'The mortality rate is puzzling': Why does Germany have a lower coronavirus death toll?

Germany has a relatively low death rate from the coronavirus compared to other countries. Why is this? Experts weigh in.

The whole world is in a state of emergency due to the novel coronavirus (COVID-19), with governments from Australia to America preparing for the worst. Yet there are striking differences in the death toll from the virus.

Germany stands out with a relatively low number of deaths - or 229 out of over 40,500 confirmed cases as of Thursday afternoon.

According to figures from Johns Hopkins University, Italy had more than twice as many confirmed coronavirus cases as Germany by Tuesday, but the case mortality rate there was more than 20 times higher than in Germany.

At 0.54 percent, Germany's death rate is far lower than Italy's rate of around 10 percent and Spain's fatality rate of 7.3 percent. France's death rate is about 5.2 percent. Why is this?

"To be honest, we still know too little," Richard Pebody, an expert from the World Health Organization (WHO) told DPA. "The mortality rate is puzzling." 

READ ALSO: What's the latest on coronavirus in Germany and what do I need to know?

He warned against comparing countries, because the basic conditions are different in each nation. "It's like comparing apples to oranges,” he said. 

But there are several possible explanations, all of which play a role:

Epidemical Time: "Countries such as Italy and Spain are probably further along in the epidemic than Germany," says Pebody. 

The first cases in these countries are likely to have appeared undetected much earlier, and the virus has probably spread unnoticed among the population. It takes a while after infection before complications arise, said Pebody, with many patients spending weeks in intensive care before they die.

Age: Because there is very little testing in many countries, only the average age of confirmed cases is known. However, there are probably many younger people who have also had the virus and have experienced no or only mild symptoms, said Pebody.

The average age of those who are proven to be infected is much higher in Italy than in other countries, including Germany. "Average age of corona cases Germany: 45 years...Italy: 63 years," German population researcher Andreas Backhaus tweeted earlier this week. 

One reason for the very different case fatality rates in Germany and Italy:
Average age of corona cases in Germany: 45 years, according to @rki_de. Average age of corona cases in Italy: 63 years, according to @iss.

— Andreas Backhaus (@AndreasShrugged) March 23, 2020

On the online platform Medium, Backhaus compared South Korea and Italy on key dates when both had about the same number of cases. In South Korea, around nine percent of confirmed infections were over 70, whereas in Italy the figure was more than 40 percent.

Younger people tend to suffer far less severe symptoms if they don’t have a pre-existing condition, although there are of course outliers, such as a 42-year-old in Berlin with no prior medical history who died on Wednesday from the disease. 

The Robert Koch Institute (RKI) only mentions the age group of 60 and over, and not over 70s, in its statistics of those infected. Yet even here, the age distribution of confirmed cases in Germany is significantly lower than in Italy: at the beginning of the week, 19 percent of confirmed cases in Germany were over 60, and more than half were between 35 and 59.

At the same time, experts have repeatedly warned that in the country where
almost a quarter of the population is over 60, the number of deaths could
still skyrocket if people do not stick to measures to help halt contagion.

Testing: The age structure of cases in a particular country says something about their testing strategy. If more younger people were tested in Italy, the case mortality rate would probably look very different. Germany has made a push to test all of those in contact with an infected person, as well as those who only show mild symptoms.

Germany is testing up to 500,000 people a week for the coronavirus, Christian Drosten, who heads the Institute of Virology at Berlin's Charite University Hospital, said on Thursday.

"Germany has a very aggressive testing strategy, so there are probably more mild cases among the total number of confirmed cases,” said WHO emergency coordinator Michael Ryan.

Yet the more advanced an epidemic is, the more difficult it becomes for a country to carry out widespread testing, because the health system is simply overwhelmed. WHO Chief Tedros Adhanom Ghebreyesus' called for countries to "Test, test, test" so that they know what the situation is.

“You can't put out a fire blind," he said.

Unlike in Italy, however, there is not widespread postmortem testing for the disease in Germany, which could also explain why more deaths from coronavirus are being recorded there.

Quality of healthcare: The better prepared hospitals are, the more lives can be saved, said WHO coordinator Ryan.

"When hospitals are overwhelmed by the number of patients, it's a simple question of how far adequate care can be provided and whether you can respond to any change in the patient's condition in the intensive care unit."

Three factors are crucial, said Pebody: the number of intensive care beds, sufficient protective clothing and well-trained staff in the intensive care units.

Italy, with a population of around 60 million, had 5,000 intensive care beds before the crisis, according to authorities. More have been created in the meantime. The UK, with 66 million inhabitants, had 4,100 intensive care beds according to the National Health Service (NHS). 

In Germany, with about 80 million inhabitants, there are about 28,000 beds, and the number is now to be doubled.

Overall, experts agree that rigorous testing, isolation of infected persons and quarantine for people who have been in contact with infected persons will slow down the epidemic - strategies that South Korea and Singapore have consistently implemented.

In some countries, curfew restrictions are also needed to slow down the spread, according to the WHO. The case mortality rate - currently about 0.4 percent in Germany - is one percent in South Korea and about 0.3 percent in Singapore.
The Asian surveillance methods are, however, unheard of for Europeans: In Singapore there is now a governmental smartphone app that uses Bluetooth to find out who has spent more than 30 minutes less than two meters away from an infected person.