COVID-19 mortality in different areas of Chinese mainland as of March 10, 2022

doi:10.21203/rs.3.rs-4920105/v1

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COVID-19 mortality in different areas of Chinese mainland as of March 10, 2022

https://doi.org/10.21203/rs.3.rs-4920105/v1

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Background

We have reported the difference of COVID-19 morbidity in different areas of Chinese mainland.

Objective

This paper aims to discover COVID-19 mortality difference among different areas and epidemic phases of Chinese mainland, and discuss the timing of the termination of strict quarantine measures.

Methods

Chinese mainland was divided into area I-III, the epidemic process was divided into phase I-IV. Daily COVID-19 death, cumulative death, death ratio, and daily severe case data were collected.

Results

Before April 15, 2020, during each epidemic phases, area I had the highest daily death and death ratio, while area III had the lowest. In phases III, the daily deaths in area I-III were higher than in phase II, and the death ratios in area II and III were higher than in phase II. After April 14, 2020, only two deaths in Chinese mainland occurred in area III; And severe case ratio dropped to almost all below 10%, especially after May 29, 2020, the ratio dropped to 0-4.76%.

Conclusion

Before mid-April 2020, the most serious COVID-19 death period in Chinese mainland is Phase III; And the most serious COVID-19 death area is Wuhan, with a mortality rate of about 0.0769 during outbreak phase. Due to adequate treatment, severe case ratio and death ratio dropped quickly, with almost zero of COVID-19 death ratio after mid-April 2020. At this time or after May 29, relaxed quarantine measure may be feasible. The intensification of SARS-CoV-2 contagiousness has led to ‘dynamic zeroing’ policy failure.

COVID-19

Wuhan

Chinese mainland

Epidemic

Mortality

It has been more than four years since the coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China [1], and the epidemic has not yet ended in the world [2]. Before January 7, 2024, there were 774 million COVID-19 cases worldwide, including over 7 million deaths [2]. The epidemic, which has had the widest impact on humanity in the past century, is also the fastest spreading, most widespread, and most difficult major public health emergency to prevent and control since the establishment of the People's Republic of China [3]. Chinese mainland has once taken the most stringent control measures, and the ‘dynamic zero clearing’ policy was stopped after the epidemic lasted for three years [4]. So far, early epidemic data of Chinese mainland remains a hot topic of global attention [1]. In the previous research, we reported the difference of early COVID-19 morbidity in different areas of Chinese mainland [1]. This paper aims to discover the changes and causes of epidemic mortality in different areas and phases in Chinese mainland by March 10, 2022. A private evaluation was also made on the termination of the strict quarantine policy.

As our previous study [1], Chinese mainland was divided into three adjacent areas: area I (Wuhan city), II (Hubei province, excluding Wuhan city) and III (Chinese mainland, excluding Hubei province), centering around Wuhan. We also called Hubei province (including Wuhan city) area IV, and called Chinese mainland (including Hubei province) area V. Based on the daily increase of COVID-19 patient's number [1], the epidemic process was divided into I-IV phases: limited cases, accelerated increase, decelerated increase and containment phases, and phases II and III were combined as outbreak phase as our previous study [1]. The epidemic in area II and III lacks phase I.

Daily COVID-19 death toll, cumulative death toll and death ratio were included in the epidemic data. Epidemic data also included incomplete data of daily severe COVID-19 inpatients. We also recorded the peak-times of daily deaths, inpatients, and severe patients in each area. The data was expressed as mean plus or minus standard error, and SPSS 13.0 was used to statistically analyze the data. ANOVA was used to compare the data differences, and a P < 0.05 was considered significant.

All health committees published daily epidemic data in their respective regions. Severe case ratio is defined as severe COVID-19 inpatients' number to COVID-19 inpatients' number. Death ratio is defined as cumulative COVID-19 death cases' number to cumulative COVID-19 cases' number. Asymptomatic infections were not included in the COVID-19 cases mentioned in this article.

Cumulative death toll of COVID-19

The cumulative death toll of COVID-19 in area I was 1 on January 10 and reached 23 on January 23, 2020. On the same day, deaths began to occur outside area I. As of March 17, 2020, the cumulative death toll in area I, II and III reached 2490, 632 and 115 respectively (Fig. 1A). On April 17, 2020, 1290 underreported deaths were reported in area I (Fig. 1A). As of March 10, 2022, the cumulative death toll in area I, II and III reached 3869, 643 and 124 respectively [5–7].

COVID-19 mortality in phase I, II and III

In phase I, 2 of the 41 confirmed patients in area I died (Fig. 1A). In area I, II and III, the peak number of deaths per day was 131, 36 and 12 respectively during the outbreak phase (Fig. 2A). In phase II, phase III and even the whole outbreak phase of area I, II and III, the most and least average daily COVID-19 death toll and average death ratio was in area I and III respectively (all P<0.01 or P<0.05, Fig. 2A and 3A, Supplementary Material 1 and 2). In phase III, the average daily death toll of area I, II and III and the average death ratio in area II and III were significantly higher than those in phase II of same-area (all P<0.01 or P<0.05, Fig. 2A and 3A, Supplementary Material 1 and 2). The difference in average death ratios between phase III and II in area I was not significant (Supplementary Material 2).

COVID-19 death during phase IV up to April 14, 2020

In area I, the cumulative death toll continued to rise in the early stage of phase IV (Fig. 1B). During phase IV, as of April 14, 2020 in area I, II and III, the average number of deaths per day was the most in area I and the least in area III (P<0.01 or 0.05) (Supplementary Material 1).

COVID-19 mortality from April 15, 2020 to March 10, 2022

From April 15, 2020 to March 10, 2022, there were no deaths in area I and II (Fig. 2B, Supplementary Material 4), while only two deaths occurred in area III on January 13 and January 25, 2021 [8, 9], respectively. In addition, on April 17, 2020, the death ratio of COVID-19 increased sharply in area I (Fig. 3B), which is the result of correcting the early death data of the epidemic [10].

Severe COVID-19 cases in hospital every day

Daily severe case data of COVID-19 in Wuhan from January 21 to February 11, 2020 is not available on the website of Wuhan City or Hubei Province Health Commission, resulting in a lack of data in both area I and II during the above period (Fig. 4). However, we can observe the peak time of severe COVID-19 cases in each area, the complete data and their changing trends in area III, IV and V, and the general trend of data changes in area I or II (Fig. 4). During the outbreak phases of area I, II and III, the number of severe cases in area I and III is the most and the least, respectively (Fig. 4).

Ratio of severe cases among COVID-19 inpatients

The number of severe COVID-19 cases from January 21 to February 11, 2020 in area I was not obtained from the websites of health committees at all levels, resulting in a lack of partial data of severe cases ratio in area I and II. In addition, when the number of COVID-19 inpatients is less than 10, we give up calculating the ratio of severe cases. In area I, II and III, the peak of the ratio of severe cases among COVID-19 inpatients all occurred after the outbreak phase. Area III had the first peak, followed by area II, and area I had the latest peak (Fig. 4A-B). The detailed times were March 13, March 24, and April 4, 2020, with detailed values of 20.80%, 29.41% and 40.99%, respectively (Fig. 4A-B). In area IV and V, the peaks of the ratio of severe cases among COVID-19 inpatients also occurred after the outbreak phase (Fig. 4C-D). During the outbreak phase, the average ratio of severe COVID-19 cases among inpatients in area III (0.1144 ± 0.0052) was significantly lower than that in area IV (0.2294 ± 0.0057) and V (0.2152 ± 0.0060) (both P = 0.00) (Fig. 4A, C). As of April 14, 2023, the average ratio of severe cases among COVID-19 inpatients in area III, IV and V was 0.1054 ± 0.0053, 0.2616 ± 0.0068, and 0.2188 ± 0.0062, respectively, with significant differences (P = 0.00) (Fig. 4A-D). From April 15, 2020 to July 02, 2020, the average ratios of severe cases among COVID-19 inpatients in area III and V were 0.0491 ± 0.0034 and 0.0557 ± 0.0039, respectively, with no significant difference (Fig. 4B, D).

Peak time of new COVID-19 cases, inpatients, severe cases, new deaths and severe case ratios in area I, II and III

In area I, II and III, the numbers of new COVID-19 cases [1], inpatients [1], severe cases and new death cases gradually increased to the peak, and then gradually decreased (Fig. 4, 2), while the severe case ratios (after February 20, 2020) gradually increased to the peak, and then rapidly decreased (Fig. 5). However, the COVID-19 death ratio did not show the aforementioned change or peak (Fig. 3), but first decreased, and then gradually increased from the 6th day of Phase II in area I and the 2nd day of Phase II in area II and III (Fig. 3A). Among the peak times of new COVID-19 cases, inpatients, severe cases, new deaths and severe case ratios in area I, II and III, the peak time of severe case ratios appeared after outbreak phase, while the rest of the peak times occurred in outbreak phase in the order mentioned above (except for the peak time of new deaths in area II) (Supplementary Material 3). The peak time of the above indicators in area I was later than the peak time of the above indicators in area II and III respectively (Supplementary Material 3). The peak time of severe cases in area I, II and III almost coincided with the peak time of inpatients in the same area (Supplementary Material 3).

Infectious epidemics are one of the main causes of global mortality. COVID-19, the most prominent epidemic in recent years, has not only caused a large number of deaths worldwide, but also caused serious economic, social and political turmoil [11]. The causative virus of COVID-19 is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [12], which was first reported by Chinese mainland in the world. Worldwide, COVID-19 epidemic has first brought severe challenges to the life safety and economic development of Chinese mainland. It is of great significance to carefully study the development of the epidemic itself here and its harm to the people of Chinese mainland.

From COVID-19 outbreak to April 14, 2020

From the outbreak of COVID-19 to April 14, 2020, area I had the most average daily deaths, while the least in area III (Supplementary Material 1, Fig. 2). During the outbreak phase, area I had the highest death ratio, while the lowest in area III (Supplementary Material 2, Fig. 3). As of April 14, 2020, due to 1290 previously unreported deaths [10], the cumulative deaths' number in area I reached 3869, while only 823 and 120 respectively in area II and III (Fig. 1 and Supplementary Material 3). These differences should be caused by the distribution of severe COVID-19 cases in the three areas, where area I has the most and highest proportion of severe cases per day, while area III has the least and lowest proportion of severe cases per day (Fig. 4A, B; Fig. 5A, B). In addition, the peak time of daily new deaths in area I was later than that in area II and III (Supplementary Material 3; Fig. 2A; Supplementary Material 5A). These all indicate that the epidemic in area I is the most severe and poses the greatest threat to people's health, while the epidemic in area III is relatively mild. As far as we know, Wuhan (area I) was the first place in the world to face this completely unknown virus, SARS-CoV-2. COVID-19 rapid spreading had greatly exceeded the capacity of medical facilities, and there was a lack of treatment experience, effective drugs, ventilators, and vaccines, which had led to inadequate treatment, high proportion of severe cases, and high death ratio in Wuhan in a short period of time. With the establishment of a large number of quarantine and medical facilities [10], the implementation of continuous strict quarantine policies [1, 13–15], the improvement of treatment level, the timely supply of medical devices such as respirators, and the strong supervision of the Chinese government on epidemic prevention and control, the spread of the epidemic was finally contained in Wuhan. The earliest traceable onset of symptoms among confirmed COVID-19 cases in Wuhan was on December 8, 2019 [1]. From this time until March 17, 2020, the end of outbreak phase of the epidemic, and then entering containment phase in Wuhan (Supplementary Material 3), it went through a total of 100 days. Since then, the daily increase in deaths in Wuhan has dropped to below 10 (Fig. 2), and there have been no further reports of deaths after 28 days (after April 14, 2020) (Supplementary Material 3).

Whether in area I, II or III, the peak time of daily new deaths was 5–16 days later than the peak time of daily new COVID-19 cases (Fig. 2A, Supplementary Material 3), and the average daily death toll in phase III was significantly higher than that in phase II (Supplementary Material 1). This may be due to the fact that the peak time of daily COVID-19 inpatients is also 8 to 11 days later than the peak time of daily newly increased COVID-19 cases (Supplementary Material 3), and the peak time of daily severe COVID-19 cases basically coincides with the peak time of daily hospitalized COVID-19 cases (Supplementary Material 5A, B). In addition, some of these severe COVID-19 cases died after some days of sufficient rescue. In area II and III, the death ratio in phase III was significantly higher than that in phase II (Supplementary Material 2), which was related to the peaks of both severe and deceased patients being in phase III (Supplementary Material 3, Figs. 2 and 4). However, there was no significant difference in death ratios between phase III and II in Wuhan (Supplementary Material 2), which may be caused to the fact that most of the early underreported deaths in Wuhan [10] might occur in phase III, and the inadequate treatment of COVID-19 in phase II was more prominent in Wuhan. In phase III, the death ratios in area I, II and III showed troughs on February 12, 6 and 4, 2020, respectively, and gradually increased thereafter (Fig. 3). These troughs occurred between the peak time of patient increase and the peak time of death increase (Supplementary Material 3). The reason was that cumulative patients' number was large at that time, while daily deaths’ peak had not yet arrived (Figs. 2 and 3). In area I, II, and III, the peaks of severe case ratios all occurred after the outbreak phases (Fig. 5A, B), mainly due to the rapid reduction of COVID-19 inpatients at this time [1], while severe patients were still hospitalized for treatment after a period of time.

In outbreak phase, the death ratios of area I, II and III were 0.0442 ± 0.0015, 0.0212 ± 0.0012, 0.0053 ± 0.0004 respectively (Supplementary Material 2). However, on April 17, 2020, the death ratio in Wuhan suddenly rose to 0.0769 (Fig. 3B), due to the reporting of 1290 deaths missed in the early epidemic [10] on that day. This also caused that cumulative deaths' number increased from 2579 to 3869 that day (Fig. 1B), which is a 0.5-fold increase. Therefore, we speculate that the death ratio of area I in the outbreak phase is between 0.0442 and 0.0769, which is closer to 0.0769.

From April 15, 2020 to March 10, 2022

However, after April 14, 2020, only 0, 0 and 2 deaths occurred in area I, II and III respectively (Supplementary Material 4), which indicates that COVID-19 death ratio in Chinese mainland has significantly decreased to nearly zero, and the change may be caused by the reduction of severe COVID-19 cases. From April 15, 2020 to March 10, 2022, the number of newly increased COVID-19 cases in area I, II and III was 205, 54, and 29964, respectively (Supplementary Material 4). This means that almost all newly increased COVID-19 cases were in area III. And the numbers of severe COVID-19 cases in area IV (Hubei province) and area V (Chinese mainland) significantly decreased after April 14, 2020 (Fig. 4D). As a result, severe COVID-19 case ratio in Chinese mainland (area V) dropped from the peak (33.25%) to almost all below 10%, especially after May 29, 2020, this ratio dropped to 0-4.76% (Fig. 5D). Are the significant reductions of severe cases and mortality determined by the following factors? Firstly, the widespread use of COVID-19 vaccines. There are evidences to suggest that COVID-19 vaccines are effective in preventing severe cases [16, 17]. However, the legal emergency use of COVID-19 vaccine in Chinese mainland began in July 2020 [18]. Secondly, reduced pathogenicity of SARS-CoV-2 variant strains. Virological studies have shown that over time, SARS-CoV-2 undergoes constant mutations during transmission, the variants of concern including alpha, beta, gamma, delta, followed by Omicron [19]. Compared to previous strains, Alpha and Delta variant strains are more likely to cause severe COVID-19 [20], while Omicron strains are less likely to cause severe COVID-19 [21, 22]. However, Omicron mainly became prevalent globally after December 2021 [23, 24], while other variant strains became prevalent in different regions of the world after October 2020, all significantly later than April 14, 2020 [23, 24]. Finally, the improvement of COVID-19 treatment level and the guarantee of high-quality medical conditions. The prevention, diagnosis, and treatment plans for COVID-19 are timely developed and updated. For example, on March 3, 2020, the diagnosis and treatment plan for COVID-19 was updated to the seventh edition [25], and on February 14, 2020, the diagnosis and treatment plan for severe COVID-19 cases was updated to the second edition [26]. China has developed infrastructure technology and manufacturing industry, resulting in rapid construction of medical facilities and rapid production of drugs, medical devices, especially ventilators for the treatment of severe illnesses. This ensured the need to fight against the COVID-19. Traditional Chinese medicine has also played an important role in the prevention and treatment of COVID-19 [27]. In addition, the strict supervision of COVID-19 prevention and control by the Chinese government is a strong guarantee for the early improvement of the epidemic and the reduction of deaths. These factors can not only reduce the conversion of mild COVID-19 to severe COVID-19, but also ensure sufficient treatment for severe COVID-19.

Accordingly, the continuous improvement of treatment level and the strong supervision from Chinese government on COVID-19 have provided adequate treatment for COVID-19 cases and played a vital role in reducing severe cases and mortality. From January 10, 2020 to April 14, 2020, after 95 days, the mortality rate of COVID-19 has been reduced to almost zero.

Three-year strict quarantine and defense policies

Chinese government implemented strict quarantine measures and effectively guaranteed the supply of medical places, facilities, instruments, drugs and medical staff. As a result, the epidemic was controlled as early as possible and deaths were minimized to the greatest extent possible. However, the three-year strict quarantine and defense measures have also hindered national economy development, reduced personal economic income, and disrupted personal daily work and life. When to stop strict quarantine measures is a major test for China. So far, SARS-CoV-2 mutations all increase its infectivity [28–32]. In December 2021, Chinese mainland reported the first case of Omicron [33], and then it spread rapidly. Some studies showed that the infectivity of Omicron was 13 times higher than the original strain [34], and 40.50% of the infected people were asymptomatic carriers [34], [35]. Therefore, the increasing infectivity of COVID-19 and the inevitable frequent contact between people have predicted that COVID-19 will inevitably coexist with humans and lead to the failure of the ‘dynamic zero clearing’ policy. The pathogenicity of COVID-19 determines its lethality, and studies have shown that the alpha and delta variant strains are more pathogenic than previous strains [20]. However, the spread of the Alpha strain did not significantly increase the severe COVID-19 rate and mortality rate [36], and after April 14, 2020, with the increase of COVID-19 cases, there were almost no deaths in Chinese mainland (Supplementary Material 4). All these reminders indicate that after mid-April 2020, although the continuous mutation of SARS-CoV-2 has increased its infectivity and gradually increased the number of infected individuals, it has not posed a threat to individual life safety, and strict quarantine measures cannot completely eliminate the virus. Therefore, we are curious whether replacing strict quarantine with relaxed quarantine measures after mid-April 2020, or at a slightly later time (May 29, 2020), would not only not lead to a significant increase of deaths, but also not affect the national economy and individual life. Of course, this requires scientific experiments on the pathogenicity of viruses as a prerequisite, as well as sufficient medical facilities, medical equipment, drugs, vaccines, and medical staff as guarantees.

All authors have no conflict of interest. This manuscript is not applicable for ethical approval and participant consent. The data of this manuscript are all from the official websites of health committees at all levels in Chinese mainland, and the data collected can be obtained through the email of the corresponding author. All authors participated in data collection, chart creation, and manuscript writing.

Funding Declaration

This study was supported by Shandong Province Traditional Chinese Medicine Science and Technology Development Plan Project (No. 20190906; Yuehai Wang). This article is also one of the achievements of Liaocheng Philosophy and Social Sciences Planning Project (Research on Guidelines and Consensus Information Platform for Medical and Health Services; NDYB2023012; Jinghong Yu).

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No competing interests reported.

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Supplementary Material 5 Daily COVID-19 inpatients, severe cases and deaths in area I, II and IIIarea I, Wuhan city. area II, Hubei province (excluding Wuhan city). area III, Chinese mainland (excluding Hubei province).

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You are reading this latest preprint version

COVID-19 mortality in different areas of Chinese mainland as of March 10, 2022

Status:

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Abstract

Background

Objective

Methods

Results

Conclusion

Figures

Introduction

Methods

Results

Cumulative death toll of COVID-19

COVID-19 mortality in phase I, II and III

COVID-19 death during phase IV up to April 14, 2020

COVID-19 mortality from April 15, 2020 to March 10, 2022

Severe COVID-19 cases in hospital every day

Ratio of severe cases among COVID-19 inpatients

Discussion

From COVID-19 outbreak to April 14, 2020

From April 15, 2020 to March 10, 2022

Three-year strict quarantine and defense policies

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1