On June 11, the United States passed a grim milestone. That was the day health authorities logged the two millionth case of COVID-19 nationwide.
A little over a week later, the total number of novel coronavirus infections in America is north of 2.2 million, according to Johns Hopkins University’s Coronavirus Resource Center.
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More than 118,000 Americans have died, along with well over 300,000 people in other countries. But those are only the deaths and infections that authorities have detected.
Undetected SARS-CoV-2 infections—as the virus that causes COVID-19 is officially known—almost certainly far outnumber detected cases. That’s just the reality of widely lampooned disease surveillance in the United States.
What’s less clear is just how many cases we don’t know about.
According to Tom Frieden, a CDC director under President Obama, there could be six times as many undetected COVID-19 cases as have been officially tallied in the United States alone.
When Frieden tweeted that there may be 12 million undetected American COVID-19 cases earlier this week, he wasn’t just blowing smoke, experts say. He claimed he based his estimate on data from the CDC and his own organization, Resolve to Save Lives, a New York City-based public health shop that works in more than 70 countries.
Resolve to Save Lives didn’t respond to an email asking for more details on the calculation. But scientific studies and conversations with experts generally support figures like these, even if Frieden’s claim regarding the infection fatality rate is at the high end of most estimates.
Jeffrey Klausner, a professor of medicine and public health at UCLA who previously worked at the CDC, called Frieden’s numbers “plausible.”
An estimate like this one apparently starts with the high-end estimate of the virus’s infection fatality rate, .8 percent, and projects from there. If there are 125 infections for every death, then it would take around 14 million infections to result in more than 110,000 deaths, as the United States has counted.
Studies have found infection fatality rates as low as .02 percent and as high as .86 percent, according to a May survey by John Ioannidis, a Stanford University epidemiologist. Ioannidis’s survey has not been peer-reviewed, but sought to collate the death-rate figures floating around in the larger body of emerging COVID-19 research.
Theresa MacPhail, an author and medical anthropologist at the Stevens Institute of Technology in New Jersey, told The Daily Beast that Frieden’s estimate of 14 million total infections—about two million detected, 12 million more not—seems about right. “Just based on what we know about [fatality rate] and the numbers alone, this makes sense,” MacPhail said.
MacPhail stressed how much we don’t know about the novel coronavirus in the United States. According to the CDC, only around 8 percent of the population has been tested for infection, for instance.
And a debate is still raging over the possibility that authorities have hugely undercounted deaths attributable to the disease—not just cases. Klausner credited a potential undercount in part to states’ different ways of categorizing deaths related to coronavirus infections. “Someone with COVID-19 dies of a heart attack, in some states that’s a heart-attack death,” Klausner said. “In some states that’s COVID.”
If total deaths are higher than Frieden assumed but the fatality rate is the same, then the total number of infections—detected and undetected —is much bigger than Frieden’s 14 million.
Of course, a greater number of deaths could also be a result of a higher fatality rate than authorities currently assume, which could mean fewer total infections. “This is a mess, is what I'm saying,” MacPhail said.
But the basic point—that we’re living among millions of undetected coronavirus infections—is sound, MacPhail argued. “I would agree that the numbers of shadow cases—either asymptomatic or mild and never diagnosed—is probably huge.”
The implications are chilling. Some U.S. states have, through strict public health measures and months of extreme suffering, managed to slow the spread of the virus and drive down the local rates of infection and death. New York, for one, got off to a fairly late start but, after months of strict measures, has succeeded in reducing the rates of infections and deaths.
But other states, many of them in the conservative South and Southwest, quickly gave up on aggressive lockdowns—or never imposed them in the first place. In those states, the pandemic might still be in its early stages. And millions of undetected cases could be building toward an explosion of additional deaths.
Take South Carolina, where Gov. Henry McMaster imposed just a few weeks of containment measures in April and May before officially re-opening the state’s economy starting on May 4. By early June, overall mobility in the state was down just 13 percent compared to normal, according to the state Department of Health and Environmental Control.
Unsurprisingly, the number of infections and deaths has skyrocketed. The state of 5 million logged a record 785 new infections on June 13, triple the average daily rate of new infections in the previous month. At the same time, around 11 people per day were dying of COVID in South Carolina, compared to 10 per day who died during the initial spike in infections in early May.
Eleanor Murray, a Boston University epidemiologist, told The Daily Beast that South Carolina’s numbers point to a pathogen that is still spreading across the local population. “With a gradual upturn like this, it seems pretty clear that these data indicate an increasing circulation of the virus,” Murray said.
And if Frieden’s numbers are right, that spread includes millions of Americans who aren’t showing up in any official tallies—and likely won’t any time soon.
