Global epidemiology of coronavirus disease 2019 (COVID-19): disease incidence, daily cumulative index, mortality, and their association with country healthcare resources and economic status

Global epidemiology of coronavirus disease 2019 (COVID-19): disease incidence, daily cumulative... Article history: It has been 2 months since the first case of coronavirus disease 2019 (COVID-19) was reported in Wuhan, Received 5 March 2020 China. So far, COVID-19 has affected 85 403 patients in 57 countries/territories and has caused 2924 Accepted 12 March 2020 deaths in 9 countries. However, epidemiological data differ between countries. Although China had higher morbidity and mortality than other sites, the number of new daily cases in China has been lower than Editor: Jean-Marc Rolain outside of China since 26 February 2020. The incidence ranged from 61.44 per 1 0 0 0 0 0 0 people in the Republic of Korea to 0.0 0 02 per 1 0 0 0 0 0 0 people in India. The daily cumulative index (DCI) of COVID- Keywords: 19 (cumulative cases/no. of days between the first reported case and 29 February 2020) was greatest Coronavirus disease 2019 in China (1320.85), followed by the Republic of Korea (78.78), Iran (43.11) and Italy (30.62). However, COVID-19 the DCIs in other countries/territories were < 10 per day. Several effective measures including restricting Disease incidence travel from China, controlling the distribution of masks, extensive investigation of COVID-19 spread, and Daily cumulative index Mortality once-daily press conferences by the government to inform and educate people were aggressively con- Country healthcare resources ducted in Taiwan. This is probably the reason why there was only 39 cases (as of 29 February 2020) with a DCI of 1 case per day in Taiwan, which is much lower than that of nearby countries such as the Repub- lic of Korea and Japan. In addition, the incidence and mortality were correlated with the DCI. However, further study and continued monitoring are needed to better understand the underlying mechanism of COVID-19. © 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license. ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) 1. Global epidemiology of coronavirus disease 2019 (COVID-19) tients in 57 countries/territories and has caused 2924 deaths as of 29 February 2020, of which approximately 92.9% of cases and Since the first reported case of COVID-19 in Wuhan, China, at 97.1% of deaths have been in China [1] . Among these 57 coun- the end of 2019, COVID-19 has rapidly spread throughout China tries/territories, cases reported in 20 countries/territories were at- and has also involved many other countries despite global efforts tributed to local transmission of COVID-19, whilst those in 37 to prevent its spread [1–4] . According to a report of the World countries/regions were imported cases. However, the incidence and Health Organization (WHO), COVID-19 has affected 85 403 pa- mortality of COVID-19 varied in different countries//territories. The incidence ranged from 61.44 per 1 0 0 0 0 0 0 people in Republic of Korea to 0.0 0 02 per 1 0 0 0 0 0 0 people in India ( Table 1 ). Corresponding author. Present address: Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, Number 7, Chung-Shan South Road, Taipei 100, Taiwan. E-mail address: hsporen@ntu.edu.tw (P.-R. Hsueh). https://doi.org/10.1016/j.ijantimicag.2020.105946 0924-8579/© 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license. ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) 2 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 Table 1 Characteristics of 57 countries/territories with reported cases of coronavirus disease 2019 (COVID-19) as of 29 February 2020 [1] Country/territory Cumulative No. of Mortality Incidence per 1 0 0 0 Deaths per 1 0 0 0 DCI GDP HCI [5] Days since last Local case no. deaths rate (%) 0 0 0 population 0 0 0 population ($US) reported case transmission Asia China 79 251 2835 3.58 55.06 1.97 1320.85 10 098 64.48 0 Yes Republic of Korea 3150 17 0.54 61.44 0.33 78.78 31 430 81.97 0 Yes Japan 230 5 2.17 1.82 0.04 5.11 40 846 81.14 25 Yes Singapore 98 0 0.00 16.75 0.00 2.72 63 987 70.84 0 Yes Hong Kong SAR 94 2 2.13 12.54 0.27 2.54 49 334 66.08 0 Yes Thailand 42 0 0.00 0.60 0.00 0.89 7791 77.95 0 Yes Taiwan 39 1 2.56 1.64 0.04 1.03 24 827 86.71 0 Yes Australia 24 0 0.00 0.94 0.00 0.69 50 022 77.38 0 Yes Malaysia 24 0 0.00 0.74 0.00 0.71 11 136 68.10 2 Yes Vietnam 16 0 0.00 0.16 0.00 0.44 2740 57.70 16 Yes Macau SAR 10 0 0.00 15.40 0.00 0.27 81 151 NA 25 No Philippines 3 1 33.33 0.03 0.01 0.10 3294 67.47 33 No India 3 0 0.00 0.00 0.00 0.10 2171 67.13 0 Yes Cambodia 1 0 0.00 0.06 0.00 0.03 1620 NA 26 No Nepal 1 0 0.00 0.03 0.00 0.03 1047 56.88 47 No Sri Lanka 1 0 0.00 0.05 0.00 0.03 3946 72.53 33 No New Zealand 1 0 0.00 0.21 0.00 1.00 40 634 73.81 1 No Subtotal 82 988 2861 3.45 America USA 62 0 0.00 0.19 0.00 1.68 65 111 69.27 0 Yes Canada 14 0 0.00 0.37 0.00 0.42 46 212 71.58 0 No Brazil 1 0 0.00 0.00 0.00 0.50 8796 56.29 3 No Mexico 2 0 0.00 0.02 0.00 NA 10 118 70.12 0 No Subtotal 79 0 0.00 Europe Italy 888 21 2.36 14.69 0.35 30.62 32 946 66.59 0 Yes Germany 57 0 0.00 0.68 0.00 1.78 46 563 73.32 0 Yes France 57 2 3.51 0.87 0.03 1.63 41 760 79.99 0 Yes Spain 32 0 0.00 0.68 0.00 1.14 29 961 78.88 0 Yes UK 20 0 0.00 0.29 0.00 0.71 41 030 74.46 0 Yes Sweden 12 0 0.00 1.19 0.00 0.43 51 241 69.23 0 No Switzerland 10 0 0.00 1.16 0.00 3.33 83 716 72.44 0 No Norway 6 0 0.00 1.11 0.00 3.00 77 975 74.36 0 No Israel 5 0 0.00 0.58 0.00 0.71 42 823 73.29 0 No Austria 5 0 0.00 0.56 0.00 1.67 50 022 78.73 0 No Croatia 5 0 0.00 1.22 0.00 1.67 14 949 62.68 0 Yes Greece 3 0 0.00 0.29 0.00 1.50 19 974 56.21 2 No Romania 3 0 0.00 0.16 0.00 1.50 12 482 55.06 0 No Russian Federation 2 0 0.00 0.01 0.00 0.07 11 162 57.59 29 No Finland 2 0 0.00 0.36 0.00 0.07 48 868 75.79 3 No Denmark 2 0 0.00 0.35 0.00 1.00 59 795 80.00 0 No Georgia 2 0 0.00 0.50 0.00 1.00 4289 51.24 0 No Netherland 2 0 0.00 1.17 0.00 2.00 52 367 74.65 0 No Estonia 1 0 0.00 0.75 0.00 0.50 23 523 72.67 2 No Belgium 1 0 0.00 0.09 0.00 0.04 45 175 74.34 0 No North Macedonia 1 0 0.00 0.48 0.00 0.50 6096 56.38 3 No Belarus 1 0 0.00 0.11 0.00 1.00 6603 59.04 1 No Lithuania 1 0 0.00 0.37 0.00 1.00 19 266 69.49 1 No San Marino 1 0 0.00 29.47 0.00 NA 47 279 NA 0 Yes Subtotal 1119 23 2.06 Eastern Mediterranean region Iran 388 34 8.76 4.62 0.40 43.11 5506 51.70 0 Yes Kuwait 45 0 0.00 10.54 0.00 9.00 29 266 56.21 0 No Bahrain 38 0 0.00 22.33 0.00 9.50 25 273 NA 0 No United Arab Emirates 19 0 0.00 1.92 0.00 0.61 37 749 67.04 2 Yes Iraq 8 0 0.00 0.20 0.00 2.00 5738 41.36 2 No Oman 6 0 0.00 1.17 0.00 1.50 17 791 58.15 2 No Lebanon 2 0 0.00 0.29 0.00 0.29 9654 64.38 3 No Pakistan 2 0 0.00 0.01 0.00 1.00 1388 60.59 3 No Afghanistan 1 0 0.00 0.03 0.00 0.25 513 NA 5 No Egypt 1 0 0.00 0.01 0.00 0.07 3046 45.84 15 No Subtotal 510 34 6.67 Africa Algeria 1 0 0.00 0.02 0.33 3980 54.86 0 No Nigeria 1 0 0.00 0.00 1.00 2222 51.59 0 No Subtotal 2 0 0.00 International conveyance 705 6 0.85 29.38 3 Yes Total 85 403 2924 3.42 DCI, daily cumulative index (cumulative cases/no. of days between the first reported case and 29 February 2020); GDP, gross domestic product; HCI, Health Care Index; NA, not applicable. C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 3 90000 1200 Americas European Eastern mediterranean region African International conveyance 60000 800 Asia 30000 400 0 0 Fig. 1. Daily cumulative case number of patients with coronavirus disease 2019 (COVID-19) in five main geographical regions and the international conveyance (Diamond Princess cruise ship) as of 29 February 2020. 2. COVID-19 in different geographical regions of the world 3.1. China To date, five regions have observed COVID-19 cases, including China has the highest number of COVID-19 cases in the world Asia, Eastern Mediterranean region, Europe, America and Africa. Of ( n = 79 251), with an incidence of 55.06 per 1 0 0 0 0 0 0 people. course, the highest incidence of COVID-19 was reported in Asia Among these cases, 2835 patients died, with an overall mortality ( n = 82 988), followed by Europe ( n = 1119), Eastern Mediter- rate of 3.58%. Despite the increasing trend of daily new cases in ranean region ( n = 510), America ( n = 79) and Africa ( n = 2) the early stage, the trend of daily new cases appeared to decline ( Fig. 1 ). Within the last week of February, the number of new cases with time since late February 2020. Moreover, the number of daily was highest in Asia ( n = 5019), followed by Europe ( n = 998) and new cases in China has been lower than outside of China since 26 the Eastern Mediterranean region ( n = 467). The overall mortal- February 2020. According to the Chinese Center for Disease Con- ity rate was highest in the Eastern Mediterranean region (6.67%; trol and Prevention [5] , 81% of patients with COVID-19 had a mild n = 34), followed by Asia (3.45%; n = 2861) and Europe (2.06%; case and 87% were aged 30–79 years. In addition, 3.8% of those n = 23%). In contrast, there had been no deaths in America or with COVID-19 were healthcare personnel. The case fatality rate Africa as of 29 February 2020. was higher in those with critical cases (49%) and patients aged ≥80 years (14.8%) [5] . 3.2. International conveyance (Diamond Princess) 3. Disease incidence, mortality rate and daily cumulative index of COVID-19 by country Until the end of February 2020, 705 of the 3700 passengers on the Diamond Princess cruise ship had confirmed COVID-19 and The incidence (cases per 1 0 0 0 0 0 0 population) of COVID- 6 died, with a mortality rate of 0.85%. The basic reproduction 19 cases was highest in the Republic of Korea (61.44), followed rate (R ) was initially four times higher on-board than the R in 0 0 by China (55.06), San Marino (29.47), Bahrain (22.33), Singapore Wuhan. However, implementation of isolation and quarantine pro- (16.75, Macau Special Administrative Region (SAR) (15.40), Italy cedures helped to prevent the spread of COVID-19 in more than (14.69), Hong Kong SAR (12.54), Kuwait (10.54) and Iran (4.62). In 20 0 0 passengers and lowered the R to 1.78 [6] . Although the ex- the other 47 countries, the incidence of COVID-19 cases was < 2 per perience of this cruise ship provided a good model for understand- 1 0 0 0 0 0 0 population. Only nine countries had observed COVID- ing the behaviour of COVID-19 spread, the spread of disease could 19-associated deaths, and the mortality rate ranged from 33.33% have been prevented if all passengers and crew were evacuated (1/3) in the Philippines to 0.54% (17/3150) in the Republic of early. Korea. The daily cumulative index (DCI) of COVID-19 cases is de- 3.3. Countries/territories with more than 100 cumulative cases fined as the cumulative cases/no. of days between the first re- ported case and 29 February 2020. The DCI was greatest in China In addition to China, four countries (Republic of Korea, Japan, (1320.85), followed by the Republic of Korea (78.78), Iran (43.11), Italy and Iran) had ≥100 COVID-19 cases. Besides Japan, which Italy (30.62), Bahrain (9.50), Kuwait (9.00) and Japan (5.11). The showed slowly increasing cases, the other three countries had a DCI in other countries/SARs was < 4 per day. rapid increase in COVID-19 incidence since late February ( Fig. 2 A). No. of cumulative cases in Asia 21-Jan 22-Jan 23-Jan 24-Jan 25-Jan 26-Jan 27-Jan 28-Jan 29-Jan 30-Jan 31-Jan 1-Feb 2-Feb 3-Feb 4-Feb 5-Feb 6-Feb 7-Feb 8-Feb 9-Feb 10-Feb 11-Feb 12-Feb 13-Feb 14-Feb 15-Feb 16-Feb 17-Feb 18-Feb 19-Feb 20-Feb 21-Feb 22-Feb 23-Feb 24-Feb 25-Feb 26-Feb 27-Feb 28-Feb 29-Feb No. of cumulative cases 4 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 Among these four countries, Iran had the highest mortality though the first COVID-19 case reported in these five sites oc- ( n = 34), with a mortality rate of 8.76%. Although these countries curred in late January 2020, the number of cases continued to had more COVID-19 cases than other sites except China, the num- increase at the end of February ( Fig. 2 B). Seven countries had ber of cases appeared to increase with time. 20–49 cumulative cases, including Taiwan, Australia, Malaysia, the UK, Spain, Bahrain and Kuwait. Except the five countries whose first cases were reported in late January 2020, the first 3.4. Countries/territories with 10–99 cumulative cases COVID-19 cases in Bahrain and Kuwait were reported on 25 February and 29 February 2020, respectively ( Fig. 2 C). Six coun- Five countries/territories had 50–99 cumulative cases, includ- tries/territories had 10–19 cumulative cases, including Switzerland, ing Hong Kong SAR, Singapore, USA, Germany and France. Al- (A) Republic of Korea Japan Italy Iran International conveyance (B) Hong Kong special administrative region Singapore United States Germany France Fig. 2. Daily cumulative case number of patients with coronavirus disease 2019 (COVID-19) in four different categories of countries according to number of reported cases as of 29 February 2020: (A) ≥100 reported cases; (B) 50–99 reported cases; (C) 20–49 reported cases; and (D) 10–19 reported cases. Inverted triangles with different colours denote the date of the first reported case in each indicated country. No. of cumulative cases No. of cumulative cases 21-Jan 21-Jan 22-Jan 22-Jan 23-Jan 23-Jan 24-Jan 24-Jan 25-Jan 25-Jan 26-Jan 26-Jan 27-Jan 27-Jan 28-Jan 28-Jan 29-Jan 29-Jan 30-Jan 30-Jan 31-Jan 31-Jan 1-Feb 1-Feb 2-Feb 2-Feb 3-Feb 3-Feb 4-Feb 4-Feb 5-Feb 5-Feb 6-Feb 6-Feb 7-Feb 7-Feb 8-Feb 8-Feb 9-Feb 9-Feb 10-Feb 10-Feb 11-Feb 11-Feb 12-Feb 12-Feb 13-Feb 13-Feb 14-Feb 14-Feb 15-Feb 15-Feb 16-Feb 16-Feb 17-Feb 17-Feb 18-Feb 18-Feb 19-Feb 19-Feb 20-Feb 20-Feb 21-Feb 21-Feb 22-Feb 22-Feb 23-Feb 23-Feb 24-Feb 24-Feb 25-Feb 25-Feb 26-Feb 26-Feb 27-Feb 27-Feb 28-Feb 28-Feb 29-Feb 29-Feb C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 5 (C) Taiwan Australia Malaysia United Kingdom Spain Bahrain Kuwait (D) Switzerland United Arab Emirates Macau specific administrative region Sweden Vietnam Canada Fig. 2. Continued United Arab Emirates, Macau SAR, Sweden, Vietnam and Canada. Vietnam and Egypt. The days since last reported case was highest Except Switzerland, all of the other five reported the first cases for Nepal ( n = 47), followed by Sri Lanka ( n = 33) and Cambodia before February ( Fig. 2 D). In addition, no new cases were re- ( n = 26). Except Vietnam and Macau SAR (which had 16 and 10 ported in Macau SAR and Vietnam for 25 days and 16 days, COVID-19 cases, respectively), the other eight countries had a total respectively. of ≤3 cases. In addition to the Philippines, none of them reported of any COVID-19-related deaths. 3.5. Countries/territories with a stable number of COVID-19 cases 3.6. Taiwan Ten of fifty-seven countries/regions had stable numbers of COVID-19 cases for ≥15 days, including Nepal, Cambodia, Sri Lanka, Taiwan is a country geographically near China and that has a Russian Federation, India, Macau SAR, the Philippines, Belgium, close contact with China, making it more susceptible to COVID-19 No. of cumulative cases No. of cumulative cases 21-Jan 21-Jan 22-Jan 22-Jan 23-Jan 23-Jan 24-Jan 24-Jan 25-Jan 25-Jan 26-Jan 26-Jan 27-Jan 27-Jan 28-Jan 28-Jan 29-Jan 29-Jan 30-Jan 30-Jan 31-Jan 31-Jan 1-Feb 1-Feb 2-Feb 2-Feb 3-Feb 3-Feb 4-Feb 4-Feb 5-Feb 5-Feb 6-Feb 6-Feb 7-Feb 7-Feb 8-Feb 8-Feb 9-Feb 9-Feb 10-Feb 10-Feb 11-Feb 11-Feb 12-Feb 12-Feb 13-Feb 13-Feb 14-Feb 14-Feb 15-Feb 15-Feb 16-Feb 16-Feb 17-Feb 17-Feb 18-Feb 18-Feb 19-Feb 19-Feb 20-Feb 20-Feb 21-Feb 21-Feb 22-Feb 22-Feb 23-Feb 23-Feb 24-Feb 24-Feb 25-Feb 25-Feb 26-Feb 26-Feb 27-Feb 27-Feb 28-Feb 28-Feb 29-Feb 29-Feb 6 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 (A) New case Cumulative case st Nosocomial 1 local st st 1 death 1 case infection transmission 6 45 No mask Mask by Mask export control identification No import No import from China 4 from Hubei 30 2 15 0 0 (B) Total No. of No. of 17 98 no. of domestic imported cases cases cases (C) Chinese visitors Taiwan businessmen Transmission route Domestic cases Discharged from China and women from China Infection acquisition outside Taiwan Infection acquisition inside Taiwan Spouse transmission Foreign caregiver Familial transmission Nosocomial transmission Fig. 3. (A) Epidemic curve (‘epicurve’) of the 39 patients with coronavirus disease 2019 (COVID-19) and implementation of primary control measures in Tai- wan from 21 January to 29 February 2020. (B) Geographical distribution of the 39 patients with COVID-19 and (C) the possible modes of transmission [https://www.cna.com.tw/news/ahel/202003010211.aspx; accessed 2 March 2020]. Taiwanese businesswoman returning from China who had negative real-time RT-PCR for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the respiratory tract but positive anti-SARS-CoV-2 antibody in the serum. No. of new cases 21-Jan 22-Jan 23-Jan 24-Jan 25-Jan 26-Jan 27-Jan 28-Jan 29-Jan 30-Jan 31-Jan 1-Feb 2-Feb 3-Feb 4-Feb 5-Feb 6-Feb 7-Feb 8-Feb 9-Feb 10-Feb 11-Feb 12-Feb 13-Feb 14-Feb 15-Feb 16-Feb 17-Feb 18-Feb 19-Feb 20-Feb 21-Feb 22-Feb 23-Feb 24-Feb 25-Feb 26-Feb 27-Feb 28-Feb 29-Feb No. of cumulative cases C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 7 Fig. 4. Incidence (per 1 0 0 0 0 0 0 population), mortality rate (%) and deaths per 1 0 0 0 0 0 0 population of patients with coronavirus disease 2019 (COVID-19) and their association (Spearman’s rank-order correlation) with (A) daily cumulative index (DCI), (B) Health Care Index (HCI) and (C) Healthcare Access Quality Index (HAQI) by country. Table 2 spread. To manage this challenge, infection control measures in- Disease incidence (per 1 0 0 0 0 0 0 population), mortality rate (%) and deaths per cluding prohibiting travel from China, controlling the distribution 1 0 0 0 0 0 0 population of patients with coronavirus disease 2019 (COVID-19) and of face masks, extensive investigation of COVID-19 spread, and their association with daily cumulative index (DCI) , Health Care Index (HCI) and a once-daily press conference by the government to inform and Healthcare Access Quality Index (HAQI) by country according to transmission route educate people were aggressively conducted in Taiwan ( Fig. 3 A). Countries with local Countries with imported Under these interventions, Taiwan has a total of 39 cases with transmission cases only a DCI of 1 case per day, which was much lower than that of r P -value r P -value the nearby countries such as the Republic of Korea and Japan Disease incidence (per 1 000 000 population) ( Fig. 3 B). Among the 39 patients, 18 acquired the COVID-19 in- DCI 0.737 < 0.001 0.524 0.001 fection outside of Taiwan, of whom 3 were Chinese visitors from HCI −0.050 0.835 0.384 0.030 China, whilst the other 21 developed the infection in Taiwan HAQI 0.307 0.201 0.628 < 0.001 (http://nidss.cdc.gov.tw/ch/SingleDisease.aspx?dc = 1&dt = 5&disease Mortality rate (%) = 19CoV). Four familial cluster transmissions and one nosocomial DCI 0.642 0.002 −0.171 0.327 HCI 0.000 1.000 0.010 0.958 transmission were reported. To date, 11 patients were discharged HAQI 0.161 0.510 −0.215 0.263 ( Fig. 3 C). Several important actions and responses conducted by Deaths (per 1 000 000 population) the National Health Command Center of Taiwan, including border DCI 0.747 < 0.001 −0.168 0.351 control, resource re-allocation, case identification (using new data HCI −0.073 0.760 −0.011 0.955 HAQI 0.177 0.468 −0.215 0.273 and technology), quarantine of suspicious cases using big data analytics, reassurance and education of the public, mask control a DCI = cumulative cases/no. of days between the first reported case and 29 and hand hygiene, and formulation of policies toward schools February 2020). and childcare, have so far successfully alleviated the crisis and contained the epidemic in Taiwan [7] . Healthcare Access and Quality Index (HAQI) [10] . The HCI is based on surveys from visitors of one open website and questions for 4. Association between mortality and disease incidence these surveys are similar to many similar scientific and govern- ment surveys [9] . The HAQI uses 32 scaled cause values, providing Based on the earlier experience in China, Ji et al. found a signif- an overall score of 0–100 of personal healthcare access and quality icant correlation between mortality and healthcare resource avail- by location over time [10] . First, we found that the mortality rate, ability ( r = 0.61) [8] . We wonder whether the association between incidence and death per 1 0 0 0 0 0 0 people were correlated with mortality and healthcare burden can be demonstrated outside of the DCI (Spearman’s rank-order correlation, all P < 0.05) ( Fig. 4 A) China and whether there are other confounding factors, such as and this association was more prominent in countries with local the level of health care. Therefore, we used two indexes to rep- transmission ( Table 2 ). This finding is consistent with the find- resent the level of healthcare: Health Care Index (HCI) [9] and ings of Ji et al. [8] and suggests that rapidly increasing cases in 8 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 a short time can result in more cases and even more deaths. Sec- References ond, the incidence was associated with life expectancy ( r = 0.613, [1] World Health Organization (WHO). Coronavirus disease 2019 (COVD-19). Situ- P < 0.001). This could be because countries with more older adults ation report –40, Geneva, Switzerland: WHO; 2020. Data as reported by 10AM were more likely to acquire COVID-19. Finally, the incidence was CET 29 February 2020 https://www.who.int/docs/default-source/coronaviruse/ found to be correlated with both HAQI ( r = 0.516, P < 0.001) and situation- reports/20200229- sitrep- 40- covid- 19.pdf?sfvrsn=849d0665 _ 2 [ac- cessed 17 March 2020] . HCI ( r = 0.345, P < 0.012), but mortality and deaths per 1 0 0 0 0 0 0 [2] Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of people were not associated with the level of health care ( Fig. 4 B,C). coronavirus disease 2019 in China. N Engl J Med 2020 Feb 28 [Epub ahead of This finding may be explained by the fact that countries with more print]. doi: 10.1056/NEJMoa2002032 . [3] Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syn- advanced healthcare systems have better diagnostic ability to iden- drome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): tify more cases. By contrast, no death cases were reported in most the epidemic and the challenges. Int J Antimicrob Agents 2020;55:105924. countries; thus, no significant correlation could be found. However, doi: 10.1016/j.ijantimicag.2020.105924 . [4] Lai CC, Liu YH, Wang CY, Wang YH, Hsueh SC, Yen MY, et al. Asymptomatic further study is warranted to clarify these findings. carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): facts and myths. J Micro- 5. Conclusion biol Immunol Infect 2020 March 4. doi: 10.1016/j.jmii.2020.02.012 . [5] Wu Z, McGoogan JM. Characteristics of and important lessons from the coron- avirus disease 2019 (COVID-19) outbreak in China. Summary of a report of 72 Between 31 December 2019 and 29 February 2020, COVID-19 314 cases from the Chinese Center for Disease Control and Prevention. JAMA has affected more than 80 0 0 0 patients in 57 countries/territories 2020 Feb 24 [Epub ahead of print]. doi: 10.1001/jama.2020.2648 . and caused 2924 deaths in 9 countries. Although China had higher [6] Rocklov J, Sjodin H, Wilder-Smith A. COVID-19 outbreak on the Diamond Princess cruise ship: estimating the epidemic potential and effectiveness of morbidity and mortality rates than other sites, the number of daily public health countermeasures. J Travel Med 2020 Feb 28 pii: taaa030 [Epub new cases has been lower in China than outside of China since ahead of print]. doi: 10.1093/jtm/taaa030 . 26 February 2020. Seven countries had a DCI of > 5 cases per day, [7] Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA 2020 Mar 3 [Epub ahead of print]. but the DCI of the other fifty countries/territories was < 4 cases doi: 10.1001/jama.2020.3151 . per day. The incidence and mortality rates were correlated with [8] Ji YMZ, Peppelenbosch MP, Pan Q. Potential association between COVID-19 DCI, especially in countries with local transmission. Overall, this mortality and health-care resource availability. Lancet Glob Health 2020 Febru- ary 25 [Epub ahead of print]. doi: 10.1016/S2214-109X(20)30068-1 . preliminary report shows us the initial epidemiological findings of [9] Health Care Index by country 2020. https://www.numbeo.com/health-care/ COVID-19, but continuous monitoring of patients with this disease rankings _ by _ country.jsp [accessed 1 March 2020]. is still warranted. [10] GBD 2016 Healthcare Access and Quality Collaborators Measuring perfor- mance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Funding: None. Global Burden of Disease Study 2016. Lancet 2018;391:2236–71. doi: 10.1016/ S0140- 6736(18)30994- 2 . Competing interests: None declared. Ethical approval: Not required. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Antimicrobial Agents Pubmed Central

Global epidemiology of coronavirus disease 2019 (COVID-19): disease incidence, daily cumulative index, mortality, and their association with country healthcare resources and economic status

International Journal of Antimicrobial Agents, Volume 55 (4) – Mar 19, 2020

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Article history: It has been 2 months since the first case of coronavirus disease 2019 (COVID-19) was reported in Wuhan, Received 5 March 2020 China. So far, COVID-19 has affected 85 403 patients in 57 countries/territories and has caused 2924 Accepted 12 March 2020 deaths in 9 countries. However, epidemiological data differ between countries. Although China had higher morbidity and mortality than other sites, the number of new daily cases in China has been lower than Editor: Jean-Marc Rolain outside of China since 26 February 2020. The incidence ranged from 61.44 per 1 0 0 0 0 0 0 people in the Republic of Korea to 0.0 0 02 per 1 0 0 0 0 0 0 people in India. The daily cumulative index (DCI) of COVID- Keywords: 19 (cumulative cases/no. of days between the first reported case and 29 February 2020) was greatest Coronavirus disease 2019 in China (1320.85), followed by the Republic of Korea (78.78), Iran (43.11) and Italy (30.62). However, COVID-19 the DCIs in other countries/territories were < 10 per day. Several effective measures including restricting Disease incidence travel from China, controlling the distribution of masks, extensive investigation of COVID-19 spread, and Daily cumulative index Mortality once-daily press conferences by the government to inform and educate people were aggressively con- Country healthcare resources ducted in Taiwan. This is probably the reason why there was only 39 cases (as of 29 February 2020) with a DCI of 1 case per day in Taiwan, which is much lower than that of nearby countries such as the Repub- lic of Korea and Japan. In addition, the incidence and mortality were correlated with the DCI. However, further study and continued monitoring are needed to better understand the underlying mechanism of COVID-19. © 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license. ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) 1. Global epidemiology of coronavirus disease 2019 (COVID-19) tients in 57 countries/territories and has caused 2924 deaths as of 29 February 2020, of which approximately 92.9% of cases and Since the first reported case of COVID-19 in Wuhan, China, at 97.1% of deaths have been in China [1] . Among these 57 coun- the end of 2019, COVID-19 has rapidly spread throughout China tries/territories, cases reported in 20 countries/territories were at- and has also involved many other countries despite global efforts tributed to local transmission of COVID-19, whilst those in 37 to prevent its spread [1–4] . According to a report of the World countries/regions were imported cases. However, the incidence and Health Organization (WHO), COVID-19 has affected 85 403 pa- mortality of COVID-19 varied in different countries//territories. The incidence ranged from 61.44 per 1 0 0 0 0 0 0 people in Republic of Korea to 0.0 0 02 per 1 0 0 0 0 0 0 people in India ( Table 1 ). Corresponding author. Present address: Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, Number 7, Chung-Shan South Road, Taipei 100, Taiwan. E-mail address: hsporen@ntu.edu.tw (P.-R. Hsueh). https://doi.org/10.1016/j.ijantimicag.2020.105946 0924-8579/© 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license. ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) 2 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 Table 1 Characteristics of 57 countries/territories with reported cases of coronavirus disease 2019 (COVID-19) as of 29 February 2020 [1] Country/territory Cumulative No. of Mortality Incidence per 1 0 0 0 Deaths per 1 0 0 0 DCI GDP HCI [5] Days since last Local case no. deaths rate (%) 0 0 0 population 0 0 0 population ($US) reported case transmission Asia China 79 251 2835 3.58 55.06 1.97 1320.85 10 098 64.48 0 Yes Republic of Korea 3150 17 0.54 61.44 0.33 78.78 31 430 81.97 0 Yes Japan 230 5 2.17 1.82 0.04 5.11 40 846 81.14 25 Yes Singapore 98 0 0.00 16.75 0.00 2.72 63 987 70.84 0 Yes Hong Kong SAR 94 2 2.13 12.54 0.27 2.54 49 334 66.08 0 Yes Thailand 42 0 0.00 0.60 0.00 0.89 7791 77.95 0 Yes Taiwan 39 1 2.56 1.64 0.04 1.03 24 827 86.71 0 Yes Australia 24 0 0.00 0.94 0.00 0.69 50 022 77.38 0 Yes Malaysia 24 0 0.00 0.74 0.00 0.71 11 136 68.10 2 Yes Vietnam 16 0 0.00 0.16 0.00 0.44 2740 57.70 16 Yes Macau SAR 10 0 0.00 15.40 0.00 0.27 81 151 NA 25 No Philippines 3 1 33.33 0.03 0.01 0.10 3294 67.47 33 No India 3 0 0.00 0.00 0.00 0.10 2171 67.13 0 Yes Cambodia 1 0 0.00 0.06 0.00 0.03 1620 NA 26 No Nepal 1 0 0.00 0.03 0.00 0.03 1047 56.88 47 No Sri Lanka 1 0 0.00 0.05 0.00 0.03 3946 72.53 33 No New Zealand 1 0 0.00 0.21 0.00 1.00 40 634 73.81 1 No Subtotal 82 988 2861 3.45 America USA 62 0 0.00 0.19 0.00 1.68 65 111 69.27 0 Yes Canada 14 0 0.00 0.37 0.00 0.42 46 212 71.58 0 No Brazil 1 0 0.00 0.00 0.00 0.50 8796 56.29 3 No Mexico 2 0 0.00 0.02 0.00 NA 10 118 70.12 0 No Subtotal 79 0 0.00 Europe Italy 888 21 2.36 14.69 0.35 30.62 32 946 66.59 0 Yes Germany 57 0 0.00 0.68 0.00 1.78 46 563 73.32 0 Yes France 57 2 3.51 0.87 0.03 1.63 41 760 79.99 0 Yes Spain 32 0 0.00 0.68 0.00 1.14 29 961 78.88 0 Yes UK 20 0 0.00 0.29 0.00 0.71 41 030 74.46 0 Yes Sweden 12 0 0.00 1.19 0.00 0.43 51 241 69.23 0 No Switzerland 10 0 0.00 1.16 0.00 3.33 83 716 72.44 0 No Norway 6 0 0.00 1.11 0.00 3.00 77 975 74.36 0 No Israel 5 0 0.00 0.58 0.00 0.71 42 823 73.29 0 No Austria 5 0 0.00 0.56 0.00 1.67 50 022 78.73 0 No Croatia 5 0 0.00 1.22 0.00 1.67 14 949 62.68 0 Yes Greece 3 0 0.00 0.29 0.00 1.50 19 974 56.21 2 No Romania 3 0 0.00 0.16 0.00 1.50 12 482 55.06 0 No Russian Federation 2 0 0.00 0.01 0.00 0.07 11 162 57.59 29 No Finland 2 0 0.00 0.36 0.00 0.07 48 868 75.79 3 No Denmark 2 0 0.00 0.35 0.00 1.00 59 795 80.00 0 No Georgia 2 0 0.00 0.50 0.00 1.00 4289 51.24 0 No Netherland 2 0 0.00 1.17 0.00 2.00 52 367 74.65 0 No Estonia 1 0 0.00 0.75 0.00 0.50 23 523 72.67 2 No Belgium 1 0 0.00 0.09 0.00 0.04 45 175 74.34 0 No North Macedonia 1 0 0.00 0.48 0.00 0.50 6096 56.38 3 No Belarus 1 0 0.00 0.11 0.00 1.00 6603 59.04 1 No Lithuania 1 0 0.00 0.37 0.00 1.00 19 266 69.49 1 No San Marino 1 0 0.00 29.47 0.00 NA 47 279 NA 0 Yes Subtotal 1119 23 2.06 Eastern Mediterranean region Iran 388 34 8.76 4.62 0.40 43.11 5506 51.70 0 Yes Kuwait 45 0 0.00 10.54 0.00 9.00 29 266 56.21 0 No Bahrain 38 0 0.00 22.33 0.00 9.50 25 273 NA 0 No United Arab Emirates 19 0 0.00 1.92 0.00 0.61 37 749 67.04 2 Yes Iraq 8 0 0.00 0.20 0.00 2.00 5738 41.36 2 No Oman 6 0 0.00 1.17 0.00 1.50 17 791 58.15 2 No Lebanon 2 0 0.00 0.29 0.00 0.29 9654 64.38 3 No Pakistan 2 0 0.00 0.01 0.00 1.00 1388 60.59 3 No Afghanistan 1 0 0.00 0.03 0.00 0.25 513 NA 5 No Egypt 1 0 0.00 0.01 0.00 0.07 3046 45.84 15 No Subtotal 510 34 6.67 Africa Algeria 1 0 0.00 0.02 0.33 3980 54.86 0 No Nigeria 1 0 0.00 0.00 1.00 2222 51.59 0 No Subtotal 2 0 0.00 International conveyance 705 6 0.85 29.38 3 Yes Total 85 403 2924 3.42 DCI, daily cumulative index (cumulative cases/no. of days between the first reported case and 29 February 2020); GDP, gross domestic product; HCI, Health Care Index; NA, not applicable. C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 3 90000 1200 Americas European Eastern mediterranean region African International conveyance 60000 800 Asia 30000 400 0 0 Fig. 1. Daily cumulative case number of patients with coronavirus disease 2019 (COVID-19) in five main geographical regions and the international conveyance (Diamond Princess cruise ship) as of 29 February 2020. 2. COVID-19 in different geographical regions of the world 3.1. China To date, five regions have observed COVID-19 cases, including China has the highest number of COVID-19 cases in the world Asia, Eastern Mediterranean region, Europe, America and Africa. Of ( n = 79 251), with an incidence of 55.06 per 1 0 0 0 0 0 0 people. course, the highest incidence of COVID-19 was reported in Asia Among these cases, 2835 patients died, with an overall mortality ( n = 82 988), followed by Europe ( n = 1119), Eastern Mediter- rate of 3.58%. Despite the increasing trend of daily new cases in ranean region ( n = 510), America ( n = 79) and Africa ( n = 2) the early stage, the trend of daily new cases appeared to decline ( Fig. 1 ). Within the last week of February, the number of new cases with time since late February 2020. Moreover, the number of daily was highest in Asia ( n = 5019), followed by Europe ( n = 998) and new cases in China has been lower than outside of China since 26 the Eastern Mediterranean region ( n = 467). The overall mortal- February 2020. According to the Chinese Center for Disease Con- ity rate was highest in the Eastern Mediterranean region (6.67%; trol and Prevention [5] , 81% of patients with COVID-19 had a mild n = 34), followed by Asia (3.45%; n = 2861) and Europe (2.06%; case and 87% were aged 30–79 years. In addition, 3.8% of those n = 23%). In contrast, there had been no deaths in America or with COVID-19 were healthcare personnel. The case fatality rate Africa as of 29 February 2020. was higher in those with critical cases (49%) and patients aged ≥80 years (14.8%) [5] . 3.2. International conveyance (Diamond Princess) 3. Disease incidence, mortality rate and daily cumulative index of COVID-19 by country Until the end of February 2020, 705 of the 3700 passengers on the Diamond Princess cruise ship had confirmed COVID-19 and The incidence (cases per 1 0 0 0 0 0 0 population) of COVID- 6 died, with a mortality rate of 0.85%. The basic reproduction 19 cases was highest in the Republic of Korea (61.44), followed rate (R ) was initially four times higher on-board than the R in 0 0 by China (55.06), San Marino (29.47), Bahrain (22.33), Singapore Wuhan. However, implementation of isolation and quarantine pro- (16.75, Macau Special Administrative Region (SAR) (15.40), Italy cedures helped to prevent the spread of COVID-19 in more than (14.69), Hong Kong SAR (12.54), Kuwait (10.54) and Iran (4.62). In 20 0 0 passengers and lowered the R to 1.78 [6] . Although the ex- the other 47 countries, the incidence of COVID-19 cases was < 2 per perience of this cruise ship provided a good model for understand- 1 0 0 0 0 0 0 population. Only nine countries had observed COVID- ing the behaviour of COVID-19 spread, the spread of disease could 19-associated deaths, and the mortality rate ranged from 33.33% have been prevented if all passengers and crew were evacuated (1/3) in the Philippines to 0.54% (17/3150) in the Republic of early. Korea. The daily cumulative index (DCI) of COVID-19 cases is de- 3.3. Countries/territories with more than 100 cumulative cases fined as the cumulative cases/no. of days between the first re- ported case and 29 February 2020. The DCI was greatest in China In addition to China, four countries (Republic of Korea, Japan, (1320.85), followed by the Republic of Korea (78.78), Iran (43.11), Italy and Iran) had ≥100 COVID-19 cases. Besides Japan, which Italy (30.62), Bahrain (9.50), Kuwait (9.00) and Japan (5.11). The showed slowly increasing cases, the other three countries had a DCI in other countries/SARs was < 4 per day. rapid increase in COVID-19 incidence since late February ( Fig. 2 A). No. of cumulative cases in Asia 21-Jan 22-Jan 23-Jan 24-Jan 25-Jan 26-Jan 27-Jan 28-Jan 29-Jan 30-Jan 31-Jan 1-Feb 2-Feb 3-Feb 4-Feb 5-Feb 6-Feb 7-Feb 8-Feb 9-Feb 10-Feb 11-Feb 12-Feb 13-Feb 14-Feb 15-Feb 16-Feb 17-Feb 18-Feb 19-Feb 20-Feb 21-Feb 22-Feb 23-Feb 24-Feb 25-Feb 26-Feb 27-Feb 28-Feb 29-Feb No. of cumulative cases 4 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 Among these four countries, Iran had the highest mortality though the first COVID-19 case reported in these five sites oc- ( n = 34), with a mortality rate of 8.76%. Although these countries curred in late January 2020, the number of cases continued to had more COVID-19 cases than other sites except China, the num- increase at the end of February ( Fig. 2 B). Seven countries had ber of cases appeared to increase with time. 20–49 cumulative cases, including Taiwan, Australia, Malaysia, the UK, Spain, Bahrain and Kuwait. Except the five countries whose first cases were reported in late January 2020, the first 3.4. Countries/territories with 10–99 cumulative cases COVID-19 cases in Bahrain and Kuwait were reported on 25 February and 29 February 2020, respectively ( Fig. 2 C). Six coun- Five countries/territories had 50–99 cumulative cases, includ- tries/territories had 10–19 cumulative cases, including Switzerland, ing Hong Kong SAR, Singapore, USA, Germany and France. Al- (A) Republic of Korea Japan Italy Iran International conveyance (B) Hong Kong special administrative region Singapore United States Germany France Fig. 2. Daily cumulative case number of patients with coronavirus disease 2019 (COVID-19) in four different categories of countries according to number of reported cases as of 29 February 2020: (A) ≥100 reported cases; (B) 50–99 reported cases; (C) 20–49 reported cases; and (D) 10–19 reported cases. Inverted triangles with different colours denote the date of the first reported case in each indicated country. No. of cumulative cases No. of cumulative cases 21-Jan 21-Jan 22-Jan 22-Jan 23-Jan 23-Jan 24-Jan 24-Jan 25-Jan 25-Jan 26-Jan 26-Jan 27-Jan 27-Jan 28-Jan 28-Jan 29-Jan 29-Jan 30-Jan 30-Jan 31-Jan 31-Jan 1-Feb 1-Feb 2-Feb 2-Feb 3-Feb 3-Feb 4-Feb 4-Feb 5-Feb 5-Feb 6-Feb 6-Feb 7-Feb 7-Feb 8-Feb 8-Feb 9-Feb 9-Feb 10-Feb 10-Feb 11-Feb 11-Feb 12-Feb 12-Feb 13-Feb 13-Feb 14-Feb 14-Feb 15-Feb 15-Feb 16-Feb 16-Feb 17-Feb 17-Feb 18-Feb 18-Feb 19-Feb 19-Feb 20-Feb 20-Feb 21-Feb 21-Feb 22-Feb 22-Feb 23-Feb 23-Feb 24-Feb 24-Feb 25-Feb 25-Feb 26-Feb 26-Feb 27-Feb 27-Feb 28-Feb 28-Feb 29-Feb 29-Feb C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 5 (C) Taiwan Australia Malaysia United Kingdom Spain Bahrain Kuwait (D) Switzerland United Arab Emirates Macau specific administrative region Sweden Vietnam Canada Fig. 2. Continued United Arab Emirates, Macau SAR, Sweden, Vietnam and Canada. Vietnam and Egypt. The days since last reported case was highest Except Switzerland, all of the other five reported the first cases for Nepal ( n = 47), followed by Sri Lanka ( n = 33) and Cambodia before February ( Fig. 2 D). In addition, no new cases were re- ( n = 26). Except Vietnam and Macau SAR (which had 16 and 10 ported in Macau SAR and Vietnam for 25 days and 16 days, COVID-19 cases, respectively), the other eight countries had a total respectively. of ≤3 cases. In addition to the Philippines, none of them reported of any COVID-19-related deaths. 3.5. Countries/territories with a stable number of COVID-19 cases 3.6. Taiwan Ten of fifty-seven countries/regions had stable numbers of COVID-19 cases for ≥15 days, including Nepal, Cambodia, Sri Lanka, Taiwan is a country geographically near China and that has a Russian Federation, India, Macau SAR, the Philippines, Belgium, close contact with China, making it more susceptible to COVID-19 No. of cumulative cases No. of cumulative cases 21-Jan 21-Jan 22-Jan 22-Jan 23-Jan 23-Jan 24-Jan 24-Jan 25-Jan 25-Jan 26-Jan 26-Jan 27-Jan 27-Jan 28-Jan 28-Jan 29-Jan 29-Jan 30-Jan 30-Jan 31-Jan 31-Jan 1-Feb 1-Feb 2-Feb 2-Feb 3-Feb 3-Feb 4-Feb 4-Feb 5-Feb 5-Feb 6-Feb 6-Feb 7-Feb 7-Feb 8-Feb 8-Feb 9-Feb 9-Feb 10-Feb 10-Feb 11-Feb 11-Feb 12-Feb 12-Feb 13-Feb 13-Feb 14-Feb 14-Feb 15-Feb 15-Feb 16-Feb 16-Feb 17-Feb 17-Feb 18-Feb 18-Feb 19-Feb 19-Feb 20-Feb 20-Feb 21-Feb 21-Feb 22-Feb 22-Feb 23-Feb 23-Feb 24-Feb 24-Feb 25-Feb 25-Feb 26-Feb 26-Feb 27-Feb 27-Feb 28-Feb 28-Feb 29-Feb 29-Feb 6 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 (A) New case Cumulative case st Nosocomial 1 local st st 1 death 1 case infection transmission 6 45 No mask Mask by Mask export control identification No import No import from China 4 from Hubei 30 2 15 0 0 (B) Total No. of No. of 17 98 no. of domestic imported cases cases cases (C) Chinese visitors Taiwan businessmen Transmission route Domestic cases Discharged from China and women from China Infection acquisition outside Taiwan Infection acquisition inside Taiwan Spouse transmission Foreign caregiver Familial transmission Nosocomial transmission Fig. 3. (A) Epidemic curve (‘epicurve’) of the 39 patients with coronavirus disease 2019 (COVID-19) and implementation of primary control measures in Tai- wan from 21 January to 29 February 2020. (B) Geographical distribution of the 39 patients with COVID-19 and (C) the possible modes of transmission [https://www.cna.com.tw/news/ahel/202003010211.aspx; accessed 2 March 2020]. Taiwanese businesswoman returning from China who had negative real-time RT-PCR for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the respiratory tract but positive anti-SARS-CoV-2 antibody in the serum. No. of new cases 21-Jan 22-Jan 23-Jan 24-Jan 25-Jan 26-Jan 27-Jan 28-Jan 29-Jan 30-Jan 31-Jan 1-Feb 2-Feb 3-Feb 4-Feb 5-Feb 6-Feb 7-Feb 8-Feb 9-Feb 10-Feb 11-Feb 12-Feb 13-Feb 14-Feb 15-Feb 16-Feb 17-Feb 18-Feb 19-Feb 20-Feb 21-Feb 22-Feb 23-Feb 24-Feb 25-Feb 26-Feb 27-Feb 28-Feb 29-Feb No. of cumulative cases C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 7 Fig. 4. Incidence (per 1 0 0 0 0 0 0 population), mortality rate (%) and deaths per 1 0 0 0 0 0 0 population of patients with coronavirus disease 2019 (COVID-19) and their association (Spearman’s rank-order correlation) with (A) daily cumulative index (DCI), (B) Health Care Index (HCI) and (C) Healthcare Access Quality Index (HAQI) by country. Table 2 spread. To manage this challenge, infection control measures in- Disease incidence (per 1 0 0 0 0 0 0 population), mortality rate (%) and deaths per cluding prohibiting travel from China, controlling the distribution 1 0 0 0 0 0 0 population of patients with coronavirus disease 2019 (COVID-19) and of face masks, extensive investigation of COVID-19 spread, and their association with daily cumulative index (DCI) , Health Care Index (HCI) and a once-daily press conference by the government to inform and Healthcare Access Quality Index (HAQI) by country according to transmission route educate people were aggressively conducted in Taiwan ( Fig. 3 A). Countries with local Countries with imported Under these interventions, Taiwan has a total of 39 cases with transmission cases only a DCI of 1 case per day, which was much lower than that of r P -value r P -value the nearby countries such as the Republic of Korea and Japan Disease incidence (per 1 000 000 population) ( Fig. 3 B). Among the 39 patients, 18 acquired the COVID-19 in- DCI 0.737 < 0.001 0.524 0.001 fection outside of Taiwan, of whom 3 were Chinese visitors from HCI −0.050 0.835 0.384 0.030 China, whilst the other 21 developed the infection in Taiwan HAQI 0.307 0.201 0.628 < 0.001 (http://nidss.cdc.gov.tw/ch/SingleDisease.aspx?dc = 1&dt = 5&disease Mortality rate (%) = 19CoV). Four familial cluster transmissions and one nosocomial DCI 0.642 0.002 −0.171 0.327 HCI 0.000 1.000 0.010 0.958 transmission were reported. To date, 11 patients were discharged HAQI 0.161 0.510 −0.215 0.263 ( Fig. 3 C). Several important actions and responses conducted by Deaths (per 1 000 000 population) the National Health Command Center of Taiwan, including border DCI 0.747 < 0.001 −0.168 0.351 control, resource re-allocation, case identification (using new data HCI −0.073 0.760 −0.011 0.955 HAQI 0.177 0.468 −0.215 0.273 and technology), quarantine of suspicious cases using big data analytics, reassurance and education of the public, mask control a DCI = cumulative cases/no. of days between the first reported case and 29 and hand hygiene, and formulation of policies toward schools February 2020). and childcare, have so far successfully alleviated the crisis and contained the epidemic in Taiwan [7] . Healthcare Access and Quality Index (HAQI) [10] . The HCI is based on surveys from visitors of one open website and questions for 4. Association between mortality and disease incidence these surveys are similar to many similar scientific and govern- ment surveys [9] . The HAQI uses 32 scaled cause values, providing Based on the earlier experience in China, Ji et al. found a signif- an overall score of 0–100 of personal healthcare access and quality icant correlation between mortality and healthcare resource avail- by location over time [10] . First, we found that the mortality rate, ability ( r = 0.61) [8] . We wonder whether the association between incidence and death per 1 0 0 0 0 0 0 people were correlated with mortality and healthcare burden can be demonstrated outside of the DCI (Spearman’s rank-order correlation, all P < 0.05) ( Fig. 4 A) China and whether there are other confounding factors, such as and this association was more prominent in countries with local the level of health care. Therefore, we used two indexes to rep- transmission ( Table 2 ). This finding is consistent with the find- resent the level of healthcare: Health Care Index (HCI) [9] and ings of Ji et al. [8] and suggests that rapidly increasing cases in 8 C.-C. Lai, C.-Y. Wang and Y.-H. Wang et al. / International Journal of Antimicrobial Agents 55 (2020) 105946 a short time can result in more cases and even more deaths. Sec- References ond, the incidence was associated with life expectancy ( r = 0.613, [1] World Health Organization (WHO). Coronavirus disease 2019 (COVD-19). Situ- P < 0.001). This could be because countries with more older adults ation report –40, Geneva, Switzerland: WHO; 2020. Data as reported by 10AM were more likely to acquire COVID-19. Finally, the incidence was CET 29 February 2020 https://www.who.int/docs/default-source/coronaviruse/ found to be correlated with both HAQI ( r = 0.516, P < 0.001) and situation- reports/20200229- sitrep- 40- covid- 19.pdf?sfvrsn=849d0665 _ 2 [ac- cessed 17 March 2020] . HCI ( r = 0.345, P < 0.012), but mortality and deaths per 1 0 0 0 0 0 0 [2] Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of people were not associated with the level of health care ( Fig. 4 B,C). coronavirus disease 2019 in China. N Engl J Med 2020 Feb 28 [Epub ahead of This finding may be explained by the fact that countries with more print]. doi: 10.1056/NEJMoa2002032 . [3] Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syn- advanced healthcare systems have better diagnostic ability to iden- drome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): tify more cases. By contrast, no death cases were reported in most the epidemic and the challenges. Int J Antimicrob Agents 2020;55:105924. countries; thus, no significant correlation could be found. However, doi: 10.1016/j.ijantimicag.2020.105924 . [4] Lai CC, Liu YH, Wang CY, Wang YH, Hsueh SC, Yen MY, et al. Asymptomatic further study is warranted to clarify these findings. carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): facts and myths. J Micro- 5. Conclusion biol Immunol Infect 2020 March 4. doi: 10.1016/j.jmii.2020.02.012 . [5] Wu Z, McGoogan JM. Characteristics of and important lessons from the coron- avirus disease 2019 (COVID-19) outbreak in China. Summary of a report of 72 Between 31 December 2019 and 29 February 2020, COVID-19 314 cases from the Chinese Center for Disease Control and Prevention. JAMA has affected more than 80 0 0 0 patients in 57 countries/territories 2020 Feb 24 [Epub ahead of print]. doi: 10.1001/jama.2020.2648 . and caused 2924 deaths in 9 countries. Although China had higher [6] Rocklov J, Sjodin H, Wilder-Smith A. COVID-19 outbreak on the Diamond Princess cruise ship: estimating the epidemic potential and effectiveness of morbidity and mortality rates than other sites, the number of daily public health countermeasures. J Travel Med 2020 Feb 28 pii: taaa030 [Epub new cases has been lower in China than outside of China since ahead of print]. doi: 10.1093/jtm/taaa030 . 26 February 2020. Seven countries had a DCI of > 5 cases per day, [7] Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA 2020 Mar 3 [Epub ahead of print]. but the DCI of the other fifty countries/territories was < 4 cases doi: 10.1001/jama.2020.3151 . per day. The incidence and mortality rates were correlated with [8] Ji YMZ, Peppelenbosch MP, Pan Q. Potential association between COVID-19 DCI, especially in countries with local transmission. Overall, this mortality and health-care resource availability. Lancet Glob Health 2020 Febru- ary 25 [Epub ahead of print]. doi: 10.1016/S2214-109X(20)30068-1 . preliminary report shows us the initial epidemiological findings of [9] Health Care Index by country 2020. https://www.numbeo.com/health-care/ COVID-19, but continuous monitoring of patients with this disease rankings _ by _ country.jsp [accessed 1 March 2020]. is still warranted. [10] GBD 2016 Healthcare Access and Quality Collaborators Measuring perfor- mance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Funding: None. Global Burden of Disease Study 2016. Lancet 2018;391:2236–71. doi: 10.1016/ S0140- 6736(18)30994- 2 . Competing interests: None declared. Ethical approval: Not required.

Journal

International Journal of Antimicrobial AgentsPubmed Central

Published: Mar 19, 2020

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