Estimating COVID-19 under-reporting across 86 nations: implications for projections and control

COVID-19 prevalence and mortality remain uncertain. For all 86 countries with reliable testing data we estimate how asymptomatic transmission, disease acuity, hospitalization, and behavioral responses to risk shape pandemic dynamics. Estimated cumulative cases and deaths through 10 July 2020 are 10.5 and 1.47 times official reports, yielding an infection fatality rate (IFR) of 0.65%, with wide variation across nations. Despite underestimation, herd immunity remains distant. Sufficient early testing could have averted 39.7 (35.3-45.3) million cases and 218 (191-257) thousand deaths. Responses to perceived risk cause the reproduction number to settle near 1, but with very different steady-state incidence, while some nations experience endogenous rebounds. Scenarios through March 2021 show modest enhancements in responsiveness could reduce cumulative cases ≈80%, to 271 (254-412) million across these nations.