ID. ANTAGE [nsciMaren 25, 20201625) Ierratina Journal of Antimicrobial Agents Ge) 200 Contents lists available at ScioncaDiract International Journal of Antimicrobial Agents ELSEVIER Journal homepage: www.clsevier com/ocataiiantimicag Global epidemiology of coronavirus disease 2019 (COVID-19): disease incidence, daily cumulative index, mortality, and their association with country healthcare resources and economic status Chih-Cheng Lai*, Cheng-Yi Wang”, Ya-Hui Wang‘, Shun-Chung Hsueh", Wen-Chien Ko", Po-Ren Hsueh “Deparment of neat Medicine, Kok Vers General Hospital Tainan Branch, Tian, Tava ® eparenent of nternl Medine Cadina Ten Hosp and Sco of Med, Caege of Medcne, Jen Cathe Universi New Tapl Cy, Tava “ea esearch ene, Carina! Ten Hosp and School of Meine, Cole of Med, Pu en Catoe University Mew Tapel Cy, Tava “Dypartment of Made, Clege of Mein Tepe! Metical Unies, Teige Tea “Depuronet of Medicine Coleg of Meine National Cheng Kang Unie Tina, Tan “Department of Labertory Meine Natal Tatar University Herp, Nationa Taiwan Univers Cle of Medic, apt, Tran "Deparment ef ternal Metin, Nana Teen Uniesiy Hes Nationa ewan Univesity Collegeof Medi, Tape Tian ARTICLE INFO ABSTRACT ‘ce or ‘Accepted 12 March 2020, ‘alae onine 01 ithas been 2 months since the fret ease of coronavirus disease 2019 (COVID-19) was reported in Wulban, China, So far, COVID-19 has afected 85 403 patients in 57 countresftesitories and has caused 2924 deaths in 9 counties, However, epidemiological data difer between countries. Although China had higher ‘morbidity and morality than other sites, the number of new daily cases in China as been lower than dutsde of China sine 26 February 2020, The incidence ranged from 61.44 per 1 000 000 people inthe Republic of Korea to 00002 per 1 000 000 people in India. The daly cumulative index (DC) of COVID Fata: jean Mare Haan Ce dvewse 2019 19 (camelae casesno. of ays between the Sst reported case nd 2 Febrssry 2020) was greatest Soot in China (132085), followed by the Republic of Korea (78.78), ran (43.1) and ttaly (30362). However, the DCI in other countiesfterritories were <10 per day Several elective measies including restricting tuavel from China, controlling the distribution of masks, extensive investigation of COVID-19 spread, and once-daily press conferences by the government to inform and educate people were aggressively con- dlucced in Talwan. This is probably the reason why thete was only 39 cass (as of 29 February 2020) with DCL of 1 case per day in Taiwan, which is much lower than that of nearby countries such a the Repub- lic of Korea and Japan. In dition. the incidence and mortality were cacelated with the DCL. However, Further study and continued monitoring are needed to better understand the underying mechanism of coups, ‘County eathare resources (© 2020 The Authors). Published by Blsevier BY. This isan open access article under the CC BY-NC-ND license (hep jjereativecommons orglicensesby-nc-nd/4.0)) 1. Global epider gy of coronavirus disease 2019 (COVID-19) tients in 57 countriesjteritories 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 the end of 2019, COVID-19 has rapidly spread throughout China and has also involved many other countries despite global efforts to prevent its spread [1~4). According to a report of the World ‘Health Organization (WHO), COVID-19 has affected 85 403 pa- Conesponding author. Present adress: Deparments of Laboratory Medline and Internal Medicine. National Taiwan Unversity Hospital, Number 7, Chung Shan ‘South Rea, Tiel 10, Tvan Emel adres: hpoentedasw (PR Hsueh. psd og/0 106 antic 2070105946, ‘97.1% of deaths have been in China |1. Among these 57 coun- tties|teritories, cases reported in 20 countriesterrtories were at- ‘mibuted to local transmission of COVID-19, whilst those in 37 countries|regions were imported cases. However, the incidence and ‘mortality of COVID-19 varied in different countres/jterritories. The incidence ranged from 61.44 per 1 000 000 people in Republic of Korea to 0.0002 per 1 000 000 people in India (Table 1). (524-8579 2020 Te Auchan Published by Elsevier BY. This isan open acess article under the CC BY-NC-ND cease (up creatvecommensorgcensesby-2e-a.0) Please cite this article as: C-C. Lai, C-¥. Wang and Y.-H. Wang et al, Global epidemiology of coronavinis 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, ftps: /doi.org/10.1016)jsjantimicag.2020.105946aS 2 (© tak C3 Wang nd YL Wane alternation Journal of imal Agen x Ce) ‘ble ‘Characerss of 57 countsesteritores wit reported cases f coronavirus dsease 2019 (COVID-19) a of 29 February 2029 |), ‘Counteytentory ‘Cmutaive Ne af Moraliy Incidence per 1000 Deatis per 1000. DG GDP ——_-HCI[S) Days since Ist Local case no. eats rate) 600 population 000 population (sus reported ease _ansmision ‘china yeast aes 3585805 197 ams 10008 6Las 0 ve epubleofvora = 150s ad 033 jam ao nay 8 ve Japa 230 Snir ase 0% su Bria 35 ve Singapore os Doon 675 00 am Giaay oso ve Hong ong sak 4 221s asa 027 234 48334 6508 ve ‘Thatand a2 > d00 as bo 09 7st 795 0 Yee awa 8 13561 os tox ez? a7 0 ves Astin 2% Dana bo os 50022 738 0 Ye Malaysia 24 0 0007 500 on 11136 sai 2 Ys Vietnam 6 Dog ae 00 04 2a) 5770 16 Ye Phipines 3 1 333 ons oor 10 hee gray 3s xe nepal 1 0 000003 100 00s ia? 5688 47 Ne Si tanks 1 5 oon ons oo 00s 3845725333 Ne ew zealand 1 D000 at 0 TI) Ne subtoul woos esl Sas meri anads 1" 5 am aa bm og 6212 7138 8 Ne Bas 1 Bama bm 030 gras Saan 3 Ne Sober is 0 00 ope ray 88 212381469 035 sasr 2945 6859 0 ves Germany a 0 000 ose bo ie 4650 32 0 Ye France 2 2 3st oR? bos ve 760 7999 0 Ys Span 2 0 oon ss 00 ie 29961 78s 0 Ye ve 2 0 dana oo on 030 7408 0 Ye Norway ‘ 0 000 tat 0 300 7975 7436 0 Ne Israel 5 D000 3k oo on «aaa as 0 Ne Asti 5 D000 se oo ver 50022 74730 Ne Cross 5 Doon 120 oo 1s? 14949 6268 0 ves Greece 3 Dao 029 oo so 9974 Sear 2 Ne Romania 3 bam ae bm tao pas S300 0 Ne ussan Federation 2 5 oo oat bm oor ite rsa 29 Ne Finland 2 5 ama bm oor ace 7579 3 Ne Georgie 2 D ooo so 00 too ao Si24 0 Ne Eston 1 ooo ays oo os 523 6) 2 Ne Bem 1 0 00000 bo Oo 45175 34 Ne North Macedonia 5 dona bo 030 aise 5838 3 Ne elas 1 0 oan oa 00 100 603 S808 7 Ne than 1 0 oa 03 0 Yoo 9265 6049 1 Ne Sin Marino 1 o oan nar oo M20 Ye Subeoul inp 308 ran 388 4 ams am oan 41155055170 0 Yes ait 4“ 0 oon 05a 0 900 29.265 S621 0 Ne Darin 38 Doon 233 0 8502 NRO Ne United Arab Emirates 19 Dao 490 oo os 749 G70 2 ves Ing 8 0 00020 00 200 S38 M1362 Ne Oman 6 oo 4a bo iso 7791 $aIs 2 % tenon 3 bam age ry ome cue ‘ Paka 2 5 oan oa bm tao ae 60393 Ne Aighanssan 1 Doon ns 00 0 nS Ne Eevee 1 Doon 00 oor is saa 5 Ne ‘Algeria 1 0 000002 on sem saa 0 Ne Iigeia 1 0 oon o00 too 2251590 Neo subtotal 2 ooo Incernationl cmveyance 705 5 oss 2028 3 Yes eal re eS DCL diy cama index (emulate casesva of dys between the Fst reported case and 29 February 2020; GDF, res domestic produc: HCL, Health Care Index; WA ot aplaeta Wine ond YH Wane oimeratoel ura of Anibal Agr Gn) ID. ANTAGE ‘90000 msAmericas ‘20000 || European s=Eastern mediterranean region 70000 || ==African mInternational conveyance 60000 || —Asia 50000 2 : 40000 30000 20000 No. of eumulati 10000 200 ae ore ore 2isan 2ian aan aan aan aan 3tan Tesco 29, 2020:16:25) 3 1200 1000 No. of cumulative cases 200 a2 RERRAR RS ore 11800 15Fe 168 108 ? saFe i. Daily cumulative case numberof patients wih coronavirus disease 208 (COVID-1) in five main georapicl resins and te international conveyance (Diamond ‘rncess crue shi) as of 25 February 2020. 2. COVID-19 in different geographical regions of the world ‘To date, five regions have observed COVID-19 cases, including ‘sia, Eastern Mediterranean region, Europe, America and Africa. Of course, the highest incidence of COVID-19 was reported in Asia (n = 82 988), followed by Europe (n = 1119), Eastern Meciter- ranean region (n — 510), America (n — 79) and Africa (n = 2) (Pig. 1). Within the last week of February the number of new cases ‘was highest in Asia (n = 5019), followed by Europe (n = 998) and the Eastern Mediterranean tegion (n ~ 467). The overall mortal- ity rate was highest in the Eastern Mediterranean region (6.67%; n= 34), followed by Asia (3.45%; n = 2861) and Europe (206%; n = 23%). In contrast, there had been no deaths in America or Aca as of 29 February 2020. 3, Disease incidence, mortality rate and daily cumulative index ‘of COVID-19 by country “The incidence (cases per 1 000 000 population) of COvID- 19 cases was highest in the Republic of Korea (61.44), followed by China ($5.06), San Marino (23.47), Bahrain (22.33), Singapore (16.75, Macau Special Administrative Region (SAR) (15.40), Italy (14.69), Hong Kong SAR (12.54), Kuwait (10.54) and Iran (4.62). In the other 47 countries, the incidence of COVID-19 cases was <2 per 1000 000 population. Only nine countries had observed COVID- iS-associated deaths, and the mortality rate ranged from 33.33% (1/3) in the Philippines to 0.54% (17/3150) in the Republic of Korea, ‘The daily cumulative index (Dt) of COVID-19 cases is de- fined as the cumulative cases(no. of days between the first re- ported case and 29 February 2020. The DCI was greatest in China (1320.85), followed by the Republic of Korea (78.78), ran (43.11), Italy (30.62), Bahrain (9.50), Kuwait (9.00) and Japan (5.11), The DCL in other countres(SARs was <4 per day. 34. China (China has the highest number of COVID-19 cases in the world (n = 79 251), with an incidence of 55.06 per 1 000 000 people. ‘Among these cases, 2835 patients died, with an overall mortality rate of 3.58% Despite the increasing trend of daily new cases in the early stage, the trend of daily new cases appeared to decline ‘with time since late February 2020. Moreover, the number of daily ‘new cases in China has been lower than outside of China since 26 February 2020. According to the Chinese Center for Disease Con- ‘ol and Prevention [5], 81% of patients with COVID-19 had a mild case and 87% were aged 30-79 years. In addition, 3.8% of those with COVID-19 were healthcare personnel. The case fatality rate ‘was higher in those with critical cases (49%) and patients aged 280 years (148%) [5] 42.2, International conveyance (Diamond Princess) Until the end of February 2020, 705 of the 3700 passengers, (on the Diamond Princess cruise ship had confirmed COVID-19 and 6 died, with a mortality rate of 085%. The basic reproduction rate (Rp) was initially four times higher on-board than the Ro in ‘Wuhan, However, implementation of isolation and quarantine pro- cedures helped to prevent the spread of COVID=19 in more than 2000 passengers and lowered the Ro to 1.78 (6). Although the ex- perience ofthis cruise ship provided a good model for understand ing the behaviour of COVID-19 spread, the spread of disease could have been prevented if all passengers and crew were evacuated early 3.3 Countriesteritories with more than 100 cumulative cases In addition to China, four countries (Republic of Korea, Japan, Italy and tran) had >100 COVID-19 cases. Besides Japan, which showed slowly increasing cases, the other three countries had a rapid increase in COVID-19 incidence since late February (Fis. 2A). Please cite this article as: C-C. Lai, C-¥. Wang and V-H. Wang et al, Global epidemiology of coronavinis 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, ips: /doi.ons/10.1016)j.jantimicag-2020.105946(© tak C3 Wang nd YL Wane alternation Journal of imal Agen x Ce) ‘Among these four countries, Iran had the highest mortality (n = 34), with a mortality rate of 8.76%, Although these countries hhad more COVID-19 cases than other sites except China, the num- ber of cases appeared to increase with time. 3.4. Countriesjteritories with 10-99 cumulative cases Five countres|territories had 50-99 cumulative cases, includ ing Hong Kong SAR. Singapore, USA, Germany and France. Al- (A) though the first COVID-19 case reported in these five sites oc- curred in late January 2020. the number of cases continued to increase at the end of February (Fig. 2B). Seven countries had 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 COVID-19 cases in Bahrain and Kuwait were reported on 25 February and 29 February 2020, respectively (Fiz. 2C). Six coun- tties/tetitories had 10-19 cumulative cases, including Switzerland, Republic of Korea —Japan Italy tran International conveyance 3500 3000 No. of cumulative cases 3 3 (B) Peehiiiill |—United States |—France [—Hong Kong special administrative region —Singapore —Germany YW v No. of cumulative cases 6 8 8 S352 id ffi Hiiliiiil ie Fig. 2. Dally cumulative cate numberof patents with cranavies seat 209 [COVID-1) in our deren! categories of counties scoring to amber of sept cases 23039 Febraty 2020 (A) 10D reported eats (B) 50.99 reported cae; (C) 20-49 seported cases sd (0) 10-19 reported cases Invered tangles eth lle outs ‘enct the date ofthe Sst eported ene each indicated county.ies (© ta C3 We and YL Wane eoineratonel our of Anibal Agents Go) ea (c) —Taiwan —Australia —Malaysia —United Kingdom —Spain —Bahrain — Kuwait 50 45 vy voy y w | 325 & 3% 20 Bias 3S 20 & y TE USPETEP Sree ee eee ) Switzerland United Arab Emirates —Macau specific administrative region | —Sweden 20) | —Vietnam —Canada 8 vy vv ov v g 16 Sn Pr) z 28 36 24 2 of PAALLLEL UDP EESUS TESS EE CEP United Arab Emirates, Macau SAR, Sweden, Vietnam and Canada. Except Switzerland, all of the other five reported the first cases before February (Fig. 2D). In addition, no new cases were re- ported in Macau SAR and Vietnam for 25 days and 16 days, respectively. 35, Couneriesftrrtores with a stable number of COVID-19 cases ‘Ten of fifty-seven countiesjregions had stable numbers of ‘COVID-19 cases for 215 days, including Nepal, Cambodia, Sri Lanka, Russian Federation, India, Macau SAR, the Philippines, Belgium, Vietnam and Egypt. The days since last reported case was highest ot Nepal (n ~ 47) followed by Sti Lanka (n ~ 33) and Cambodia (n = 26), Except Vietnam and Macau SAR (Which had 16 and 10, COVID-19 cases, respectively), the other eight countries had a total ‘of <3 cases. In addition to the Philippines, none of them reported of any COVID-19-related deaths. 36 Taiwan ‘Taiwan is a country geographically near China and that has a close contact with China, making it more susceptible to COVID-19aS (© tak C3 Wang nd YL Wane alternation Journal of imal Agen x Ce) “ (Cw caecum ce] | §S BS : 8 i oI i, =i i aie = 3 2 we we Chinese vistors 5 Taiwan businessme + Transmission route @ Chinese vst wsloesemen @ Domestic cases © Discharged Fig. (A) Epidemic curve (epicure) of the 39 patients sath coronas disease 2019 (COVID-19) and implementation of primary contal measures in Tae ‘wan fom 21 Jentary to 29 Febrary 2020. (8) Geographical dstrbution of the 38 patents with COVIDI9 and (C) the possible modes of transmission Titpspwwocnacom wjnews/ahe/202003012ttaspe: sctessed 2 March 2020)" Tawanese Busipesswoman return fom China who had epative real-time REPCR for Severe acute espatary sypirome coronavirs 2 (S4RS-CoV-2) in the respiratory act Bu posit at-ARS-COV-2 amtiody inthe serum.ARTICLE IN PRESS ti CX Wand YH We evn J of Ain arse 7 (a) ® «© y=0a0 | yeo.e yrooer Sy pe 0.003 BR pom 555 i E pa prom Zp ps “ fy i ” pt) peso i z4 fa 1 if rE WS eins 4 c *) yond “ (p= <0.001 a ease ! ! | : : i" i- i+ io Fig. 4 Incidence (per 1 000-000 population). morality ate (3) and éeaths per 1 000 000 population of patients with coreravirs diease 2019 (COMID-8) and their _ocation (Spearman's enkorder creation) with (A) dally cumulative index (DC (8 Hel Care Inde (HT) and (C) Hela Access Quality dex (HAC by ecu. spread, To manage this challenge, infection conttol measures in- cluding prohibiting travel from China, controlling the distribution fof face masks, extensive investigation of COVID-19 spread, and a once-daily press conference by the government to inform and feucate people were aggressively conducted in Taiwan (Fig. 3A). Under these interventions, Taiwan has a total of 39 cases with 4 DCI of 1 case per day, which was much lower than that of the nearby countries such as the Republic of Korea and Japan (Fig, 38), Among the 39 patients, 18 acquired the COVID-i9 in- fection outside of Taiwan, of whom 3 were Chinese visitors from China, whilst the other 21 developed the infection in Taiwan http:/nidss.cdc.gox.tw/ch/SingleDisease aspx?dc=1&dt-=S&disease ‘=19CoV), Four familial cluster transmissions and one nosocomial transmission were reported. To date, 11 patients were discharged (ig. 30) Several important actions and responses conducted by ‘the National Health Command Center of Taiwan, including border control, resource re-allocation, case identification (using new data land technology), quarantine of suspicious cases using big data Analytics, reassurance and education of the public, mask control ‘and hand hygiene, and formulation of polices toward schools and childcare, have so far successfully alleviated the crisis and Contained the epidemic in Taiwan [7 4. Association between mortality and disease incidence Based on the earlier experience in China, ji etal found a signif leant correlation between mortality and healthcare resource avall- ability (r = 061) (S|. We wonder whether the association between ‘mortality and healthcare burden can be demonstrated outside of China and whether there are other confounding factors, such as the level of health care. Therefore, we used two indexes to rep- resent the level of healthcare: Health Care index (HCI) [9] and Disease incidence (per 1 000 000 population), mortality ate () and deaths yer 1000 000 population of patients with coronavirus disease 2019 (COM 19) and {heir asseiion with daly cumulative inden (Dl). Health Case Index (HC) and Healthcare Access Quality Index (HAD) by county according co tansmision route Counties wit oak Counties with pete ‘aniston acs oly 7 alae Pale ‘Disease icdence (pe 1000 00 popsaton) usar sor 21 os “e001 Morality rte (3) a. ose oom = 0x1 ox ka. ‘000 ow G10 0958 Agi ost aso 0215 026 Death (ger 1 000 000 population) sa air ass 0315 027 TDG = cumulative casino. of days between tbe Fist reparied ase and 29 ebrury 2020 Healthcare Access and Quality Index (HAQI) [10]. The HCI is based fon surveys from visitors of one open website and questions for these surveys are similar to many similar scientific and govern- ‘ment surveys (5). The HAQl uses 32 scaled cause values, providing an overall score of 0-100 of personal healthcare access and quality by location ever time |10). Fist, we found that the mortality rat, incidence and death per 1 000 000 people were correlated with ‘the DCI (Spearman's rank-order correlation, all P = 005) (Fig. 4A) and this association was more prominent in countries with local transmission (Table 2). This finding is consistent with the find ings of Ji et al. [8] and suggests that rapidly Increasing eases inaS 5 (© tak C3 Wang nd YL Wane alternation Journal of imal Agen x Ce) ‘a short time can result in more cases and even more deaths. Sec- ‘ond, the incidence was associated with life expectancy (r = 0.613, P< 0.001) This could be because countries with mote older adults ‘were more likely to acquite COVID-19. Finally, the incidence was found to be correlated with both HAQI (r = 0.516, P < 0.001) and HCI (r = 0.345, P < 0.012), but mortality and deaths per 1 000 000, people were not associated with the level of health care (Fig, 4B. ‘This finding may be explained by the fact that countries with more advanced healthcare systems have better diagnostic ability to iden- tify more cases. By contrast, no death cases were reported in most ‘countries; thus, no significant correlation could be found. However, further study is warranted to clatify these findings. 5. Conclusion Between 31 December 2019 and 29 February 2020, COVID-19, has affected mote than 80 000 patients in $7 countriesjterttories and caused 2924 deaths in 9 countries. Although China had higher ‘morbidity and mortality rates than other sites, the number of daily new cases has been lower in China than outside of China since 26 February 2020. Seven countries had a DCI of »5 cases per day, but the DCI of the other fifty countriesfterritories was <4 cases pet day. The incidence and mortality rates were correlated with DDL, especially in countries with local transmission. Overall, this preliminary report shows us the initial epidemiological findings of ‘COVID-19, but continuous monitoring of patients with this is stil warranted, Funding: None. ‘Competing interests: None declared. Ethical approval: Not required. References, [1] etd Heath Orgaizaton (WHO) Coronas disease 2019 (COVD.19) St tion report ~ 40, Geneva, Switzcand: WHO: 2020 Data es reported by TOAM {er 2 trary 2020 hip hot doc detale sure erooare) Shustionrepats2oz00226slsep-a0-coud ISparteso8A00056S 2 fae cessed 17 March 2020] (2) Guna Wy NZX Hu, Lang WH, Ou CQ Me Pt Clana caraceistics of feronars dices 2019 1m Cine. 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