Article

Global Epidemiology of First 90 Days Journal of Health Management

22(2) 117–128, 2020
into COVID-19 Pandemic: Disease © 2020 Indian Institute of
Health Management Research
Incidence, Prevalence, Case Fatality
Rate and Their Association with Reprints and permissions:
in.sagepub.com/journals-permissions-india
Population Density, Urbanisation DOI: 10.1177/0972063420932762
journals.sagepub.com/home/jhm
and Elderly Population

Shivam Gupta1, Kamalesh Kumar Patel2,

Shobana Sivaraman2 and Abha Mangal3

Abstract
As the COVID-19 pandemic marches exponentially, epidemiological data is of high importance to ana-
lyse the current situation and guide intervention strategies. This study analyses the epidemiological data
of COVID-19 from 17 countries, representing 85 per cent of the total cases within first 90 days of lock-
down in Wuhan, China. It follows a population-level observational study design and includes countries
with 20,000 cases (or higher) as of 21 April 2020. We sourced the data for these 17 countries from
worldometers.info, a digital platform being used by several media and reputed academic institutions
worldwide. We calculated the prevalence, incidence, case fatality rate and trends in the epidemiology of
COVID-19, and its correlation with population density, urbanisation and elderly population.The analysis
represents 85 per cent (N = 2,183,661) of all cases within the first 90 days of the pandemic. Across the
analysed period, the burden of the pandemic primarily focused on high- and middle-income countries
of Asia, Europe and North America. While the total number of cases and deaths are highest in USA, the
prevalence, incidence and case fatality rates are higher in the European countries. The prevalence and
incidence vary widely among countries included in the analysis, and the number of cases per million and
the case fatality rate are correlated with the proportion of the elderly population and to a lesser extent
with the proportion of the urban population.

Keywords
COVID-19, pandemic, epidemiology, prevalence, incidence, elderly population

1
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
2
Department of Research, IIHMR University, Jaipur, India.
3
Community Health Department, St Stephens Hospital, New Delhi, India.
Corresponding author:
Shivam Gupta, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
21205, USA.
E-mail: sgupta23@jhu.edu
118 Journal of Health Management 22(2)

Background
The COVID-19 (coronavirus disease 2019) pandemic caused by severe acute respiratory syndrome coro-
navirus 2 (SARS-CoV-2) has swiftly created a cataclysm for the human civilisation (Wu et al., 2020).
Since its appearance in the city of Wuhan (Hebei district) in China, it has been a relentless march of new
cases and deaths (Wu et al., 2020). A total of 2,397,217 confirmed cases and 162,956 deaths have been
reported worldwide due to COVID-19 (Coronavirus Disease 2019 (COVID-19) Situation Report—92,
2020). The pandemic has been primarily focused on industrialised, high- and middle-income countries,
and the eventual march towards low-income countries of Africa and Asia seems inevitable.
No aspect of human society is untouched by this pandemic. The unprecedented strain on health sys-
tems along with job loss, business closures and the economic downturn has become a worldwide phe-
nomenon. The virus primarily spreads through droplets and aerosols generated by an infected individual
who might be asymptomatic with illness at the time (Rothan & Byrareddy, 2020b; L. Wang et al., 2020)
The primary symptoms are fever, dry cough and difficulty in breathing (Rothan & Byrareddy, 2020a).
While the clinical severity of disease seems to be higher among the elderly and the immunocompro-
mised, the socio-economic fallout is falling more severely on the poor and the marginalised groups
(Harapan et al., 2020; Rothan & Byrareddy, 2020b) The current lack of any successful treatment or
viable vaccine is threatening to make the negative effects more prolonged, thereby delaying recovery (L.
Wang et al., 2020).
The Epidemiologic Triangle is a model which can be helpful to understand the epidemiology of an
infectious disease like COVID-19 and how it has spread around the world (Centers for Disease Control
and Prevention, 2012). The Triangle has three corners (called vertices) (Centers for Disease Control and
Prevention, 2012). The agent is the cause of the disease, and for COVID-19 pandemic it is the virus
SARS-CoV-2. Hosts are organisms, usually humans or animals, which are exposed to and harbour the
agent (Centers for Disease Control and Prevention, 2012). The ‘host’ heading also includes symptoms of
the disease that can vary among different hosts for the same agent. The environment is the favourable
surroundings and conditions external to the host which cause or allow the disease agent to be transmitted
(Centers for Disease Control and Prevention, 2012). Initial reports indicated that the spread and recovery
from the novel coronavirus have varied between the countries, pointing towards the variation in agent,
host and environmental factors present in these different settings (Centers for Disease Control and
Prevention, 2012). Therefore, there is an urgent need to explore the differences in epidemiological meas-
ures and demographic distribution of COVID-19 between different countries. This would include a dif-
ference in progression (new and cumulative cases), case fatality, recovery, morbidity among different
age and chronic disease groups, population size, density and urban population (Jordan et al., 2020; Yang
et al., 2020).
The main objective of this study is to describe the situation in countries with a total of more than
20,000 cases by 21 April 2020, 90 days after Wuhan, China was placed under quarantine on 23 January
2020. The aim is to identify the most heavily affected countries and hence contribute to a substantial
body of knowledge to understand the pandemic progression. We thought this was of paramount impor-
tance since it would help understand the differences between characteristics of the pandemic in the most
affected countries, identify the lessons available and explore unknowns associated with COVID-19 at
this relatively early stage of the pandemic and help plan future course of action.
Gupta et al. 119

Methodology
This is a population-level observational study using pooled data from worldometers.info, a digital plat-
form being used by several academic and media institutions, including Oxford University press, Johns
Hopkins Centre for System Science and Engineering (CSSE), Wiley, Pearson, European Organization
for Nuclear Research (CERN), Worldwide Web Consortium (W3C), The Atlantic, British Broadcasting
Corporation (BBC) (worldometer, n.d.). Worldometer provides de-identified COVID-19 patient data in
real time from all over the world, obtained by collecting information through official reports and govern-
ment communication channels (directly or indirectly). The available data are in the public domain, and
therefore the study did not require ethical clearance.

Data Compilation
The COVID-19 case data between 22 January 2020 to 21 April 2020 were used to extract daily new
cases, new deaths, cumulative cases, cumulative deaths, recovery rate and total tests per 1 million popu-
lation. The de-identified patient data were collected for 85 per cent of total cases and this included all
countries with more than 20,000 cases (cumulative count) as of 21 April 2020. We obtained data for
these 17 countries (USA, Spain, Italy, France, Germany, UK, Turkey, Iran, China, Russia, Brazil,
Belgium, Canada, the Netherlands, Switzerland, Portugal and India) and entered and formatted them in
Microsoft Excel for further quantitative data analysis.
Data on population density (people per km2), percentage of urban population and percentage of the
elderly population (>65 years) for each of the 17 countries were also collected. The projected population
density, urban population and elderly population were compiled from the 2019 Revision of World
Population Prospects prepared by Population Division of the Department of Economic and Social Affairs
of the United Nations Secretariat.1

Statistical Analysis
We analysed the compiled data for each country and calculated the following epidemiological
indicators.

Total number of cases till 21 April 2020
Prevelance per million = *1, 000, 000
Projected total population 2020

Total number of deaths till 21 April 2020
Deaths per million = *1, 000, 000
Projected total population 2020

Number of new cases on 21 April 2020
Incidence per million = *1, 000, 000
Projected total population 2020

Total number of recovered cases till 21 April 2020
Recovery per100 = *100
Total number of cases till 21 April 2020
120 Journal of Health Management 22(2)

Total number of death cases till 21 April 2020

Case fatality rate = *100
Total number of cases till 21 April 2020
Total number of tests conducted till 21 April 2020
Tests per million = *1, 000, 000
Projected total population 2020

The trends in distribution of new cases and deaths were analysed for every 15-day interval. We used the
Stata statistical software (version 14) for additional statistical analysis. Pearson correlation test was
applied to study the strength of association between the prevalence per million with the percentage of
urban population, population density, tests per million and elderly population (≥65 years). We also ana-
lysed the data similarly for the association between the case fatality rate with population density, urban
population, the elderly population (>65 years) and tests per million.

Results
The 17 countries representing 85 per cent (N = 2,183,661) of all cases within the first 90 days of the
pandemic were USA, Spain, Italy, France, Germany, UK, Turkey, Iran, China, Russia, Brazil, Belgium,
Canada, the Netherlands, Switzerland, Portugal and India. Among 17 countries, the highest number of
cases were reported in USA (37.5 per cent) followed by Spain (9.4 per cent), Italy (8.4 per cent), France
(7.2 per cent), Germany (6.8 per cent), UK (5.9 per cent), Turkey (4.4 per cent), Iran (3.9 per cent), China
(3.8 per cent), Russia (2.4 per cent), Brazil (2 per cent), Belgium (1.9 per cent), Canada (1.8 per cent),
the Netherlands (1.6 per cent), Switzerland (1.3 per cent), Portugal (1 per cent) and India (0.9 per cent).
As per WHO situation report, out of 17 countries, cases reported in 12 countries were attributed to com-
munity transmission, while those in three countries (China, India and Russia) were a cluster of cases and
two (Spain and Portugal) were still pending to report (Coronavirus Disease 2019 (COVID-19) Situation
Report—92, 2020). The prevalence per million, incidence per million and death per million varied
widely between countries. The prevalence of COVID-19 ranged between 14.6 per million in India and
4,367 per million in Spain, whereas incidence ranged from 0.04 per million in India to 14.7 per million
in Belgium. Deaths ranged from 0.5 per million in India to 517.5 per million in Belgium (Table 1).
The case fatality rate (per 100 cases) recorded was highest in Belgium (14.6 per cent) and lowest in
Russia (0.9 per cent). The recovery rate (per 100 cases) ranged from 93.2 per cent in China to 4.3 per cent
in Portugal (Figure 1). Six countries, namely USA, Italy, Spain, France, Germany, UK, had more than
100,000 cumulative cases by 21 April 2020. Out of these six countries, USA and UK have a continuous
rapid increase in COVID-19 cases in every 15-day interval. A rapidly increasing trend of COVID-19
cases was observed till 5 April 2020 in Spain, Italy, France and Germany. Later, in the following 15-day
interval, Spain, Italy and Germany have shown a decreasing trend in COVID-19 cases (Figure 2). Four
countries have between 50,000 and 100,000 COVID-19 cases and they include Turkey, Iran, China and
Russia (Figure 3). Turkey, Russia and Iran have shown a continuously increasing trend of COVID-19
cases. Besides, Iran has shown a decreasing trend in cases in the last observed 15-day interval between
6 and 21 April 2020. Seven out of 17 countries have less than 50,000 cumulative cases of COVID-19 and
they include Brazil, Belgium, Canada, the Netherlands, Switzerland, Portugal and India. Although the
first COVID-19 case reported in these seven countries was in mid and/or late February 2020, except
Switzerland, the number of cases has continued to increase till 21 April 2020 (Figure 4).
Table 1. Countries with >20,000 Cumulative Reported Cases of COVID-19 on 21 April 2020

S. Total Projected Total Total Total New New Prevalence Incidence Death Per Case Fatality Rate Recovery Per
No Country Population, 2020 Cases Deaths Recovered Cases Deaths Per Million Per Million Million Per 100 Cases 100 Cases
0 World 7,794,798,739 2,554,568 177,402 690,039 74,065 7,005 327.7 0.9 22.8 6.94 27.01
1 USA 331,002,651 817,952 45,279 82,860 25,193 2,765 2,471.1 8.35 136.8 5.54 10.13
2 Spain 46,754,778 204,178 21,282 82,514 3,968 430 4,367 9.2 455.2 10.42 40.41
3 Italy 60,461,826 183,957 24,648 51,600 2,729 534 3,042.5 8.83 407.7 13.4 28.05
4 France 65,273,511 158,050 20,796 39,181 2,667 531 2,421.3 8.13 318.6 13.16 24.79
5 Germany 83,783,942 148,453 5,086 95,200 1,388 224 1,771.9 2.67 60.7 3.43 64.13
6 UK 67,886,011 129,044 17,337 N/A 4,301 828 1,900.9 12.2 255.4 13.43 N/A
7 Turkey 84,339,067 95,591 2,259 14,918 4,611 119 1,133.4 1.41 26.8 2.36 15.61
8 Iran 83,992,949 84,802 5,297 60,965 1,297 88 1,009.6 1.05 63.1 6.25 71.89
9 China 1,439,323,776 82,758 4,632 77,123 11 N/A 57.5 0 3.2 5.6 93.19
10 Russia 145,934,462 52,763 456 3,873 5,642 51 361.6 0.35 3.1 0.86 7.34
11 Brazil 212,559,417 43,079 2,741 24,325 2,336 154 202.7 0.72 12.9 6.36 56.47
12 Belgium 11,589,623 40,956 5,998 9,002 973 170 3,533.9 14.67 517.5 14.64 21.98
13 Canada 37,742,154 38,422 1,834 13,188 1,593 144 1,018 3.82 48.6 4.77 34.32
14 The 17,134,872 34,134 3,916 N/A 729 165 1,992.1 9.63 228.5 11.47 N/A
Netherlands
15 Switzerland 8,654,622 28,063 1,478 19,400 119 49 3,242.5 5.66 170.8 5.27 69.13
16 Portugal 10,196,709 21,379 762 917 516 27 2,096.7 2.65 74.7 3.56 4.29
17 India 1,380,004,385 20,080 645 3,975 1,541 53 14.6 0.04 0.5 3.21 19.8
Source: https://www.worldometers.info/coronavirus/
122 Journal of Health Management 22(2)

Table 2. Total Cases (Per 1,000,000 Population), Case Fatality Rate Per 100 Cases and Their Association with
Population Density, Urban Population, Tests Per Million and Elderly Population (>65 Years) by Country as on 21
April 2020

Case Population Elderly

Total Fatality Density, 2020 Urban Population
Cases Per Rate Per (People Per Population Tests Per (>65 Years),
S. No. Country Million 100 Cases km2) 2020 (%) Million 2019 (%)

0 World 327.7 6.9 52 56.20 NA 9.1

1 USA 2,471.1 5.5 36 82.5 12,650.6 16.2

2 Spain 4,367.0 10.4 94 80.3 19,895.9 19.6

3 Italy 3,042.5 13.4 206 69.5 23,984.6 23.0

4 France 2,421.3 13.2 119 81.5 7,103.4 20.4

5 Germany 1,771.9 3.4 240 76.3 20,628.7 21.6

6 UK 1,900.9 13.4 281 83.2 7,885.9 18.5

7 Turkey 1,133.4 2.4 110 75.7 8,458.8 8.7

8 Iran 1,009.6 6.2 52 75.5 4,354.2 6.4

9 China 57.5 5.6 153 60.8 NA 11.5

10 Russia 361.6 0.9 9 73.7 14,682.0 15.1

11 Brazil 202.7 6.4 25 88.0 1,373.4 9.3

12 Belgium 3,533.9 14.6 383 98.3 14,418.9 19.0

13 Canada 1,018.0 4.8 4 81.0 15,099.2 17.6

14 The 1,992.1 11.5 508 92.0 10,003.9 19.6

Netherlands

15 Switzerland 3,242.5 5.3 219 74.0 26,292.8 18.8

16 Portugal 2,096.7 3.6 111 66.5 26,671.5 22.4

17 India 14.6 3.2 464 35.0 324.5 6.4

Source: https://www.worldometers.info/coronavirus/
Gupta et al. 123

Figure 1. Case Fatality Rate and Recovery Rate (Per 100 Cases) of COVID-19 as of 21 April 2020
Source: https://www.worldometers.info/coronavirus/

Figure 2. Daily Cumulative Cases of COVID-19 Recorded for Every 15 Days—Countries with Total Cumulative
Cases >100,000 as on 21 April 2020
Source: https://www.worldometers.info/coronavirus/

Figure 3. Daily Cumulative Cases of COVID-19 Recorded for Every 15 Days—Countries with Total Cumulative
Cases between 50,000 and 100,000 as on 21 April 2020
Source: https://www.worldometers.info/coronavirus/
124 Journal of Health Management 22(2)

Figure 4. Daily Cumulative Cases of COVID-19 Recorded for Every 15 Days—Countries with Total Cumulative
Cases ≤50,000 as on 21 April 2020
Source: https://www.worldometers.info/coronavirus/

The total cases per million showed a weak correlation with population density (r = 0.14, p = 0.58, N
= 17) and a moderate correlation with urban population (r = 0.44, p = 0.07, N = 17) (Table 2). Tests per
million (r = 0.67, p = 0.003, N = 17) and elderly population (r = 0.70, p = 0.002, N = 17) showed a strong
correlation with total cumulative cases per million (Figure 5). This association was found to be more
prominent in countries with community transmission. The case fatality rate showed a weak correlation
with test per million (r = 0.02, p = 0.934, N = 17). It was observed that population density (r = 0.38, p =
0.12, N = 17), urban population (r = 0.49, p = 0.04, N = 17) and elderly population (r = 0.45, p = 0.06, N
= 17) showed a moderate correlation with case fatality rate (Figure 6).

Figure 5. Total COVID-19 Cases Per Million and Their Association with Population Density, Urban Population,
Elderly Population and Tests Per Million
Source: The authors.
Gupta et al. 125

Figure 6. Case Fatality Rate of COVID-19 and Their Association with Population Density, Urban Population,
Elderly Population and Tests Per Million
Source: The authors.

Discussion
Our observational study reports on the early phase of COVID-19 pandemic and includes countries with
85 per cent of the reported cases in the first 90 days from the start of quarantine in Wuhan, China. Our
findings indicate the burden of the pandemic during this early phase primarily focused on high- and
middle-income countries of Asia, Europe and North America. While the total number of cases and deaths
is highest in USA, the prevalence, incidence and case fatality rates are higher in European countries. The
number of cumulative cases for every 15 days since 22 January 2020 is on a rise in most countries and it
indicates a rising trend of the pandemic. Cumulative cases are declining in China, Italy and Spain, each
exposed to the pandemic earlier than other countries. Two notable exceptions with relatively late onset
and declining trend in cumulative cases are Germany and Switzerland. Across the 17 countries, the num-
ber of cases per million and the case fatality rate are correlated with the proportion of elderly population
and to a lesser extent with the proportion of urban population.
The rising burden of COVID-19 across the 17 countries represents the early stages of the pandemic
caused by a highly infectious airborne viral agent. However, the variation in epidemiological parameters
in these countries seems to be associated with host and environmental level factors. Older age of the host
has been reported as an important risk factor in several studies, and our study indicates a higher burden
in countries with a higher proportion of the elderly population (Guan et al., 2020; Jordan et al., 2020;
Manary et al., 2004; Mb et al., 2020; Raoult et al., 2020; D. Wang et al., 2020; Wu et al., 2020). Higher
population density and subsequent increase in physical proximity of infected and susceptible hosts in
urban centres are reported to facilitate the transmission of airborne virus particles (Lee et al., 2020;
Rocklöv & Sjödin, 2020). Similar to other studies on factors that promote airborne transmission of
illnesses, in our study a higher proportion of the urban population is an environmental risk factor
126 Journal of Health Management 22(2)

associated with a higher burden of COVID-19 (Lee et al., 2020; Mb et al., 2020; Rocklöv & Sjödin,
2020). The prominent urban nature of this pandemic is reflected in the virus, first originating from
Wuhan and spreading to other urban cities including Milan, Madrid, Seattle, New York, Detroit and New
Orleans (Mb et al., 2020; D. Wang et al., 2020). Our study also indicates that some countries seem to be
more successful at disrupting the agent, host and environment triad and stem the rising trend to ‘flatten
the curve’ more quickly. The importance of rapid scale-up of testing, tracing and isolation of infectious
cases has been repeatedly reported in the literature and the news media; however, testing rates vary
widely among the countries included in our study (Verity et al., 2020). Italy and Spain were ahead in the
pandemic curve and subsequently were able to scale up testing efforts successfully. Germany, Portugal
and Switzerland were part of the later wave of infection; however, they were able to scale up testing
faster than other countries, thereby able to flatten the curve faster.
While our study describes the disease burden and some of the agent, host and environmental factors
associated with COVID-19 pandemic in the first 90 days, some caution is needed in comparing across
countries that might calculate these estimates differently. There is no accepted international standard for
how deaths or their causes should be measured. Some countries count a death due to COVID-19 only if
the virus is recorded as the main cause of death, while others count a death due to COVID-19 if there is
any mention of the virus on the death certificate. Moreover, medical certification of deaths varies widely
across countries. While for most European countries, certification is almost universal, in India only 22
per cent of registered deaths are medically certified. A characteristic feature of the infective agent is a
vast pool of asymptomatic cases, that if not tested would recover without being counted as a case of
COVID-19 (Cascella et al., 2020; Ye et al., 2020). The wide variation in testing rates across countries
would probably also affect the number of confirmed cases reported in each country (Verity et al., 2020).
Therefore, comparing the death rate in confirmed cases is difficult across multiple countries. Moreover,
some countries record the number of people tested, while others record the total number of tests carried
out (many people need to be tested more than once to get an accurate result).
While the findings of our study are instructive of important host and environmental factors during the
early phase of COVID-19 pandemic, it will be useful to follow up with additional epidemiological stud-
ies during the mid and late stages and its eventual transmission in low-income countries of Africa, Asia
and South America (Adhikari et al., 2020). Additional host factors that would be important to explore are
comorbidities among infected patients, including hypertension, chronic respiratory disease, kidney dis-
ease and diabetes (Guan et al., 2020; Yang et al., 2020). Several important environmental factors could
also be included in future studies, including rural versus urban location; weather conditions (e.g. tem-
perature); effect of different interventions (e.g. lockdown, testing, tracing and isolation) being imple-
ment by governments around the world (Chan et al., 2011; Lee et al., 2020; Rocklöv & Sjödin, 2020).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of
this article.

Funding
The authors received no financial support for the research, authorship and/or publication of this article.

Note
1. The 2019 Revision of World Population Prospects is the 26th round of official United Nations population
estimates and projections prepared by Population Division of the Department of Economic and Social Affairs
of the United Nations Secretariat.
Gupta et al. 127

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