Covid-19: What is Germany low deaths rate secret?

Whereas Italy has gained much coverage due to the extent of the country's coronavirus epidemic, there is another European nation deserving a closer look: Germany.

With the fifth-most coronavirus cases in the world, Germany has only a fraction of the deaths that we witness in other nations. And the reason continues to be a mystery. "We don't know the cause for the lower death rate," Marieke Degen, deputy spokeswoman of Germany's Robert Koch Institute (RKI), said.

The Robert Koch Institute, part of Germany's Federal Ministry of Health, is at the lead of the country's coronavirus response. According to RKI's most recent data, the confirmed Covid-19 cases in Germany are over 31,500. But with only 149 deaths as of March 26, the country's death rate remained a low 0.5 per cent.

By comparison, Italy has more than 74,300 confirmed cases and over than 7,500 deaths; the fatality rate is 10 per cent. According to the Centers for Disease Control and Prevention, the death rate is currently 1.4 per cent in the United States.

The vast discrepancy in death rates between Germany and Italy is also shocking because both nations have some of the oldest populations in the world, according to the Washington, DC-based Population Reference Bureau. The World Health Organization (WHO) has identified those over the age of 60 and people with preexisting conditions as being at higher risk of more severe symptoms from Covid-19.

"We need to work all together to protect older people from the virus," WHO Director-General Dr Tedros Adhanom Ghebreyesus said on Wednesday. "Older people carry the collective wisdom of our societies."

"We don't do anything special compared to other countries."

Much like governments around the world, Germany has imposed restrictions on social events and forced non-essential stores, bars and restaurants to stay temporarily closed. Chancellor Angela Merkel urged her fellow citizens to adhere to the restrictions to control the spread in a rare, televised address on March 18.

"This is serious," Merkel said. "Since German unification — no, since the Second World War — no challenge has ever demanded, our nation, such a degree of common and united action."

It was a firm message — not least because, as Carnegie Europe's Judy Dempsey notes, it came from a leader who, apart from her annual New Year's addresses, hasn't given a public televised communication since she became chancellor in 2005.

Yet aside from the vigorous speech of Merkel, Germany has more or less adopted similar approaches to counter the spread of the virus as many other countries. "Compared to other countries we do nothing different," German virologist Martin Stürmer said.

"In general, we have an excellent intensive care setting in Germany," Stürmer said. "We have highly specialised experts and equipment, and perhaps that's part of the reason why our critically ill patients survive compared to those in other countries."

Stürmer, who is in quarantine at home after having tested positive for Covid-19 after a relative, also claims that Germany's accelerated monitoring contributed to its lower rate of fatality. Early on, the RKI advised extensive testing to identify cases and control the spread as quickly as possible.

"This could be why we began to see cases very early; also very mild ones, which in different circumstances would have been missed," RKI's Degen said. "If you start seeing deaths, it shows that the virus has already been active in the community for some time. That also happens with seasonal flu."

Data from RKI also shows that most confirmed cases in Germany are among the younger population. Most cases are, in fact, between the ages of 35 and 59. The fact that most Covid-19 cases in Germany are in an age demographic not regarded as part of the high-risk group could be an additional important factor.

"The age profile of cases can influence the case fatality rate; deaths usually are more likely in the elderly," Stephanie Brickman, communications consultant at the WHO's office for Europe, said. "In the early stages of the epidemic, it is likely that the spread happens in working-age adults before it reaches the older populations, where the fatality rate is higher."

But as the number of confirmed cases raises, a spokesperson for Germany's health ministry is inviting to be vigilant: "It is far too early to indicate the all-clear."

"We are at the very beginning of the epidemic."

Those who died of Covid-19 worldwide were on average infected two to three weeks prior, according to the WHO's European office. Which means there is a possibility that Germany and other countries will soon see an increase in deaths in a similar stage of the outbreak.

"Italy's epidemic has developed for longer than other places in Europe, and therefore more people should have reached the final outcome and been discharged or sadly died," said Brickman.

But virologist Stürmer believes it is more likely the global fatality rate will be lower when all is said and done. "I think the fatality rates will go down all over the world because there are many people with mild or moderate symptoms, which are not being tested and therefore not displayed in the data," he said.

We do not know if Germany will be able to maintain its death rate way below those of other nations; however, German health officials are conscious that circumstances could evolve at any time going forward.

"In Germany, we are right at the beginning of the epidemic," Degen said. "We see more and more deaths, and we don't know how everything will unfold. And of course, everything must be done to slow the spread for the time being to protect medical capabilities."