 7,913 12,040 258 7/79 36/57
France 66.99 2.583 11.6 16,018 674 2,200 13,144 1,746 245 4/21 13/73
S. Korea 51.47 1.531 10.6 8,961 111 3,166 5,684 59 175 1/24 35/33
Switzerland 8.57 0.6789 11 7,474 98 131 7,245 141 864 1/31 1/75
UK 66.44 2.622 6.6 5,683 281 93 5,309 20 84 4/94 1/64
Netherlands 17.18 0.8262 6.4 4,204 179 2 4,023 354 245 4/26 0/05
Austria 8.822 0.4166 21.8 3,582 16 9 3,557 15 398 0/45 0/25
Belgium 11.4 0.4927 15.9 3,401 75 263 3,063 288 293 2/21 7/73
Norway 5.368 0.3988 8 2,385 7 6 2,372 28 440 0/29 0/25
Sweden 10.12 0.538 5.8 1,934 21 16 1,897 76 191 1/09 0/83
Australia 24.6 1.323 8 1,629 7 88 1,534 11 64 0/43 5/40
Portugal 10.29 0.2176 4.2 1,600 14 5 1,581 26 157 0/88 0/31
Brazil 209.3 2.056 6.7 1,546 25 2 1,519 18 7 1/62 0/13
Canada 37.59 1.653 13.5 1,470 20 14 1,436 1 39 1/36 0/95
Denmark 5.603 0.3249 6.7 1,395 13 1 1,381 42 241 1 0/07
Malaysia 31.62 0.3145 3.7 1,306 10 139 1,157 26 40 1 10/64
Turkey 80.81 0.8511 2.9 1,236 30 1,206 15 2 0/00
Czechia 10.65 0.2157 11.6 1,120 1 6 1,113 19 105 0 0/54
Japan 126.8 4.872 7.3 1,101 41 235 825 49 9 4 21/34
Israel 8.712 0.3509 6.3 1,071 1 37 1,033 18 124 0 3/45
All countries with less than 1,000 cases ---- ---- --- 21,381 324 1,812 19,255 264 --- --- ----

Total ---- ---- --- 337,570 14,665 98,884 224,031 10,553 43.4 4.34 29.29

Only countries with total cases over 1,000 are depicted (population in million and GDP in trillion US dollars).

GDP = gross domestic product; ICU = intensive care unit.

Figure & Data

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    Figure

    PHRP : Osong Public Health and Research Perspectives