key: cord-0756640-dxkkiezt authors: He, M.; Li, L.; Dehner, L. P.; Dunn, L. title: Cremation based estimates suggest significant under- and delayed reporting of COVID-19 epidemic data in Wuhan and China date: 2020-06-06 journal: nan DOI: 10.1101/2020.05.28.20116012 sha: 31db7e5143727e65c9b57b08646d6b3b61828dea doc_id: 756640 cord_uid: dxkkiezt Background: Epidemiological data provide important information for decision making. COVID-19 statistics from China fall outside of recognized and accepted medical norms. As the epicenter of the COVID-19 initial outbreak, the epidemiological information from Wuhan affects the response and preparation of other parts of China and rest of the world. Here we estimated the incidence, death and starting time of the COVID-19 outbreak in Wuhan and China based on medical literature from China, official and non-official Chinese data sources. Methods: Data sources included literature on COVID-19 in China, official Chinese government figures, state-run and non state-run media reports. Our estimates are based on investigative media reports of crematory operations in Wuhan, which is considered as a common data end point to life. A range of estimates is presented by an exponential growth rate model from lockdown (Jan 23,2020) until the intervention started to show effects, which was estimated 14.5 days after lockdown. Results: For the cumulative infections and total deaths, under different assumptions of death rates (from 2.5% to 10%) and doubling time 6.4 days, the estimates projected on February 7, 2020 in Wuhan range from 305,000 to 1,272,000 for infections and from 6,811 to 7,223 for deaths - on the order of at least 10 times the official figures (13,603 and 545). The implied starting time of the outbreak is October 2019. Under the assumption of the official 3.14% death rate and doubling time of 2.54 days (which was derived based on Chinese official data), the infection cases reached 2.2 million on February 7. The estimates of cumulative deaths, based on both funeral urns distribution and continuous full capacity operation of cremation services up to March 23, 2020, give results around 36,000, more than 10 times of the official death toll of 2,524. Conclusions: Our study indicates a significant under-reporting in Chinese official data on the COVID-19 epidemic in Wuhan. The magnitude of discrepancy between our estimates based on cremation related data and Chinese official figures in early February, the critical time for response to the COVID-19 pandemic, suggests the need to reevaluate official statistics from China and consider all available and reasonable data sources for a better understanding of the COVID-19 pandemic. IV. To extrapolate from the Wuhan cremation data to the total number of infected cases, 126 alternative assumptions of 2.5%, 5%, and 10% were utilized for the case fatality rate. V. Though media reported that Wuhan cremation service operated around the clock since 128 January 25, 2020, 6-12 we assumed no full capacity was utilized until two weeks later, on February 129 7, 2020. This assumption will be further discussed below. The Model Estimates of the total cases were calculated from an exponential growth model. At time . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. . https://doi.org/10.1101/2020.05.28.20116012 doi: medRxiv preprint on 44 th day, that the exponential growth model is unreliable. From the 45 th day, we take into 144 account the declining number of susceptible individuals, and the model was modified (as in the 145 SIR simulation model) so that the relationship ( ) = ( − 1) becomes ( ) = where P is the population size of Wuhan after lock down. The 95% confidence intervals presented in Table 2 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 6, 2020. deaths. We assume that cremation service did not reached 100% utilization until February 7, and 177 the utilization was 80% between January 25 to February 6, 2020. The results of these estimates 178 are listed in Table 3 . Cumulative deaths are 9,384, for the nineteen days (January 25 to February 179 12, 2020) only. Based on the official crude case fatality rate of 3.14% (February 12, 2020, Table 180 1), the estimated cumulative infection was 298,854 within nineteen days (Table 3) . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 6, 2020. . https://doi.org/10.1101/2020.05.28.20116012 doi: medRxiv preprint rate, 20 and under assumption of the crude fatality rates of 2.5%, 5%, and 10%, cumulative Estimates based of a 2.54 day doubling rate are also presented with estimated confidence 189 intervals in Table 3 . Since this doubling time was derived using Chinese official data, we 190 applied the official 3.14% fatality rate in the calculation. The total cases are projected to be 2.23 191 million with 95% confidence interval (2.12 million, 2.38 million) on February 7, 2020. (c) Estimates based on funeral urn distribution No one was allowed to pick up urns during the lockdown. Beginning on March 23, Wuhan residents were allowed to collect crematory urns, with the target date as April 4 to 195 complete the distribution of the backlog. Estimates based urn collection are listed in Table 4 . Estimate of COVID related deaths and cumulative infections in all of China If we use the Wuhan/China ratio based on China's official data listed in Table 1 198 (confirmed cases 39.4%), we can extrapolate estimates for China, with cumulative infections 199 potentially reaching 5.67 million on February 7, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. . https://doi.org/10.1101/2020.05.28.20116012 doi: medRxiv preprint the officially announced figures of the outbreak. As the epicenter of the COVID-19 outbreak, the necessary epidemiological information about Wuhan was not made available n for the world to 206 initiate plans for a response and to prepare for the potential crisis that is now upon us. Challenges for getting needed information in China The strength of this approach is that cremation is a common data end point. We applied . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. . https://doi.org/10.1101/2020.05.28.20116012 doi: medRxiv preprint normal death rate as COVID-19 related. We do not include deaths that would happen on a later 228 date, due to delayed medical treatments of other diseases, the lockdown itself, the resulting 229 financial stress and the lack of social and emotional support, which may result in under- Newsweek reported that roughly 5,000 urns were shipped to one of the eight Wuhan cremation 262 facilities. The number of urns that arrived in that one facility was already about twice of the 263 city's official overall death from COVID-19 toll. 33 Potential COVID-19 related death counts 264 from urn distribution for Wuhan could be 35,708 for seven funeral houses (Table 3) . This is CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. . https://doi.org/10.1101/2020.05.28.20116012 doi: medRxiv preprint 8. Jinxin Kandian. "I am at the first line of Wuhan funeral service, now needs some help". February 15, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. . https://doi.org/10.1101/2020.05.28.20116012 doi: medRxiv preprint Enterprise Institute. https://www.aei.org/research-products/report/estimating-the-true- is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 6, 2020. . ** The maximum capacity is calculated for the seven funeral houses, assuming non-stop cremation, and simplified procedure, since no farewell ceremony was allowed during lockdown period. *** In the linear calculation methodology, we assumed constant daily death from Jan 25-Feb 12, and the total confirmed cases were only calculated to reflect the accumulated cases within 19 days. Marked increase during one night! 242 Deaths in Hubei + Funeral Wuhan pneumonia: Henan and Chongqing funeral teams going straight to support Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus 361 html#:~:text=The%20incubation%20period%20for%20COVID,CoV%2D2%20i Doubling 373 time of the COVID-19 epidemic by province, China. Emerg Infect Dis An investigation of transmission control measures during the 382 first 50 days of the COVID-19 epidemic in China