Case fatality rate considering the lag time from the onset of COVID-19 infection to related death from 2020 to 2022 in Japan

IMPORTANCE: On an ecological scale, the lag time between coronavirus disease 2019 (COVID-19) infection and related fatality has varied between epidemic waves and prefectures in Japan. The variability in lag time across areas of Japan during the seven distinct waves can help derive a more appropriate estimation of the weekly confirmed case fatality rate (CFR) of COVID-19. OBJECTIVE: To estimate the 7-day moving average CFR across area block levels in Japan from February 2020 to July 2022 using the lag time between COVID-19 infection and related fatality. MAIN OUTCOMES AND MEASURES: The 7-day moving average CFR of COVID-19 for area blocks in Japan considering the lag time between infection and death (total and subgroup analysis of elderly). RESULTS: Lag time was found to vary substantially among prefectures in Japan from the first wave to the seventh wave of the COVID-19 epidemic. The estimated 7-day moving average CFR based on the lag time reflects the Japanese COVID-19 pandemic and related policy interventions (e.g. vaccination of elderly people) rather than other standard CFR estimations. CONCLUSIONS AND RELEVANCE: The variation in estimated lag time across prefectures in Japan for different epidemic waves indicates that it is inadequate to use the clinical results of the period from the start of infection to death for evaluation of the ecological scale of the CFR. Moreover, the lag time between infection and related fatality was found to be either shorter or longer than the clinically reported period. This revealed that preliminary reports of CFR may be overestimated or underestimated, even if they consider the lag based on clinical reports.