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Accounting for underreporting, what is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease burden in the US?
In this cross-sectional study using data from public health surveillance of reported coronavirus disease 2019 cases and seroprevalence surveys, an estimated 46 910 006 SARS-CoV-2 infections, 28 122 752 symptomatic infections, 956 174 hospitalizations, and 304 915 deaths occurred in the US through November 15, 2020.
Findings of this study suggest that although more than 14% of the US population was infected with SARS-CoV-2 by mid-November, a substantial gap remains before herd immunity can be reached.
Estimates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease burden are needed to help guide interventions.
To estimate the number of SARS-CoV-2 infections, symptomatic infections, hospitalizations, and deaths in the US as of November 15, 2020.
Design, Setting, and Participants
In this cross-sectional study of respondents of all ages, data from 4 regional and 1 nationwide Centers for Disease Control and Prevention (CDC) seroprevalence surveys (April [n = 16 596], May, June, and July [n = 40 817], and August [n = 38 355]) were used to estimate infection underreporting multipliers and symptomatic underreporting multipliers. Community serosurvey data from randomly selected members of the general population were also used to validate the underreporting multipliers.
Main Outcomes and Measures
SARS-CoV-2 infections, symptomatic infections, hospitalizations, and deaths. The median of underreporting multipliers derived from the 5 CDC seroprevalence surveys in the 10 states that participated in 2 or more surveys were applied to surveillance data of reported coronavirus disease 2019 (COVID-19) cases for 5 respective time periods to derive estimates of SARS-CoV-2 infections and symptomatic infections, which were summed to estimate SARS-CoV-2 infections and symptomatic infections in the US. Estimates of infections and symptomatic infections were combined with estimates of the hospitalization ratio and fatality ratio to derive estimates of SARS-CoV-2 hospitalizations and deaths. External validity of the surveys was evaluated with the April CDC survey by comparing results to 5 serosurveys (n = 22 118) that used random sampling of the general population. Internal validity of the multipliers from the 10 specific states was assessed in the August CDC survey by comparing multipliers from the 10 states to all states. A sensitivity analysis was conducted using the interquartile range of the multipliers to derive a high and low estimate of SARS-CoV-2 infections and symptomatic infections. The underreporting multipliers were then used to adjust the reported COVID-19 infections to estimate the full SARS-COV-2 disease burden.
Adjusting reported COVID-19 infections using underreporting multipliers derived from CDC seroprevalence studies in April (n = 16 596), May (n = 14 291), June (n = 14 159), July (n = 12 367), and August (n = 38 355), there were estimated medians of 46 910 006 (interquartile range [IQR], 38 192 705-60 814 748) SARS-CoV-2 infections, 28 122 752 (IQR, 23 014 957–36 438 592) symptomatic infections, 956 174 (IQR, 782 509–1 238 912) hospitalizations, and 304 915 (IQR, 248 253–395 296) deaths in the US through November 15, 2020. An estimated 14.3% (IQR, 11.6%-18.5%) of the US population were infected by SARS-CoV-2 as of mid-November 2020.
Conclusions and Relevance
The SARS-CoV-2 disease burden may be much larger than reported COVID-19 cases owing to underreporting. Even after adjusting for underreporting, a substantial gap remains between the estimated proportion of the population infected and the proportion infected required to reach herd immunity. Additional seroprevalence surveys are needed to monitor the pandemic, including after the introduction of safe and efficacious vaccines.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: November 24, 2020.
Published: January 5, 2021. doi:10.1001/jamanetworkopen.2020.33706
Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2021 Angulo FJ et al. JAMA Network Open.
Corresponding Author: Frederick J. Angulo, DVM, PhD, Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 4024 NE Alameda St, Portland, OR 97212 (email@example.com).
Author Contributions: Dr Angulo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Obtained funding: Angulo.
Administrative, technical, or material support: Angulo, Finelli.
Supervision: All authors.
Conflict of Interest Disclosures: Dr Angulo reported being employed by Pfizer Vaccines and owning stock and stock options in Pfizer. Dr Finelli reported being employed by Merck & Co Inc and may own stock in the company. Dr Swerdlow reported being employed by Pfizer Vaccines and owning stock and stock options in Pfizer, as well as providing overviews of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome epidemiology to a consulting firm for a minimal honorarium.
Funding/Support: This work was supported by Pfizer and Merck.
Role of the Funder/Sponsor: Pfizer and Merck had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; and approved the decision to submit the manuscript for publication.
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