A potentially explosive new study published on the preprint server medRxiv* in June 2020 suggests that the official Chinese statistics on COVID-19 cases or mortality are neither reliable nor credible. If true, such unreliable data during a crucial period of the pandemic in February and March 2020 could have seriously skewed the response and preparation of the rest of the world and altered the future course of the viral pneumonic illness.
The ongoing pandemic of COVID-19 has taken hundreds of thousands of lives and sickened over 7 million people all over the world in just over five months. Originating in China's Wuhan city, it has rapidly and extensively spread to over 188 countries and territories.
The Credibility Issue
Even as data on infections and mortality continue to pour in, the rapid and sudden decline in China's COVID-19 statistics has raised widespread skepticism. The importance of this data for an epidemiological understanding of the disease, given its origin in China, mandates that accurate figures should be provided. However, the researchers say, "China's COVID-19 statistics fall outside of recognized and accepted medical norms."
The outbreak is estimated to have begun in October 2019 and not in December. Even with the December date, the first report from Wuhan City Health Commission announced that 27 recent cases of pneumonia of unknown origin had been detected. At this point, other official figures and one media report showed over 45,100 cases and 266 cases, respectively.
Moreover, official Chinese state media at the time reported that many cases which may well have been caused by COVID-19 fell through the reporting gaps because private establishments treated them. This, say the researchers, has "led many to believe there may be serious gaps in our understanding of the outbreak based on what can be determined from this official government data."
Modeling for Actual Statistics in China
The researchers from Washington University in St. Louis School of Medicine and Ohio State University gathered their data from COVID-19 figures reported as Chinese government statistics, as well as reports by both official and non-official media, including investigative media reports on the number of cremations in Wuhan.
According to the current study, the infection estimates as of February 7, 2020, fell between 305,000 to 1,272,000, while the death estimates are projected to be between 6,811 to 7,223 for deaths. This is at least ten times the official figure, which is at about 13,600 and 545, respectively.
Data on Crematories
Reports from established media show that whereas the eight crematories in Wuhan operated for about 4 hours a day, on average, before the outbreak, and typically in the morning in keeping with Chinese funeral rituals, a change occurred at around January 25, 2020.
At this point, the crematories were found to be operating almost round the clock or at about six times normal levels. If the normal daily mortality is pegged at about 136, for this population of about 9 million, the increased hours of operation would show an excess of about 680 per day above the normal or a total of about 816 deaths a day. It is to be noted that the maximal cremation capacity is reported to be up to 2,100 bodies a day.
Additional cremation staff are reported to have been imported to Wuhan, as well as 40 mobile cremation stations, which were sent into the city from outside from February 19, 2020, to cope with the increasing need for cremation.
A simple linear estimate showed that at 80% utilization from January 25, 2020, to February 6, 2020, and then 100% until February 12, 2020, the cumulative deaths would be above 9,300. With the crude case fatality rate as officially reported, at 3.14%, the cumulative infection would be almost 300,000 in 19 days.
Data on Funeral Urn Distribution
If the number of funeral urns distributed and the period over which cremation services operated at full capacity operation up to March 23, 2020, are considered, the estimate of the total deaths up to this date reaches 36,000, which is over tenfold the official figure of 2,524. The cumulative infection could potentially be over 700,000. These estimates do not account for the mobile crematories and are likely to be significant under-estimates.
Exponential Growth Model
The researchers then used a model showing an exponential growth rate, from January 23, 2020, when the lockdown began, to the beginning of observed effects at about 15 days later. This is a valid approach provided the assumption made, that lockdown effects will begin to show only after February 7, 2020, is correct.
Beginning with a doubling rate of 6.4 days, a figure of 680 deaths per day on February 7, 2020, and at varying crude case fatality rates of 2.5%, 5%, and 10%, they estimate a cumulative infection in Wuhan of 1,27 million, 650,900 and 305,000 respectively. The number of deaths would be about 7,000 in all cases.
The start dates for the outbreak would be, in such a case, October 4, 2019, October 11, 2019, and October 17, 2019, respectively. If the doubling time is 2.54 days, the start date would be December 14, 2019, but the projected total number of infections would be over 2.2 million by February 7, 2020.
Either the news of the outbreak was significantly delayed and under-reported, in the first scenario, or the official case numbers were reduced by millions, in the second case.
Finally, if China's data on the 39% ratio of infections in Wuhan and China are used, the number of Chinese infections would reach over 5.6 million by February 7, 2020.
Chinese media pointed out the strain on Wuhan's medical resources in January-February 2020, even though the city was reported to have about 90,000 beds by the end of 2018, plus an additional 100,000 beds allotted in hotels and schools by the beginning of February. This ratio of 190,000 available beds to about 33,000 confirmed cases has not been explained.
Neither has the fact that despite the more than 90,000 doctors and other healthcare professionals in Wuhan at the start, another 42,600 were sent in from other provinces, with almost 170,000 ventilators imported to Wuhan, to look after only 50,000 officially reported cases as on March 23, 2020. Earlier researchers have also pointed out mathematically "impossible" COVID-19 figures from China's establishment, estimating that over 85% of infections were not reported and that by February 20, 2020, the number of confirmed cases in China would have been well over 230,000 and not 55,000 as officially reported.
The study's conclusions are limited by the fact that it did not include other causes of excessive death during the lockdown, such as those occurring due to the difficulty in accessing medical treatment of other diseases at this time, the financial stress, and lack of support for emotional and social needs.
Nonetheless, the researchers conclude that official reports of COVID-19 cases and deaths from China are lopsided, with a huge discrepancy between the cremation-based estimates prepared in the current study and the Chinese official figures available in early February.
The significance of this is grave since the period from February to the end of March was a critical one with respect to preparing for an adequate response to the worldwide spread of the pandemic. The investigators comment that this "suggests the need to reevaluate China's official statistics and consider all available and reasonable data sources for a better understanding of the COVD-19 pandemic."
The study concludes, "The magnitude of the discrepancy between the results from their analysis and China's official figures suggests that the potential impact on the global efforts to control the pandemic is obvious. Transparency in China is of critical importance for the world to learn from this infection and for those in the future."
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
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