Abstract
Background: The assessment of the severity and case fatality rates of coronavirus disease 2019 (COVID-19) and the determinants of its variation is essential for planning health resources and responding to the pandemic. The interpretation of case fatality rates (CFRs) remains a challenge due to different biases associated with surveillance and reporting. For example, rates may be affected by preferential ascertainment of severe cases and time delay from disease onset to death. Using data from Spain, we demonstrate how some of these biases may be corrected when estimating severity and case fatality rates by age group and gender, and identify issues that may affect the correct interpretation of the results. Methods: Crude CFRs are estimated by dividing the total number of deaths by the total number of confirmed cases. CFRs adjusted for preferential ascertainment of severe cases are obtained by assuming a uniform attack rate in all population groups, and using demography-adjusted under-ascertainment rates. CFRs adjusted for the delay between disease onset and death are estimated by using as denominator the number of cases that could have a clinical outcome by the time rates are calculated. A sensitivity analysis is carried out to compare CFRs obtained using different levels of ascertainment and different distributions for the time from disease onset to death. Results: COVID-19 outcomes are highly influenced by age and gender. Different assumptions yield different CFR values but in all scenarios CFRs are higher in old ages and males. Conclusions: The procedures used to obtain the CFR estimates require strong assumptions and although the interpretation of their magnitude should be treated with caution, the differences observed by age and gender are fundamental underpinnings to inform decision-making.