Given the shortage of testing kits for COVID-19 around the world, the current testing regimen includes primarily (if not exclusively) symptomatic patients, making the rate of death appear to be worse than it might actually be. According to the U.S. Centers for Disease Control, asymptomatic persons are not routinely tested, so the prevalence of asymptomatic infection and detection of pre-symptomatic infection is not well understood. Similarly, a high percentage of patients who are either elderly or have underlying medical conditions that make them more susceptible to succumbing to the virus may test positive and die, skewing the rate of death among younger, otherwise healthy individuals. Death rates among persons over 80 years of age have been as high as 20%.

As a point of comparison, during the 2009 swine flu outbreak, initial death rate estimates were thought to be as much as 10 times higher than ordinary flu outbreaks (with a typical death rate of 0.2%), but after the passage of time, it was determined that death rates were actually no higher than the ordinary flu. Much attention was paid in the media to the high infection rate among passengers of the Diamond Princess cruise ship in Japan earlier this year, but even in that case, the death rate among passengers turned out to be about 1% (7 deaths among 700 positive (mostly elderly) individuals).

COVID-19 has taken a particularly high toll from a percentage perspective in Italy, but doctors from the Istituto Superiore di Sanità in Rome noted in a Journal of the American Medical Association commentary last week that a combination of Italy’s relatively older population (23% are 65 years and older) and the lethality of the coronavirus in that age group partly explains its high death rate (7.2% as of March 17). When stratified by age group, death rates of people under 70 in Italy and China look similar, but rates are higher in Italy among individuals aged 70 years or older, and in particular among those aged 80 years or older. The Italian death rate as of March 31st has been about 11%, with many deaths hastily labeled as COVID-19-related when they may not have been.

That said, there is a very real risk that COVID-19 may turn out to be deadlier in its second or subsequent wave(s) of infection than has been the case as a result of its initial outbreak. As occurred in the case of the 1918 Spanish flu, during which a third of the world’s population was believed to have been infected, resulting in more than 50 million deaths. The mortality rate for the initial outbreak is believed to have been similar to that of the ordinary flu (0.1%), while its second wave has been estimated to be approximately 2.5%. Mortality was high in the under 5, 20-40, and over 65 years age brackets. Its high mortality in healthy people, including those in the 20-40 year age group, was a unique feature of that pandemic. Let us hope history does not repeat itself.

We should resist jumping to conclusions about what the real rates of infection and death are, have been, or will be as a result of COVID-19. It is simply too early to say, we have too few tests to do a proper job in many countries and globally, and the tests that are being conducted automatically imply being heavily skewed in the direction of symptomatic individuals. Governments around the world will continue to grapple with the best course of action to try to prevent more infections, but they, and the global medical community, should be similarly focused on getting the testing regimen and interpretation of the results of those tests right.

This article first appeared in Fair Observer.