This is why Germany’s coronavirus death rate seems so low

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Since the first reports of a new flu-like illness emerged from China on December 31, 2019, every nation has kept a grim scorecard – coronavirus cases, recoveries and deaths. And as the worst public health crisis of a generation is brought to us live via a 24 hour news cycle, citizens have begun to compare each other’s records, and question why they diverge.

One area where a big gap has opened between countries is death rates. Germany, as of March 25, has recorded 35,714 Covid-19 infections but just 181 Germans have died from the disease. That puts its case fatality rate – the number of deaths out of confirmed coronavirus cases – at about 0.4 per cent. In Italy, this figure is nine per cent while in the UK – which has 8,328 confirmed cases – it’s 4.6 per cent. So what is Germany doing right?

At such an early stage in the pandemic, it’s difficult to draw firm conclusions. “We are really still at the start of the outbreak – there’s still a lot of time for things to change,” says Michael Head, senior research fellow in global health at the University of Southampton. “And rates of increase or decrease with infectious diseases aren’t a linear thing. We will see peaks and troughs on those graphs as we go forward.”

But there are some hints as to why Germany seems to be handling the coronavirus outbreak better than the rest of Europe. One of the most convincing is Germany’s demographics. Though Italy and Germany have similar median population ages – on average they are the oldest and second-oldest nations in the EU, respectively – this similarity is not reflected in the median age of the infected. In Italy it is 63; in Germany it is just 46. (Worryingly, Britain’s is thought to be 64).

We already know from studies out of China that older people are much more likely to be hit with more severe cases of coronavirus or die from the disease. Data from the Robert Koch Institute shows that 80 per cent of all people infected in Germany are younger than 60. The country’s death rate is comparatively low, therefore, because it’s sick are comparatively young for the time being.

There’s also been speculation that Germany’s ‘super spreaders’ returned from skiing resorts in Austria or Italy, and were therefore young and healthy people less likely to die from symptoms. “The early cases in Italy, when it was spotted anyway, either started in high risk populations such as the elderly, or reached them fairly quickly,” says Head. “We can probably expect Germany’s mortality to slowly increase as the outbreak spreads through more vulnerable populations, and we can probably expect the Italian mortality rates to come down a bit.”

Data from South Korea supports this hypothesis. There, women represent more than 60 per cent of infections, and nearly a third of the cases have been people between the ages of 20 and 29. The country’s case fatality rate sits at a comparatively low 1.38 per cent.

“Germany’s also a little bit earlier on in the process than Italy,” says Martin Hibberd, professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine. “It takes two or three weeks of intensive care before people often succumb to the disease.” The case fatality rate tends to lag behind the number of new cases as it takes time for people to get seriously ill and then die.

One grim suggestion is that while Italian hospitals are being overwhelmed by patients, Germany is stemming the tide. “Another contributing factor is the health surge capacity,” says Hibberd. “Clearly, if you can’t give intensive care to the most severely ill, then that will have an impact as well.”

Germany has one of the highest numbers of critical care beds in Europe. According to data from 2011, Germany had 29.2 critical care beds per 100,000 people. Italy had 12.5 while the UK had just 6.6. Germany’s figures put it way above the European average of 11.5 beds per 100,000 people. “The German health service has a lot of spare capacity – more so than the UK or Italy,” says Head. “Their health services have not yet been overwhelmed by it.”

This, combined with a more forgiving distribution of infections, might account for the lower case fatality rate, says Matthias Stoll, a professor of medicine at the University of Hanover. While northern Italy’s hospitals – already low on intensive care beds to begin with – have become overwhelmed with cases, in Germany infections have been more evenly-distributed. “There’s just a little bit of luck involved in these things as well as to who gets infected, and whether those people have significant mixing patterns,” says Head.

But all of this should be taken with a large pinch of salt since case fatality rates will fluctuate depending on how widely countries are testing for coronavirus, and who they are testing. If, for instance, as is the case in the UK, you test only the seriously sick people brought into hospital, then your mortality rate will skew high. Potentially hundreds of thousands of asymptomatic and mildly ill patients will go unrecorded.

Germany, on the other hand, has for several months tested thousands of people displaying only mild symptoms. Lothar Wieler, the president of the Robert Koch Institute, told journalists that German laboratories can conduct 160,000 coronavirus tests every week. The country’s low mortality rate is likely to be where much of the rest of the world will eventually end up. “The UK mortality rates now and in the near future will be artificially high compared to Germany,” says Head. “I think where Germany and South Korea have done well is to scale up their testing capacities to much higher rates than, for example, the UK.”

Sociological reasons could also come into play. Do Italians kiss each other on the cheeks more often than Germans? Do grandchildren meet more frequently with grandparents? Population density is a key factor, too. “Take London, for example,” says Head. “The last few days people have been crammed onto the tube, and they’ve still been going to pubs and bars. So they’re exposing themselves to potential transmission.”

In the quest for definitive answers, the UK’s government’s recently announced antibody tests will be a game changer – the country has ordered 3.5 million of the kits to see whether people have been previously exposed to the virus. Only once we know who has been infected will the discrepancies between nations’ rates of death become clearer. “For things like influenza, we have a very good antibody-based test – we can see, at the end of each season, how many people were infected with that disease,” says Hibberd. “This is why the influenza death rate looks very low – because we have a very accurate number about how many people were infected through these serological sampling techniques. We haven’t yet done that for Covid-19.”

Will Bedingfield is a staff writer for WIRED. He tweets from @WillBedingfield

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