As of February 7, 2020, mainland China has reported 31,111 confirmed cases of infections with the 2019 novel coronavirus (2019-nCoV) resulting in 635 deaths. This translates to a serious case fatality rate of 2.04 per cent. Behind these headline numbers, however, is a striking divergence between the hardest hit region, central Hubei province (and especially the city of Wuhan), and the rest of China. The numbers for Hubei province are highly unreliable, because the healthcare system is overburdened and has to turn patients away, and there is also an acute lack of testing capacities for suspected cases. Anecdotal evidence suggests that even many fatal cases occurring outside of hospital settings cannot be properly diagnosed, because resources have to be conserved for the hospitals and their patients.
On the other hand, province-level divisions other than Hubei have so far coped well with the outbreak and have not experienced the kind of runaway overload of new cases that was already clear in Wuhan before January 20 and spread to neighboring cities shortly after the lockdown of Wuhan on January 23. The numbers and case histories reported from these other administrative divisions are therefore more useful for gauging the fundamental seriousness of the disease caused by the 2019-nCoV outbreak in a well-functioning, well-resourced and highly responsive (even proactive) health care system. As of February 7, 2020, 8999 cases had been confirmed outside Hubei province, with 13 resulting in fatalities, a case-fatality ratio of 0.144 per cent.
The numbers of fatalities from outside Hubei province suggest that the disease is much less lethal than would appear from the national headline numbers; the high case-fatality ratio in Hubei province might be due to the compromised quality of the overburdened health care system, to a huge number of unreported mild cases, from a local aggravating condition (such as air pollution), or a combination of these factors. It is not possible to answer this enigma at the moment. We can however look at the case histories of individual fatalities to see if the quality of the health care system plays a role, and if there is some reason to suspect that the numbers of deaths are underreported.
Unlike the huge numbers of fatalities from Hubei province, most of the cases from “outside provinces” have been reported with varying amounts of detail. To my knowledge, these reports have not yet been summarized in any language. To remedy this, I have compiled a brief summary of relevant information known about all the Chinese fatalities in “outside provinces”, with a preliminary analysis of the patterns revealed.
Hebei Province reported one fatality in Cangzhou prefecture. The patient was 80 years old and had spent two months in Wuhan. He was admitted to hospital (date not reported) for respiratory distress and heavy bronchitis and pneumonia, and died on January 22. His diagnosis was confirmed one day later.
Heilongjiang Province reported three fatalities. The first two were members of the same family from Suihua city. Mrs. Jiang (age not reported) was hospitalized on January 17, had diagnosis confirmed on January 23, and died the next day. She had several underlying chronic conditions. Mrs. Jiang’s husband Mr. Wang was 69 years old and had been paralyzed on the lower half of the body for ten years. He was hospitalized on January 24, had diagnosis confirmed on January 25, and died on January 30, one hour after his condition suddenly deteriorated. Both patients were likely infected by Mrs. Jiang’s 33-year old grandson, who had visited Wuhan previously, but all his tests came back negative (the report does not say when the tests were performed, possibly many days after he had infected the two fatal cases).
The third case was a 72-year old diabetic woman from Zhaozhou County under Daqing City. She probably got infected at Wuhan airport on January 8 or 14 while waiting for a transfer to or from Thailand. She got ill on January 18, visited hospital on January 22 and was confirmed on January 23. Her condition deteriorated on January 28, when she was admitted to a hospital in Daqing, and she was transferred to an ICU on January 30. She died on February 5.
Shanghai City reported one fatality on January 25. A 88-year old male patient lived with a relative who had returned from Wuhan and had previously been diagnosed with the 2019-nCoV infection. The 88-year old patient had several serious chronic conditions, resulting in decreased function of lungs, heart and kidneys, and a compromised immune system. He died after an unspecified period of intensive care in a hospital. It was not specified when his diagnosis was confirmed.
Henan Province reported two fatal cases, both from Tanghe County. Both had recently returned from Wuhan. Mr. Chang was 79 years old and worked in waste water treatment in Wuhan. He got ill on January 16, returned to Tanghe on January 17, and was admitted to hospital on January 22. Because of underlying history of chronic bronchitis and pulmonary fibrosis, his condition deteriorated rapidly and he died on January 24. An 85-year old patient surnamed Tu (gender not reported) had been a long time resident of Wuhan. The patient had diagnosis confirmed on January 27, their treatment was directed by an online consilium, but death occurred on January 28. The patient had a 30-year history of chronic bronchitis and coronary disease.
Beijing City reported one fatality on January 27. A 50-year old man had spent one week in Wuhan and returned to Beijing on January 15 with symptoms. He was admitted to hospital on January 21, had diagnosis confirmed on January 22, and died after sudden deterioration of his condition.
Hainan Province reported one fatality on January 27. Mrs Xu, 80 years old, paralyzed and bedridden after a stroke, came with her family to Chengmai on January 17. Her son got ill on January 19, was admitted to hospital, but his tests repeatedly came back negative and he was released on January 26. His mother and wife were kept in isolation, the wife did not develop any symptoms, but Mrs. Xu died in the early hours of January 27 and her diagnosis was confirmed at 6 am the same day.
Sichuan Province reported one fatality on January 29. An 80-year old Mrs. Zhang was admitted to hospital in Chengdu on January 23 with breathing difficulties and died in the early hours of Jan 29. She had a history of hypertension and coronary disease. (The report does not clarify her epidemiology.)
Chongqing City reported two fatalities. The first was a 62-year old waiter from a rural county with no travel history to Wuhan or close contact with people from Wuhan, who got ill on January 21, was admitted to hospital on January 29 and died in the morning of January 31. His diagnosis was confirmed posthumously. His case was complicated by an opportunistic bacterial pneumonia and underlying decreased liver function.
No details seem to have been released on the second case from Wanzhou District, who died on February 2.
Tianjin City reported its first fatality on February 5 with more detail than usual for other cases. It was a 66 year old woman with diabetes, coronary disease (requiring a coronary bypass 2 years ago) and hypertension. She was patient No. 50 diagnosed in Tianjin. As at least 15 of the confirmed cases in Tianjin, she was infected in the Baodi Department Store, probably on January 22. She developed fever on February 2, was diagnosed with 2019-nCoV pneumonia on February 3 and immediately admitted to a hospital. Despite a vigorous treatment regime, she developed shortness of breath on the morning of February 5 and died within two hours.
Guizhou Province reported its first fatality on February 5. It was a 34-year old Mr. Cheng from Panzhou City in Liupanshui, resident in Kunming in Yunnan Province. He had been in Wuhan between January 15-17 and arrived from Kunming in his own car on January 21. He developed fever on January 24, was diagnosed on January 26 and transferred to the provincial capital Guiyang on January 27. His condition deteriorated on January 31 and he died five days later. The report mentions his hypertension as an underlying condition.
Analysis and discussion
We have specific information about thirteen of these fatal cases. One was 34, one 50, four in their 60s (one of them severely paralyzed) and seven were octogenarians. Most had comorbidities, as can be expected in these age groups. Seven had come from Wuhan, three had not been to Wuhan but got infected from close family members who did return from the center of the outbreak, and two were infected locally in the community. Epidemiology was not reported in two cases.
At least eleven of the fourteen cases were treated in hospital, one died at home, two other cases are not clear. Diagnosis was only confirmed posthumously in two cases that must have been strongly suggestive of the 2019-nCoV infection for clinical symptoms or epidemiologic links.
One striking thing about these cases is the very low number of “sporadic” cases; only three have not been clearly epidemiologically linked to Wuhan or suspected or confirmed cases. Given the long incubation period and high number of suspect cases all over China, one would expect more fatalities in old people where the epidemiological links have to be painstakingly reconstructed, as in the first five people from the cluster of cases in the Baodi Department Store in Tianjin. It is therefore possible that even outside Hubei province, the number of fatalities is underreported.
Most cases occurred in less developed areas, suggesting that access to high quality care is indeed a major factor in reducing case-fatality rate. However, many of the reported cases were extremely frail individuals who would be at high risk in any healthcare setting even with more common acute respiratory infections. This fact was often emphasized in the detailed fatality reports.
The analysis of these cases shows strong epidemiologic links to Wuhan, high individual risk factors that contributed to the fatal outcome, and distribution in less developed parts of China. The dearth of cases occurring without strong epidemiologic links however hints at possible underreporting of fatalities even outside Hubei province.
Unfortunately, a similar level of epidemiological detail is not generally available for the critically ill patients, many of whom must be considered delayed fatalities. Only some cities, such as Tianjin or Shenzhen, publish detailed epidemiological reports on all confirmed cases of 2019-nCoV infections. I plan to look at these numbers and case histories separately in a future submission to further test the correlation between Wuhan travel history and seriousness of disease.
Mgr. Ing. Jiří Hudeček, PhD., is a sinologist from Department of Sinology, Charles University.