Substantial underestimation of SARS-CoV-2 infection in the United States

Sean L. Wu, Andrew N. Mertens, Yoshika S. Crider, Anna Nguyen, Nolan N. Pokpongkiat, Stephanie Djajadi, Anmol Seth, Michelle S. Hsiang, John M. Colford, Art Reingold, Benjamin F. Arnold, Alan Hubbard, Jade Benjamin-Chung

Research output: Contribution to journalArticlepeer-review

189 Scopus citations


Accurate estimates of the burden of SARS-CoV-2 infection are critical to informing pandemic response. Confirmed COVID-19 case counts in the U.S. do not capture the total burden of the pandemic because testing has been primarily restricted to individuals with moderate to severe symptoms due to limited test availability. Here, we use a semi-Bayesian probabilistic bias analysis to account for incomplete testing and imperfect diagnostic accuracy. We estimate 6,454,951 cumulative infections compared to 721,245 confirmed cases (1.9% vs. 0.2% of the population) in the United States as of April 18, 2020. Accounting for uncertainty, the number of infections during this period was 3 to 20 times higher than the number of confirmed cases. 86% (simulation interval: 64–99%) of this difference is due to incomplete testing, while 14% (0.3–36%) is due to imperfect test accuracy. The approach can readily be applied in future studies in other locations or at finer spatial scale to correct for biased testing and imperfect diagnostic accuracy to provide a more realistic assessment of COVID-19 burden.

Original languageEnglish (US)
Article number4507
JournalNature communications
Issue number1
StatePublished - Dec 1 2020

ASJC Scopus subject areas

  • Chemistry(all)
  • Biochemistry, Genetics and Molecular Biology(all)
  • Physics and Astronomy(all)


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