####
We
may have far more infections than previously thought, and constructing models
to estimate numbers is extremely hard

**BY**

**TOM CHIVERS**

April 1, 2020

The national
conversation is dominated by coronavirus statistical models at the moment. The
Imperial College model, the Oxford model, the

*other*Imperial model.
I want to talk about the
models, and what they tell us, because the outputs of these models drive the
government’s response — and thousands of lives could turn on them. It’s
important, therefore, that we understand them, and why the numbers they give us
are so different. These figures led Peter Hitchens, the

*Mail on Sunday*columnist, to complain that the number of deaths has jumped around from 500,000 to 20,000, to 5,000. I can see why people are confused, if they just think “the models” are taking the same numbers and spitting out these weirdly different results.
But first, I want to talk
about something much simpler. It’s the question that many of us, I’d say, most
want to know, when we’re anxiously thinking about Covid-19 and ourselves and
our loved ones. That is: if someone gets the disease, how likely are they to
die?

The splendid Our World in
Data (OWID) — who, full disclosure, I’ve been doing some editing for during
this crisis — have been working
on answering that question. So
has Oxford’s equally splendid Centre for Evidence-Based Medicine (CEBM).

It is probably the most
basic question you can ask about a disease, and
yet it’s bloody hard to answer. It changes between places and over time, and
between different groups; it depends on a variety of hard-to-measure factors,
and the answer you get

*itself*directly affects our understanding of several other numbers, all of which are vital to any model of the disease.
So. You may have heard a
term being used: the “case fatality rate”, or CFR. That is the number of deaths
divided by the number of confirmed cases. When journalists talk about the
“death rate”, that’s often what they are referring to. If a country has 10,000
confirmed cases and 100 deaths, then the CFR in that country is (100/10,000),
or 1%.

That is not what we are
looking for, and it is probably not even very close to what we are looking for.

Instead what we want is the
“infection fatality rate”, or IFR. That is the number of deaths divided by the
number of people who

*actually have the disease*. The number of people who have*tested positive*for the disease is probably only a fraction of the total number who had it, because only a fraction of the population has actually been tested.
Obviously, the IFR is much
harder to determine accurately. The only people getting tested will be the
people who are most ill, so your IFR is probably much lower than your CFR,
because your denominator — the number you’re dividing by — is probably much
bigger.

So if your country has
tested absolutely everyone and found all cases of the disease, then your IFR is
the same as your CFR, or 1%. But if it has only found 10% of the people with
the disease, then your 10,000 confirmed cases are just the tip of a
100,000-person iceberg. With those 100 deaths, your IFR would be (100/100,000)
or 0.1%.

Sadly, all we know is the
CFR, and it changes hugely from country to country. Professor Jason
Oke, a statistician at Oxford
University and one of the people behind the CEBM analysis, points out that the
CFR in Italy is many times higher than that in Germany; 11% of confirmed cases
have died in the former, compared to 0.79% in the latter. “That can’t be down
to healthcare differences,” he says: “Italy isn’t a third-world country. And it
can’t be demographics — Italy has an old population [and older people are at
greater risk], but Germany isn’t far behind it.”

The likely explanation is
that the difference is down to testing. Italy has largely tested people with
symptoms, in hospitals; Germany has tested many thousands of people who have no
symptoms. That probably helps prevent some deaths, but the most direct impact
will be that it hugely increases the denominator; again, if you’re dividing
your 100 deaths by 100,000 instead of 10,000, your death

*rate*will be much smaller. Germany’s will be closer to (but not the same as) the IFR, the number we really want.
So, a country’s CFR will
vary depending on how many tests it’s done, because that changes the
denominator. But at least the numerator — the number being divided — is
probably pretty straightforward, right? A death is a death.

Sadly, that’s not the case
either. Dr Hannah Ritchie,
one of the data scientists at OWID, points out that the death statistics are
complex too, for two reasons. One is prosaic: a lot of people who have the
disease and will die of it have not yet died. “The period from onset to death
is about a month,” she says. So your simple “divide the numerator by the
denominator” rule — the number of deaths by the number of patients — doesn’t
work, because your number of deaths is a product of how many people had the
disease a month ago, not how many people have it now.

That’s bad enough. But there’s a more profound problem, which is
that deaths themselves can be recorded very differently in different places.
Professor Sir David
Spiegelhalter, a statistician
at the University of Cambridge, says that the UK simply counts people who have
tested positive and then died. But
in some other countries, people are recorded as having died of Covid-19 if they
had the symptoms, even if they weren’t tested (“suspected” as opposed to
“confirmed”); in others, people outside hospitals are not tested and so are not
recorded.

“Even the number of deaths
is not a perfect statistic at all,” Spiegelhalter says.

*El Pais*did an interesting look at some of the international differences here; Britain’s Office for National Statistics explains why its numbers look different from the official Government ones here.
To some extent it doesn’t
matter, says Spiegelhalter: as long as each individual country maintains the
same regime, ”the number of deaths is still a good monitor for the shape of the
epidemic”.

But it’s not clear that
they are fixed; countries may have good reasons to change the way they collect
data as circumstances change, but it apparently happens often enough that the
World Health Organisation feels that they have to ask countries to notify them when they do it. Famously, China did so
earlier in the epidemic, but others do too: in complying with the WHO’s
request, Australia has noted that
it has changed its definition of a Covid-19 “case” (and therefore a Covid-19
“death”) at least 12 times since 23 January.

So, in essence, to work out
the IFR — the number we want — we need to know two other factors: the number of
people infected with Covid-19, and the number of people who died of it; the
denominator, and the numerator. And, sadly, both numbers are uncertain.

How much does any of this
matter? Well: now, I’m going to try and build my very own, rather stupid model.
I’m not going to try to predict the future; I’m just going to try to use some
very simple numbers to “predict” the number of cases there are in the UK

*right now*.
First, the number of
reported Covid-19 deaths in the UK is 1,408.
Second, the lag between infection and death is about three or four weeks; let’s
say three. Third, the number of (confirmed) cases in the UK has been doubling
about every three to five days; let’s say five (and assume it’s staying
constant; forget social isolation for now).

With those numbers, we can
plug in our guess at the IFR (the infection fatality rate, remember: the

*real*number we want to know, the “if I get it, how likely am I to die” number) and use it to work out roughly how many cases we’d expect*now*.
So what number should we
use as our IFR? I’m going to use three: one from Imperial College London’s MRC
team, the one behind the famous model; and two from CEBM. Imperial’s latest work assumes
an IFR of 1%; CEBM estimates it to be between 0.1% and 0.26%.

If we take the Imperial 1%,
then that means that we can multiply the 1,408 deaths now by 100 to get the
number of people who’d had the disease three weeks ago, because we think about
one in 100 of them died. So about 140,000 people.

Then we can take our doubling
time — we said five days — to get how many cases we’d see now. In three weeks,
21 days, you’d see four doublings; two to the power four is 16. So 16 times
140,000, which is 2,240,000. We could imagine that we’ve probably got about two
million cases now.

But let’s use the CEBM
numbers. First the highest one, 0.26%. If we take that, we can multiply the
1,408 deaths by 400, instead of 100, to give us the number of infections three
weeks ago. That is 560,000. Then we can multiply

*that*by 16 to give us an estimate of how many there are now: about 9,000,000.
And how about if we use
their lowest estimate, 0.1%? Same routine: 1,408 multiplied by 1,000,
multiplied by 16: more than 20,000,000.

So by changing a single
number, the IFR, to one of three plausible values, in a very simple model, we
get outputs that range from “3% of people have already had it” to “30% of
people have already had it”. And that’s before we start messing around with the
other assumptions; is doubling time three days, not five? Is infection to death
four weeks, not three? Is “1,408 deaths” even correct?

I want to reiterate: this is a very simple, stupid model, put
together by a journalist, not an epidemiologist. The actual models will be far
more complex, and will take into account other things — the number of cases in
hospital and so on — to try to ground them in objective fact. Don’t mistake
this for some plausible estimate of infection numbers. And there are loads of
other things to worry about: people suffering long-term health consequences,
even if they live; people dying of other things because the healthcare system
is overwhelmed.

But the problem that I’m
illustrating is real. Small, plausible adjustments to your inputs make your
model spit out very different things. The assumptions you make are vital. We
haven’t even started to think about other crucial things — for instance,
government interventions, and how effective they are.

“The different scenarios —
isolation, closing schools, quarantines — they come with massive assumptions
about how adherent people are,” says Ritchie. “You get massively varying
outputs, depending on what you put in.” Plus, of course, it’s all circular:
your model influences how you respond; your response changes what numbers get
put back into the model.

What you need is better
numbers, to plug into the models. And that’s what people are trying to get. The
CEBM paper uses, among other things, numbers from Iceland, which — being tiny — managed to test a huge
proportion of its population, nearly 3%. It found 963 cases and just two
deaths; an CFR of 0.2%, from which the CEBM extrapolates an IFR of 0.05%. But
that’s likely an underestimate, because quarantining has protected the elderly,
the most at-risk group. Others have done something similar with passengers on the cruise ship Diamond
Princess, finding a CFR of around 1% — likely an overestimate, since the
passengers tended to be older.

Another way has been to
screen small groups who are in quarantine, such as the Diamond Princess
passengers or passengers on aircraft, to see how many people 1) test positive
and 2) show symptoms. If you know how many people have the disease but are
asymptomatic, then you can extrapolate to the wider population — if you’re
testing all the people who are symptomatic, and you know that 50% of infected
people don’t show symptoms, and you find 20,000 cases, you can estimate that
the real number is more like 40,000.

But there’s a problem here,
too, which is that “asymptomatic” is not a simple thing, according to George
Davey Smith, an epidemiologist at the University of Bristol. If you’re sitting
in quarantine and you cough, you might be recorded as symptomatic; but out in
the real world, you’re not going to take yourself to hospital for a gentle
cough, so you still won’t get tested.

Instead of there being a
neat “symptomatic/asymptomatic” division, you have a third group: people with
some symptoms but who think it’s just a cold in the chest. (As I write, I’m
coughing a little; but I don’t think that’s Covid-19, I think it’s just because
I went for a run this morning and the cold irritated my lungs. But I’d probably
be recorded as “symptomatic” if I were in quarantine and being screened.)

And yet another way is to
look at how many people die every year, and how many people are dying now, and
seeing whether more people are dying than usual. That’s how we attribute deaths
to flu each year, says Spiegelhalter; the European Monitoring of Excess
Mortality group (EuroMOMO) uses this data to say that in an average year in the
UK, 17,000 deaths are “associated” with influenza. But so far there is no
excess death at all, except in Italy: the EuroMOMO charts are all around the seasonal average. That
will likely change, but we forget that in a population of millions, you’d
expect thousands of deaths every day anyway: even the Covid-19 pandemic is
still being lost in the noise.

In the end, we need testing. And not just the sort of testing we
have now — PCR testing, which shows who has the virus right now; we need
serological testing, which shows who has had it in the past. That will come
along relatively soon, and hopefully can be quite quickly used to test randomly
selected people, like an opinion poll sampling a population; then we can see
how many people have had it, and from there work out the IFR. But for the
moment we don’t have that.

I wanted to write this to
give an impression of how appallingly difficult the modeller’s job is. I write,
sometimes, pieces about statistics — I suggested that claims about the loneliness epidemic, teen suicides,
and the media’s influence on Brexit were overstated, for instance. They
involved very basic maths, done for very low stakes: if I messed up, if I
failed to carry a 2 or whatever, I would look very stupid and would be very
embarrassed, but no one would die.

Whereas, if the Imperial
College modellers get it wrong, with their far more complex maths and their far
more uncertain inputs, they could sway government policy enormously. Whether we
lock down society or carry on as normal depends heavily on the outputs of
models like these. And it’s not that there’s an easy “better safe than sorry”
option; if we crash the economy, it will (eventually) cause real health
problems.

A February 2020 review found that 10 years of austerity may have
caused the growth in life expectancy to stall, especially among the poorest;
I’m sceptical of the “130,000 deaths caused by austerity” stat, but it’s pretty clear that it had a real
negative impact. The post-Covid-19 world will almost certainly involve huge
austerity to pay for the vast costs incurred during the virus.

Get it wrong one way, and
thousands of people die unnecessarily from the virus; get it wrong the other,
and you crash our public services and kill people that way. (I’ve only seen one
attempt to model the health outcomes of that crash, and I have no way of
judging it; for what it’s worth, though, it does say they will be extremely terrible; on the other hand, recessions don’t
seem to shorten life expectancy,
so who knows.)

So I’m very sympathetic to
the modellers. But there are things which would help, and which they can do,
but haven’t, so far at least. Ferguson’s team has not released the code his
model is based on; he says he is working with software developers to do so, but proponents of open science,
like Davey Smith and his colleague Marcus Munafò, say this isn’t happening fast
enough.

“These models are so
sensitive to their assumptions,” says Munafò. “And they’re black boxes.” The
code is 13 years old; it’s vital that other scientists are allowed to look at
it, check it for mistakes and stress-test its assumptions. There are other,
open-source models available,
but the Imperial one is still kept under wraps, and it shouldn’t be.

Because a lot rides on the
outputs. If millions have already been infected and the disease is less deadly
than we think, then our response should be very different to if millions are

*still*to be infected and tens or hundreds of thousands more will die.
The latest from Ferguson’s team suggests that between 1% and 5% of the
UK’s population has already been infected. Oke of CEBM thinks that that could
be an underestimate — he thinks that the disease was circulating in China for a
month or so before it was announced. “There were early reports of doctors
saying they were seeing unusual respiratory symptoms, which were suppressed,”
he says. That could have brought it all here much earlier.

When I mentioned the Oxford “study” — in fact a model showing what plausible
inputs could produce what we’ve seen, one of which was a very low IFR and huge
number of people already infected — he didn’t endorse it, but said “I think a
lot of people have underestimated how far this has already spread, and how
early.” Davey Smith also thinks that those Imperial figures could well be an
underestimate. I have no idea if they’re right or wrong, but whether they are
or not matters a great deal.

For the record, to take us
back to the beginning, Peter Hitchens had flatly misunderstood what was going
on. The 500,000 number was a worst-case scenario if we did nothing; the 20,000
was Ferguson’s team’s estimate of what we’d see now that social-distancing
measures and so on are in place.

The 5,000 wasn’t from
Ferguson’s team at all but from an electrical engineering group also at Imperial who just eyeballed the death curve on the
China graph, fitted the UK numbers so far onto that, and extrapolated from
there. “They explicitly say they’re not doing any epidemiological modelling at
all,” says Spiegelhalter, “and they retracted it two days later on Twitter,”
after it became obvious that it was wrong.

But we shouldn’t be
complacent and assume that, just because people are misunderstanding what the
modellers are doing, the models must be correct. Everything that comes out of
them is the product of what goes in, and

*all*of that is going to be wrong, to some degree. “The key point is that the numbers we have now are not correct,” says Ritchie.
If you look back to
previous outbreaks, such as the 2009 swine flu epidemic, the numbers people
were using while it was still going on were wildly different from the ones
scientists settled on afterward: early estimates in 2009 were between 0.1% and 5.1%; the eventual WHO estimate was just 0.02%,
similar to seasonal flu. In a fast-moving situation, it is easy to make large
mistakes. (In either direction! I am not suggesting that the Covid-19 situation
will necessarily be similarly overstated.)

These models are the best
information we have at the moment. But they are hugely uncertain, and likely to
be wrong. All we can do is try to get better information for them, and make the
best decisions we can under conditions of appalling uncertainty — and be
forgiving of the modellers who are desperately trying to make life-changing,
history-changing decisions at high speed and with bad data.