Mortality due to COVID-19

Coronavirus disease 2019 (COVID-19) has a relatively low case fatality rate, but the actual numbers of deaths are considerable given the huge scale of the pandemic.[2] As of 28 June 2020, worldwide over 503,000 people have died due to COVID-19, while more than 5.5 million people have recovered.[3] Deaths are ten times more common in those aged over 60 years and those with co-morbidities. Most people affected with the disease recover without any particular treatment. Poor outcomes and mortality are associated with old age, profound disabilities and frailty.[2]

For data on deaths over time by country, see COVID-19 pandemic deaths.
See also: Prognosis of COVID-19
Part of a series on the
COVID-19 pandemic
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Graph showing the confirmed cases (blue), deaths (red) and recoveries (green) of COVID-19 globally.[1]

History

The first confirmed death was in Wuhan on 9 January 2020.[4] The first death outside mainland China occurred in February in the Philippines,[5] and the first death outside Asia was in France on 14 February.[4] By 28 February, outside mainland China, more than a dozen deaths each were recorded in Iran, South Korea, and Italy. By end of March, nearly 100 countries reported deaths due to COVID-19.[6]

Epidemiology

As of April 2020, global death-to-case ratio, the number of deaths attributed to the disease divided by the number of diagnosed cases within the same time frame, is 7% for COVID-19.[7] A large number of cases are undiagnosed, so the actual fatality rate of the disease is likely to be lower than the present death-to-case ratio. In comparison, the case fatality rate for swine flu was between 0.1 and 5.1% ten weeks after the first international alert.[8] The death-to-case ratio is different for different regions.[9] As of June 2020, scientific studies indicate an infection fatality rate (IFR) between 0.5% and 0.9% (in countries where the average age and/or obesity rates are high).[10][11]

Mortality by age

The mortality due to COVID-19 increases with age. The overall death rate from COVID-19 in the UK is 0.0016% in children, while it is 7.8% for those aged over 80.[12]. The majority of victims had serious pre-existing health conditions.

Case fatality rates (%) by age and country
Age
Country 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90+
Argentina as of 7 May[13] 0.0 0.0 0.1 0.4 1.3 3.6 12.9 18.8 28.4
Australia as of 4 June[14] 0.0 0.0 0.0 0.0 0.1 0.2 1.1 4.1 18.1 40.8
Canada as of 3 June[15] 0.0 0.1 0.7 11.2 30.7
     Alberta as of 3 June[16] 0.0 0.0 0.1 0.1 0.1 0.2 1.9 11.9 30.8
     Br. Columbia as of 2 June[17] 0.0 0.0 0.0 0.0 0.5 0.8 4.6 12.3 33.8 33.6
     Ontario as of 3 June[18] 0.0 0.0 0.1 0.2 0.5 1.5 5.6 17.7 26.0 33.3
     Quebec as of 2 June[19] 0.0 0.1 0.1 0.2 1.1 6.1 21.4 30.4 36.1
Chile as of 31 May[20][21] 0.1 0.3 0.7 2.3 7.7 15.6
China as of 11 February[22] 0.0 0.2 0.2 0.2 0.4 1.3 3.6 8.0 14.8
Colombia as of 3 June[23] 0.3 0.0 0.2 0.5 1.6 3.4 9.4 18.1 25.6 35.1
Denmark as of 4 June[24] 0.2 4.1 16.5 28.1 48.2
Finland as of 4 June[25] 0.0 0.0 <0.4 <0.4 <0.5 0.8 3.8 18.1 42.3
Germany as of 5 June[26] 0.0 0.0 0.1 1.9 19.7 31.0
     Bavaria as of 5 June[27] 0.0 0.0 0.1 0.1 0.2 0.9 5.4 15.8 28.0 35.8
Israel as of 3 May[28] 0.0 0.0 0.0 0.9 0.9 3.1 9.7 22.9 30.8 31.3
Italy as of 3 June[29] 0.3 0.0 0.1 0.3 0.9 2.7 10.6 25.9 32.4 29.9
Japan as of 7 May[30] 0.0 0.0 0.0 0.1 0.3 0.6 2.5 6.8 14.8
Mexico as of 3 June[31] 3.3 0.6 1.2 2.9 7.5 15.0 25.3 33.7 40.3 40.6
Netherlands as of 3 June[32] 0.0 0.2 0.1 0.3 0.5 1.7 8.1 25.6 33.3 34.5
Norway as of 4 June[33] 0.0 0.0 0.0 0.0 0.3 0.4 2.2 9.0 22.7 57.0
Philippines as of 4 June[34] 1.6 0.9 0.5 0.8 2.4 5.5 13.2 20.9 31.5
Portugal as of 3 June[35] 0.0 0.0 0.0 0.0 0.3 1.3 3.6 10.5 21.2
South Africa as of 28 May[36] 0.3 0.1 0.1 0.4 1.1 3.8 9.2 15.0 12.3
South Korea as of 15 June[37] 0.0 0.0 0.0 0.2 0.2 0.7 2.6 10.1 25.6
Spain as of 17 May[38] 0.2 0.3 0.2 0.3 0.6 1.4 4.9 14.3 21.0 22.3
Sweden as of 5 June[39] 0.5 0.0 0.2 0.2 0.6 1.7 6.6 23.4 35.6 40.3
Switzerland as of 4 June[40] 0.6 0.0 0.0 0.1 0.1 0.6 3.4 11.6 28.2
United States
     Colorado as of 3 June[41] 0.2 0.2 0.2 0.2 0.8 1.9 6.2 18.5 39.0
     Connecticut as of 3 June[42] 0.2 0.1 0.1 0.3 0.7 1.8 7.0 18.0 31.2
     Georgia as of 3 June[43] 0.0 0.1 0.5 0.9 2.0 6.1 13.2 22.0
     Idaho as of 3 June[44] 0.0 0.0 0.0 0.0 0.0 0.4 3.1 8.9 31.4
     Indiana as of 3 June[45] 0.1 0.1 0.2 0.6 1.8 7.3 17.1 30.2
     Kentucky as of 20 May[46] 0.0 0.0 0.0 0.2 0.5 1.9 5.9 14.2 29.1
     Maryland as of 20 May[47] 0.0 0.1 0.2 0.3 0.7 1.9 6.1 14.6 28.8
     Massachusetts as of 20 May[48] 0.0 0.0 0.1 0.1 0.4 1.5 5.2 16.8 28.9
     Minnesota as of 13 May[49] 0.0 0.0 0.0 0.1 0.3 1.6 5.4 26.9
     Mississippi as of 19 May[50] 0.0 0.1 0.5 0.9 2.1 8.1 16.1 19.4 27.2
     Missouri as of 19 May[51] 0.0 0.0 0.1 0.2 0.8 2.2 6.3 14.3 22.5
     Nevada as of 20 May[52] 0.0 0.3 0.3 0.4 1.7 2.6 7.7 22.3
     N. Hampshire as of 12 May[53] 0.0 0.0 0.4 0.0 1.2 0.0 2.2 12.0 21.2
     Oregon as of 12 May[54] 0.0 0.0 0.0 0.0 0.5 0.8 5.6 12.1 28.9
     Texas as of 20 May[55] 0.0 0.5 0.4 0.3 0.8 2.1 5.5 10.1 30.6
     Virginia as of 19 May[56] 0.0 0.0 0.0 0.1 0.4 1.0 4.4 12.9 24.9
     Washington as of 10 May[57] 0.0 0.2 1.3 9.8 31.2
     Wisconsin as of 20 May[58] 0.0 0.0 0.2 0.2 0.6 2.0 5.0 14.7 19.9 30.4
Case fatality rates (%) by age in the United States
Age 0–19 20–44 45–54 55–64 65–74 75–84 85+
United States as of 16 March[59] 0.0 0.1–0.2 0.5–0.8 1.4–2.6 2.7–4.9 4.3–10.5 10.4–27.3
Note: The lower bound includes all cases. The upper bound excludes cases that were missing data.


Estimated prognosis by age and sex based on cases from France and Diamond Princess ship[60]
Percent of infected people who are hospitalized
0–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Total
Female 0.2
(0.1–0.3)		 0.6
(0.3–0.9)		 1.1
(0.7–1.8)		 1.6
(0.9–2.4)		 3.2
(1.9–4.9)		 6.2
(3.7–9.6)		 9.6
(5.7–14.8)		 23.6
(14.0–36.4)		 3.2
(1.9–5.0)
Male 0.2
(0.1–0.3)		 0.7
(0.4–1.1)		 1.4
(0.9–2.2)		 1.9
(1.1–3.0)		 3.9
(2.3–6.1)		 8.1
(4.8–12.6)		 13.4
(8.0–20.7)		 45.9
(27.3–70.9)		 4.0
(2.4–6.2)
Total 0.2
(0.1–0.3)		 0.6
(0.4–1.0)		 1.3
(0.8–2.0)		 1.7
(1.0–2.7)		 3.5
(2.1–5.4)		 7.1
(4.2–11.0)		 11.3
(6.7–17.5)		 32.0
(19.0–49.4)		 3.6
(2.1–5.6)
Percent of hospitalized people who go to Intensive Care Unit
0–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Total
Female 16.7
(14.4–19.2)		 8.6
(7.5–9.9)		 11.9
(10.9–13.0)		 16.6
(15.6–17.7)		 20.7
(19.8–21.7)		 23.1
(22.2–24.0)		 18.7
(18.0–19.5)		 4.2
(4.0–4.5)		 14.3
(13.9–14.7)
Male 26.9
(23.2–31.0)		 14.0
(12.2–15.9)		 19.2
(17.6–20.9)		 26.9
(25.3–28.5)		 33.4
(32.0–34.8)		 37.3
(36.0–38.6)		 30.2
(29.2–31.3)		 6.8
(6.5–7.2)		 23.1
(22.6–23.6)
Total 22.2
(19.2–25.5)		 11.5
(10.1–13.2)		 15.9
(14.6–17.3)		 22.2
(21.0–23.5)		 27.6
(26.5–28.7)		 30.8
(29.8–31.8)		 24.9
(24.1–25.8)		 5.6
(5.3–5.9)		 19.0
(18.7–19.44)
Percent of hospitalized people who die
0–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Total
Female 0.5
(0.2–1.1)		 0.9
(0.5–1.3)		 1.5
(1.2–1.9)		 2.6
(2.3–3.0)		 5.2
(4.8–5.6)		 10.1
(9.5–10.6)		 16.7
(16.0–17.4)		 25.2
(24.4–26.0)		 14.4
(14.0–14.9)
Male 0.7
(0.3–1.5)		 1.3
(0.8–1.9)		 2.2
(1.7–2.7)		 3.8
(3.4–4.4)		 7.6
(7.0–8.2)		 14.8
(14.1–15.6)		 24.6
(23.7–25.6)		 37.1
(36.1–38.2)		 21.22
(20.8–21.7)
Total 0.6
(0.3–1.3)		 1.1
(0.7–1.6)		 1.9
(1.5–2.3)		 3.3
(2.9–3.7)		 6.5
(6.0–7.0)		 12.6
(12.0–13.2)		 21.0
(20.3–21.8)		 31.6
(30.9–32.4)		 18.1
(17.8–18.4)
Percent of infected people who die – infection fatality rate (IFR)
0–19 20–29 30–39 40–49 50–59 60–69 70–79 80+ Total
Female 0.001
(<0.001–0.002)		 0.005
(0.002–0.009)		 0.02
(0.01–0.03)		 0.04
(0.02–0.07)		 0.2
(0.1–0.3)		 0.6
(0.4–1.0)		 1.6
(1.0–2.5)		 5.9
(3.5–9.2)		 0.5
(0.3–0.7)
Male 0.001
(<0.001–0.003)		 0.008
(0.004–0.02)		 0.03
(0.02–0.05)		 0.07
(0.04–0.1)		 0.3
(0.2–0.5)		 1.2
(0.7–1.9)		 3.3
(2.0–5.1)		 17.1
(10.1–26.3)		 0.8
(0.5–1.3)
Total 0.001
(<0.001–0.002)		 0.007
(0.003–0.01)		 0.02
(0.01–0.04)		 0.06
(0.03–0.09)		 0.2
(0.1–0.36)		 0.9
(0.5–1.4)		 2.4
(1.4–3.7)		 10.1
(6.0–15.6)		 0.7
(0.4–1.0)
Numbers in parentheses are 95% credible intervals for the estimates.


Estimate of infection fatality rates and probability of severe disease course (%) by age based on cases from China[61]
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80+
Severe disease 0.0
(0.0–0.0)		 0.04
(0.02–0.08)		 1.0
(0.62–2.1)		 3.4
(2.0–7.0)		 4.3
(2.5–8.7)		 8.2
(4.9–17)		 11
(7.0–24)		 17
(9.9–34)		 18
(11–38)
Death 0.0016
(0.00016–0.025)		 0.0070
(0.0015–0.050)		 0.031
(0.014–0.092)		 0.084
(0.041–0.19)		 0.16
(0.076–0.32)		 0.60
(0.34–1.3)		 1.9
(1.1–3.9)		 4.3
(2.5–8.4)		 7.8
(3.8–13)
Total infection fatality rate is estimated to be 0.66% (0.39–1.3). Infection fatality rate is fatality per all infected individuals, regardless of whether they were diagnosed or had any symptoms. Numbers in parentheses are 95% credible intervals for the estimates.

Mortality by gender

As of April 2020, men die more often than women after being affected with COVID-19 infection.[62][63][64] The highest risk gap for men is in their 50s, with the gap between men and women closing only at 90.[63] In China, the death rate was 2.8 percent for men and 1.7 percent for women.[63] The exact reasons for this sex-difference is not known, but genetic and behavioural factors could be a reason for this difference.[62] Sex-based immunological differences, lesser prevalence of smoking in women and men developing co-morbid conditions such as hypertension at a younger age than women could have contributed to the higher mortality in men.[63] In Europe, 57% of the infected individuals were men and 72% of those died with COVID-19 were men.[65] As of April 2020, the US government is not tracking sex-related data of COVID-19 infections.[66] Research has shown that viral illnesses like Ebola, HIV, influenza and SARS affect men and women differently.[66]

Mortality in people with co-morbidities

Individuals with comorbidities such as diabetes, hypertension and malignancy had poorer outcomes of treatment following COVID-19 infection.[67][68] In Italy, the most common comorbidities observed in deceased patients were hypertension (69%), diabetes (32%), ischemic heart disease (27%), atrial fibrillation (21%), chronic obstructive pulmonary disease (18%) and active cancer in the last 5 years (16%).[69] In New York state, 86% of deaths from COVID-19 had at least one comorbidity.[70]

Causes for mortality

The main cause of death in people with COVID-19 is respiratory failure, similar to the causes of death in types of flu.[71] In order to promote recovery, invasive mechanical ventilation is recommended until the lungs recover from the injury.[2] Extracorporeal membrane oxygenation can be used if the situation deteriorates further.[2] Other causes of mortality in COVID-19 infection are septic shock and multiple organ failure.[72][73] In Wuhan, about 15% of the patients developed severe pneumonia and 6% needed ventilatory support. In Wuhan, only around 25% of those who died received extracorporeal membrane oxygenation because of shortage of trained staff.[74] The role of secondary bacterial infections in mortality is not well-described in literature.[2] Acute kidney injury, cardiogenic shock due to acute myocardial injury or myocarditis are also causes of death due to COVID-19.[2]

It is difficult to differentiate between those who died due to COVID-19 or as a result of overload of cases in hospitals. Critically ill people infected with COVID-19 could not sometimes be given adequate treatment because of shortage of resources and a part of COVID-19 mortality could be because of insufficient hospital facilities.[75]

Predictors of mortality

Low lymphocyte count, high C-reactive protein and high D-dimer levels are frequently found in non-survivors.[71][72][74] The change of lymphocyte count during the first four days of hospital admission was highly associated with mortality in China.[74]

Mortality by country
Main article: COVID-19 pandemic deaths

The official deaths reported usually do not give accurate numbers because this may ignore those who died without testing, such as at nursing homes or residences.[76] Conversely, in countries with high rates of COVID-19 infection, patients might be admitted to the hospital due to unrelated illnesses, but they could also have COVID-19. When these patients succumb to death due to the initial condition, their deaths are usually attributed to COVID-19 although the actual contribution of COVID-19 to the death is minimal.[2] The measures for quantifying mortality are affected by the time since initial outbreak, population characteristics (prominently, age and gender), quality of healthcare system, availability of treatment options and volume of testing.[77] How COVID-19 deaths are recorded may differ between countries because of the differences in counting them.[78]

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