Cremation numbers reveal possible suppression of true COVID-19 data in China

By Dr. Liji Thomas, MDJun 8 2020

A potentially explosive new study published on the preprint server medRxiv* in June 2020 suggests that the official Chinese statistics on COVID-19 cases or mortality are neither reliable nor credible. If true, such unreliable data during a crucial period of the pandemic in February and March 2020 could have seriously skewed the response and preparation of the rest of the world and altered the future course of the viral pneumonic illness.

The ongoing pandemic of COVID-19 has taken hundreds of thousands of lives and sickened over 7 million people all over the world in just over five months. Originating in China's Wuhan city, it has rapidly and extensively spread to over 188 countries and territories.

Study: Cremation based estimates suggest significant under- and delayed reporting of COVID-19 epidemic data in Wuhan and China. Image Credit: Checkin / Shutterstock

This news article was a review of a preliminary scientific report that had not undergone peer-review at the time of publication. Since its initial publication, the scientific report has now been peer reviewed and accepted for publication in a Scientific Journal. Links to the preliminary and peer-reviewed reports are available in the Sources section at the bottom of this article. View Sources

The Credibility Issue

Even as data on infections and mortality continue to pour in, the rapid and sudden decline in China's COVID-19 statistics has raised widespread skepticism. The importance of this data for an epidemiological understanding of the disease, given its origin in China, mandates that accurate figures should be provided. However, the researchers say, "China's  COVID-19 statistics fall outside of recognized and accepted medical norms."

The outbreak is estimated to have begun in October 2019 and not in December. Even with the December date, the first report from Wuhan City Health Commission announced that 27 recent cases of pneumonia of unknown origin had been detected. At this point, other official figures and one media report showed over 45,100 cases and 266 cases, respectively.

Moreover, official Chinese state media at the time reported that many cases which may well have been caused by COVID-19 fell through the reporting gaps because private establishments treated them. This, say the researchers, has "led many to believe there may be serious gaps in our understanding of the outbreak based on what can be determined from this official government data."

Modeling for Actual Statistics in China

The researchers from Washington University in St. Louis School of Medicine and Ohio State University gathered their data from COVID-19 figures reported as Chinese government statistics, as well as reports by both official and non-official media, including investigative media reports on the number of cremations in Wuhan.

According to the current study, the infection estimates as of February 7, 2020, fell between 305,000 to 1,272,000, while the death estimates are projected to be between 6,811 to 7,223 for deaths. This is at least ten times the official figure, which is at about 13,600 and 545, respectively.

Data on Crematories

Reports from established media show that whereas the eight crematories in Wuhan operated for about 4 hours a day, on average, before the outbreak, and typically in the morning in keeping with Chinese funeral rituals, a change occurred at around January 25, 2020.

At this point, the crematories were found to be operating almost round the clock or at about six times normal levels. If the normal daily mortality is pegged at about 136, for this population of about 9 million, the increased hours of operation would show an excess of about 680 per day above the normal or a total of about 816 deaths a day. It is to be noted that the maximal cremation capacity is reported to be up to 2,100 bodies a day.

Additional cremation staff are reported to have been imported to Wuhan, as well as 40 mobile cremation stations, which were sent into the city from outside from February 19, 2020, to cope with the increasing need for cremation.

A simple linear estimate showed that at 80% utilization from January 25, 2020, to February 6, 2020, and then 100% until February 12, 2020, the cumulative deaths would be above 9,300. With the crude case fatality rate as officially reported, at 3.14%, the cumulative infection would be almost 300,000 in 19 days.

Data on Funeral Urn Distribution

If the number of funeral urns distributed and the period over which cremation services operated at full capacity operation up to March 23, 2020, are considered, the estimate of the total deaths up to this date reaches 36,000, which is over tenfold the official figure of 2,524. The cumulative infection could potentially be over 700,000. These estimates do not account for the mobile crematories and are likely to be significant under-estimates.

Exponential Growth Model

The researchers then used a model showing an exponential growth rate, from January 23, 2020, when the lockdown began, to the beginning of observed effects at about 15 days later. This is a valid approach provided the assumption made, that lockdown effects will begin to show only after February 7, 2020, is correct.

Beginning with a doubling rate of 6.4 days, a figure of 680 deaths per day on February 7, 2020, and at varying crude case fatality rates of 2.5%, 5%, and 10%, they estimate a cumulative infection in Wuhan of 1,27 million, 650,900 and 305,000 respectively. The number of deaths would be about 7,000 in all cases.

The start dates for the outbreak would be, in such a case, October 4, 2019, October 11, 2019, and October 17, 2019, respectively. If the doubling time is 2.54 days, the start date would be December 14, 2019, but the projected total number of infections would be over 2.2 million by February 7, 2020.

Either the news of the outbreak was significantly delayed and under-reported, in the first scenario, or the official case numbers were reduced by millions, in the second case.

Finally, if China's data on the 39% ratio of infections in Wuhan and China are used, the number of Chinese infections would reach over 5.6 million by February 7, 2020.

Serious Implications

Chinese media pointed out the strain on Wuhan's medical resources in January-February 2020, even though the city was reported to have about 90,000 beds by the end of 2018, plus an additional 100,000 beds allotted in hotels and schools by the beginning of February. This ratio of 190,000 available beds to about 33,000 confirmed cases has not been explained.

Neither has the fact that despite the more than 90,000 doctors and other healthcare professionals in Wuhan at the start, another 42,600 were sent in from other provinces, with almost 170,000 ventilators imported to Wuhan, to look after only 50,000 officially reported cases as on March 23, 2020. Earlier researchers have also pointed out mathematically "impossible" COVID-19 figures from China's establishment, estimating that over 85% of infections were not reported and that by February 20, 2020, the number of confirmed cases in China would have been well over 230,000 and not 55,000 as officially reported.

The study's conclusions are limited by the fact that it did not include other causes of excessive death during the lockdown, such as those occurring due to the difficulty in accessing medical treatment of other diseases at this time, the financial stress, and lack of support for emotional and social needs.

Nonetheless, the researchers conclude that official reports of COVID-19 cases and deaths from China are lopsided, with a huge discrepancy between the cremation-based estimates prepared in the current study and the Chinese official figures available in early February.

The significance of this is grave since the period from February to the end of March was a critical one with respect to preparing for an adequate response to the worldwide spread of the pandemic. The investigators comment that this "suggests the need to reevaluate China's official statistics and consider all available and reasonable data sources for a better understanding of the COVD-19 pandemic."

The study concludes, "The magnitude of the discrepancy between the results from their analysis and China's official figures suggests that the potential impact on the global efforts to control the pandemic is obvious. Transparency in China is of critical importance for the world to learn from this infection and for those in the future."

References (see paper for cross-referencing)

1. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020;382(13):1199‐1207. doi:10.1056/NEJMoa2001316. https://www.nejm.org/doi/full/10.1056/NEJMoa2001316

2. Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi. 2020 Feb 10;41(2):145-151. [Article in Chinese] https://pubmed.ncbi.nlm.nih.gov/32064853/.

3. Ma J. Coronavirus: China’s first confirmed Covid-19 case traced back to November 17. https://www.scmp.com/news/china/society/article/3074991/coronavirus-chinas-first-confirmed-covid-19-case-traced-back Last accessed on May 24, 2020.

4. 财经-统计数字之外的人：他们死于普通肺炎 [People outside the statistics: Are they dying from common pneumonia?]. https://chinadigitaltimes.net/chinese/2020/02/ Last accessed February 12, 2020. https://www.reddit.com/r/China_Flu/comments/eyifpf/people_outside_the_statistics_they_died_of/

5. www.gov.cn.

6. Yi Cao. “Epidemics in New York worse than Wuhan??” April 4, 2020. http://blog.creaders.net/u/11405/202004/370363.html Last accessed on May 25, 2020.

7. GM06. “Where do the bodies come from, that cannot be cremated even with all crematory staff and burners running 24 hours?” February 10, 2020. https://gnews.org/zh329 hans/110207/ Last accessed on May 25, 2020

8. Jinxin Kandian. “I am at the first line of Wuhan funeral service, now needs some help”. February 15, 2020. https://k.sina.cn/article_7280195342_1b1eef70e02000pydh.html?from=society Last accessed on May 25, 2020.

9. Hoonhout, T. Wuhan Residents Dismiss Official Coronavirus Death Toll: ‘The Incinerators Have Been Working Around the Clock’ National Review. https://www.nationalreview.com/ Last accessed April 6, 2020.

10. He C. Amid virus outbreak, funeral home officials in Wuhan reveal sharp increase in cremations. https://www.theepochtimes.com/exclusive-funeral-homes-in-coronavirus341 ground-zero-cremating-dozens-of-bodies-a-day_3228938.html Last accessed February 12, 2020.

11. https://www.chinatimes.com/cn/realtimenews/20200202001385-260409?chdtv Last accessed May 25, 2020.

12. “Wuhan funeral service under heavy pressure from the epidemic: Lockdown affects processing time, body designated to crematory”. January 31, 2020. http://www.infzm.com/wap/#/content/175645 Last accessed on May 25, 2020.

13. Wuhan City Administration. http://english.wuhan.gov.cn/ Last accessed February 12, 2020. Removed

14. “Marked increase during one night! 242 Deaths in Hubei + Funeral staff from all over China hurried to go to support.” http://news.migage.com/articles/一夜暴增！湖北 242 人亡+各地殡葬队急支援_3751982_yahootw.html Last accessed on May 25, 2020

15. “Wuhan pneumonia: Henan and Chongqing funeral teams going straight to support Wuhan.” https://www.chinapress.com.my/◤武汉肺炎◢-河南重庆-殡葬队-直 奔武汉施援手/ Last accessed on May 25, 2020. Removed

16. Shanghai Jiaotong University team participated in the development of "mobile medical waste incineration shelter" to support Wuhan - http://www.moe.gov.cn/jyb_xwfb/xw_zt/moe_357/jyzt_2020n/2020_zt03/zydt/zydt_gxdt/zydt_gxkx_kjgg/202002/t20200219_422354.html Last accessed May 8, 2020

17.Practical exploration of medical waste disposal in Wuhan, "vehicle-style" shelter is about to go to Vulcan Mountain -  http://www.xinhuanet.com/politics/2020-02/21/c_1125606332.htm, 2020.

18. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. Last accessed on May 25, 2020.

19. Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China. J Med Virol. 2020;92(4):441‐447. doi:10.1002/jmv.25689. https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25689

20. Wu JT, Leung K, M Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet 2020 Jan 31. PII: S0140-6736(20)30260-9. DOI:10.1016/S0140-6736(20)30260-9. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30260-9/fulltext

21. Muniz-Rodriguez K, Chowell G, Cheung C-H, Jia D, Lai P-Y, Lee Y, et al. Doubling time of the COVID-19 epidemic by province, China. Emerg Infect Dis. 2020 August [Cited on May 25, 2020]. http://dx.doi.org/10.3201/eid2608.200219.

22. China Reported a Huge Increase in New COVID-19 Cases. Here’s Why It’s Actually a Step in the Right Direction - https://time.com/5783401/covid19-hubei-cases-classification/ Last accessed May 8, 2020.

23. www.gov.cn.

24. Revision of the data of the new coronary pneumonia epidemic in Wuhan, Hubei - http://www.nhc.gov.cn/

25. Diary of Pneumonia | April 17: The revised crude death rate in Wuhan rose to 7.6% - http://m.china.caixin.com/m/2020-04-18/101544179.html.

26. https://chinadigitaltimes.net/chinese/2020/04/【立此存照】关于加强新冠肺炎科研论文发表管理 Last accessed May 8, 2020.

27. Tian H, Liu Y, Li Y, et al. An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China. Science. 2020;368(6491):638‐642. doi:10.1126/science.abb6105.https://science.sciencemag.org/content/368/6491/638

28. https://6do.news/article/2212649-61 Last accessed on May 8, 2020.

29. Li, R., Pei, S., Chen, B., Song, Y., Zhang, T., Yang, W., & Shaman, J. (2020). Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS390 CoV2). Science. doi: 10.1126/science.abb3221.https://science.sciencemag.org/content/368/6490/489

30. Scissors D. Estimating the true number of China’s COVID-19 cases. American Enterprise Institute. https://www.aei.org/research-products/report/estimating-the-true393 number-of-chinas-covid-19-cases/ Last accessed April 22, 2020.

31. Tsang TK, Wu P, Lin Y, et al. Effect of changing case definitions for COVID-19 on the epidemic curve and transmission parameters in mainland China: a modelling study. Lancet Public Health. 2020 Apr 21. pii: S2468-2667(20)30089-X. doi: 10.1016/S2468-2667(20)30089-X. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30089-X/fulltext

32. Newsweek. March 29, 2020. https://www.newsweek.com/wuhan-covid-19-death-toll399 may-tens-thousands-data-cremations-shipments-urns-suggest-1494914.

33. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020 Jan 15. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext

34. Cohen J. Wuhan seafood market may not be source of novel virus spreading globally. https://www.sciencemag.org/news/2020/01/wuhan-seafood-market-may-not-be-source404 novel-virus-spreading-globally Last accessed February 18, 2020.

This news article was a review of a preliminary scientific report that had not undergone peer-review at the time of publication. Since its initial publication, the scientific report has now been peer reviewed and accepted for publication in a Scientific Journal. Links to the preliminary and peer-reviewed reports are available in the Sources section at the bottom of this article. View Sources