Why I think that over 4 million people in Spain have been infected by SARS-COV2?
Updated: Apr 30, 2020
By Esperanza Regueras, CEO of Axis Pharma
It’s becoming a habit for many people to search the updated data of infected people by SARS-COV2 in each country every morning. It is also becoming a habit of governments to offer such data and base their press conferences on it. The habit is perfectly understandable, as people (workers, HCPs, business responsible) want to understand what is happening and how the famous curve is performing. I was one of these people until mid-March 2020, when I realized that the infected figure was not reliable. Now even the number of deaths is not reliable.
I started to make my own calculations, and have shared them sometimes within my groups. I’m going to explain what my estimation is and how I arrived to it.
People that have died of COVID-19 in Spain:
1- Official figures are saying today that 23.822  people have died since the beginning of the epidemic in our country.
2- Other data is showing that real number of dead people could even be double than the official figure 
a. Deaths are only assigned to COVID-19 if the patient has been tested positive, therefore there is a large number of patients that died without a positive test but surely were dying due to COVID-19.
b. Madrid Regional government has pointed out they estimated that almost 5,000 patients more have died in this region and were not included in the official statistics (this will represent over 50% increase). Last published information from Comunidad de Madrid, 29th April 2020showed in following table states that 13,080 people died in total, 60,8% of them died in hospitals and the rest died in other settings. Official Spanish government data for the same day is showing only 8,105 deaths in Madrid representing only the 62% of total deaths reported by Comunidad de Madrid regional government.
c. Most of the patients who died in homecare for older people were not tested . The data in previous table shows the total fatalities including tested and suspicious cases. The 40% of patients died outside hospitals.
3- Considering this information, a more accurate estimation of reality will be to consider between 35,733 and 47,644 people died of COVID-19 by end of April 2020.
Real mortality rate of COVID-19 (% of death over total infected)
1- The official rate is not valid as the number of real infected people is not accurately counted
a. The statistics are only counting for people that have been confirmed by the PCR positive test, but scientific evidence has demonstrated that a large % of infected people is not showing symptoms or showing mild-disease. Only patients attending hospitals or presenting moderate-severe form of disease have been tested. Therefore, the denominator of the fraction is wrong.
2- What is the real rate of mortality? Here I found 3 more reliable sources
a. Mortality rates in Iceland   : small country with a total of 357,000 inhabitants.
i. 10% of the population has been tested (35,000); 1,789 were positive (5.11%) and only 10 died (0.56%). Iceland has been recognized internationally as a country offering COVID-19 test to all its people.
ii. Test ratio has been 100/1,000 inhabitants (versus 10/1,000 in South Korea).
iii. 43% of positive cases were asymptomatic
iv. Mortality rate in Iceland is 0.6% (end of April).
b. NEJM: “The mortality rate associated with COVID-19 may be considerably less than 1%, instead of the 2% reported by some groups”, write Anthony Fauci, MD (director of the National Institute of Allergy and Infectious Diseases) and colleagues in NEJM 
c. Data from a highly controlled environment, the Diamond Princess Cruise ship : this is a very good example to analyze what happened to a small population where the number of positives and deaths are easily counted.
i. 3,711 passengers
ii. 3,063 PCR test were performed and 634 were positive (21% of tested)
iii. 328 positive patients were asymptomatic (52%) and 306 were symptomatic (48%)
iv. 7 patients died, representing a 1.1% mortality rate over positive cases. Estimated all-age fatality rate in publication was 1.3%. Fatality rate in patients older than 70 years old was 6.4%.
My estimation of accumulated people that has been infected with COVID-19 in Spain by end of April 2020:
My conclusions to these calculations
Between 8% and 17% of population have been infected in Spain
This is far from the official figure of 210,733 
This is far from the % needed to achieve immunization that could allow normalization of life (estimated 60-70%)
The mortality rate is lower that the figures offered in official figures: 11.3% fatality rate 
The only alternative to continuous or intermittent lock-downs is massive testing in 4 phases as I propose in the following point.
Massive testing is already the cornerstone in other EU countries, France has a plan to test 2.8 M people per month .
My preliminary proposal of massive testing plan for Spain
Massive testing could be the only alternative to lock-down in the wait of an effective and safe vaccine . To perform such massive testing, I propose to segment the population in 4 groups:
Group 1: People with high risk of contact with virus (HCPs, military, police, families and contacts of confirmed positives, etc…)
Group 2: Workers going to work-place (no home-workers)
Group 3: The rest of workers that must return to working places and are currently home-working.
Group 4: The rest of the population that may have symptoms, contact with confirmed-suspicious positives (go to G1) or are returning to working and public areas (go to G3).
Resources that will need the Spanish government to address massive testing:
As PCR is a limiting factor government has to double PCR capacity by investing in equipment and human qualified technicians in hospitals. In short term use all the PCR capacity outside health system (universities for instance).
Set up a big buy of serological rapid test with confirmed acceptable specificity and sensitivity.
Invest in accelerate the development of antigen rapid test that will increase dramatically the testing capacity in all groups.
Involve the web of pharmacies in performing testing services that will be traced with patient’s health electronic card.
 Actualización nº 89. Enfermedad por el coronavirus (COVID-19). 28.04.2020 (datos consolidados a las 21:00 horas del 27.04.2020) SITUACIÓN EN ESPAÑA. Centro de Coordinación de Alertas y Emergencias Sanitarias. Retrieved online from : https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov-China/documentos/Actualizacion_89_COVID-19.pdf
 ¿Cuántos muertos hay más allá de las cifras oficiales de coronavirus? Luis Cano. ABC. 24.04.2020. Retrieved online from: https://www.abc.es/sociedad/abci-cuantos-muertos-mas-alla-cifras-oficiales-coronavirus-202004232254_noticia.html
 Islandia: récord del mundo en pruebas de Covid-19 y ejemplo 'de libro' de cómo frenar la pandemia. El Mundo. 15.04.2020. Retrieved online from: https://www.elmundo.es/ciencia-y-salud/salud/2020/04/15/5e969fa721efa0242d8b45da.html
 Coronavirus: los asintomáticos suponen el 43% de los casos positivos. Redacción Médica. 21.04.2020. Retrieved online from:
 Islandia: test gratuitos a todos para romper el contagio. Pedro G. Poyatos. La Razón. 26.04.2020. Retrieved online from: https://www.larazon.es/internacional/20200426/ahws4mb2zjbcnfjnxzkjvqfabi.html.
 Fauci AS, Lane HC, Redfield RR, Covid-19 - Navigating the Uncharted. March 26, 2020 N Engl J Med 2020; 382:1268-1269
 Russell TW, Hellewell J, Jarvis CI, van Zandvoort K, Abbott S, Ratnayake R, CMMID COVID-19 working group, Flasche S, Eggo RM, Edmunds W J, Kucharski AJ. Estimating the infection and case fatality ratio for coronavirus disease (COVID-19) using age-adjusted data from the outbreak on the Diamond Princess cruise ship, February 2020. Euro Suveill. 2020;25:pi=20000256
 Francia promete 700.000 test semanales en su ambicioso plan de desconfinamiento. El Confidencial. 28.04.2020. Retrieved online from:
 Coronavirus: la estrategia "única en el mundo" de Islandia, el país que ofrece pruebas de covid-19 a toda la población. Lioman Lima. BBC News Mundo. 10.04.2020. Retrieved online from: