Germany's low coronavirus mortality rate intrigues experts

Germany’s relatively low mortality rate continues to intrigue experts as Covid-19 spreads across Europe, with some questioning the methodology behind its data gathering while others argue the country’s high testing rates allow a more accurate approximation of the threat posed by the novel coronavirus.

While the pandemic has hit Germany with full force, with Johns Hopkins University noting 22,364 confirmed infections by Sunday morning, only 84 people are so far reported to have died.

This means Germany currently has the lowest mortality rate of the 10 countries most severely hit by the pandemic: 0.3% compared with 9% in Italy and 4.6% in the UK.

The contrast with Italy is especially surprising because the two countries have the highest percentage of citizens aged 65 or over in Europe. If anything, the Bloomberg Global Health Index would suggest Italians have a healthier lifestyle than Germans.

German politicians and senior health officials have been reluctant to comment on the low mortality rate while the situation is developing so rapidly. Lothar Wieler, the president of the Robert Koch Institute (RKI), the government’s central public health body, has said he does not expect there to be a significant difference in mortality rates between Italy and Germany in the long run.

“It’s too early to say whether Germany is better medically prepared for the Covid-19 pandemic than other countries,” said Marylyn Addo, who heads the infectiology department at Hamburg’s University Medical Centre.

One likely explanation for the discrepancy in figures, Addo suggested, was that while northern Italy’s hospitals are being overrun with new patients, Germany’s are not yet at full capacity and have had more time to clear beds, stock up on equipment and redistribute personnel.

“One advantage Germany has is that we started doing professional contact tracing when the first cases were reported,” Addo said. “It bought us some time to prepare our clinics for the coming storm.”

Crucially, Germany started testing people even with milder symptoms relatively early on, meaning the total number of confirmed cases may give a more accurate picture of the virus’s spread than in other states.

According to Germany’s National Association of Statutory Health Insurance Physicians, the country has capacity for about 12,000 Covid-19 tests per day, while Wieler has claimed it has capacity for 160,000 tests per week.

While Germany has not tested its citizens at the same high rate practised in South Korea, guidelines have been in place for more than a month for people to be tested even if they have early-stage symptoms but have either had contact with an infected person or recently visited a “high-risk area” such as Lombardy in Italy or Wuhan in China.

The age profile of those affected in the first few weeks has also been younger than in other countries, many of them fit and healthy people returning from skiing resorts in Austria or Italy, which would also help explain the low mortality rate.

“I assume that many young Italians are or were infected without ever being detected,” Christian Drosten, a virologist at Berlin’s Charité hospital, told the newspaper Die Zeit. “This also explains the virus’s supposedly higher mortality rate there.”

Drosten, who has been advising the German health ministry, has also warned that Germany’s mortality rate is likely to rise in the coming weeks as high-risk areas become harder to identify and testing capacity becomes stretched.

“It will appear that the virus has become more dangerous, but this will be a statistical artefact, a distortion. It will simply reflect what’s already starting to happen: we’re missing more and more infections.”

The methodology behind Germany’s data gathering could also play into the discrepancy between Italian and German figures.

If a patient is tested positive for Covid-19 in Germany, the doctor will notify the local health authority, which will then digitally transfer the data to the Robert Koch Institute. The lag in this process explains why the RKI’s daily figures have been consistently lower than those from Johns Hopkins University, which updates its data tables more frequently. By 10am on Sunday morning, for example, the RKI only notes 55 fatalities in Germany.

Unlike in Italy, there is currently no widespread postmortem testing for the novel coronavirus in Germany. The RKI says those who were not tested for Covid-19 in their lifetime but are suspected to have been infected with the virus “can” be tested after death, but in Germany’s decentralised health system this is not yet a routine practice.

As a result, it is theoretically possible that there could be people who may have died in their homes before being tested and who do not show up in the statistics.

Practising medical specialists such as Addo do not believe this number of unreported cases to be statistically significant. “I have yet to see any data that would suggest a large number of untested corona-related deaths that don’t show up in the statistics,” she said.

“Clinics dealing with respiratory illnesses have been on high alert about the virus for weeks, so I would be very surprised if there was a significant figure of uncharted deaths.”

The RKI’s official mortality figures include both people who have died of the virus as well as those infected and with underlying health problems, where the precise cause of death could not be determined.