The mystery of Germany’s low coronavirus death rate

Germany has the fifth most coronavirus cases worldwide — but only a fraction of the deaths.

While Italy has received much of the attention due to the severity of the coronavirus outbreak in the country, there’s another European nation that deserves a closer look: Germany.

Germany has the fifth-most coronavirus cases in the world, but only a fraction of the death toll that has been seen in other countries. And the reason remains a mystery. “We don’t know the reason for the lower death rate,” Marieke Degen, deputy spokeswoman of Germany’s Robert Koch Institute (RKI), told me.

The Robert Koch Institute, part of Germany’s Federal Ministry of Health, is at the forefront of the country’s coronavirus response. According to RKI’s most recent figures, there are more than 31,500 confirmed Covid-19 cases in Germany. But with 149 deaths as of March 25, the country’s fatality rate was a low 0.5 percent.

In comparison, Italy has more 74,300 confirmed cases and over 7,500 deaths, which puts its fatality rate at 10 percent. In the United States, the fatality rate is currently at about 1.4 percent according to the Centers for Disease Control and Prevention.

The huge discrepancy in fatality rates between Germany and Italy is also startling because both countries 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 people over the age of 60 and people with preexisting medical conditions as being at higher risk of experiencing more severe symptoms from Covid-19.

“We need to work 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”

Just as governments have elsewhere around the world, Germany has instituted restrictions on public gatherings and ordered the closure of nonessential shops, bars, and restaurants. Chancellor Angela Merkel urged her countrymen in a rare, nationally televised address on March 18 to abide by the restrictions in order to contain the spread.

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

It was a stark 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 nationally televised speech since she became chancellor in 2005.

But outside of Merkel’s forceful speech, Germany has more or less followed similar strategies to confront the spread of the virus as many other countries. “We don’t do anything special compared to other countries,” German virologist Martin Stürmer told me.

“In general, we have a rather good intensive care situation in Germany,” Stürmer said. “We have highly specialized doctors and facilities, and maybe that’s part of the reason why our severely ill patients survive compared to those in other countries.”

Stürmer, who is in quarantine at his home after a family member tested positive for Covid-19, also believes Germany’s rapid testing contributed to its lower fatality rate. The RKI early on recommended broad testing to detect cases as soon as possible and to slow the outbreak.

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“This is probably why we started to see cases very early, also mild ones, which in other circumstances might have been missed,” RKI’s Degen said. “If you start seeing deaths, it indicates that the virus has already been active in the community for some time. The same is also true with the flu.”

Data from RKI also shows that the majority of cases in Germany have been detected in people between the ages of 35 and 59. That most coronavirus cases in Germany are being detected in an age demographic that is not considered part of the high-risk population could be a further contributing factor.

”The case fatality rate can be affected by the age profile of cases; deaths usually occur in the elderly,” Stephanie Brickman, senior communications consultant at the WHO’s regional office for Europe, said in an email. “In the early stages of the epidemic, it is possible that more cases occur in working-age adults before the epidemic spreads to older populations, where the case fatality is higher.”

But as the number of confirmed cases accelerates in the country, a spokesperson for Germany’s health ministry is calling for continued vigilance: “It is far too early to signal the all-clear.”

“We are at the very beginning of the epidemic”

According to the WHO’s Europe office, those who have died from Covid-19 worldwide were on average infected two to three weeks prior. That means there’s a chance Germany and other nations in a similar stage of the outbreak could soon see a spike in deaths.

“The outbreak in Italy has been evolving for longer than other places in Europe and therefore more patients will have completed their final outcome and either been discharged or sadly passed away,” Brickman said.

But virologist Stürmer believes it is more likely the global fatality rate will be lower when all is said and done. “I think all over the world the rates will go down, because we have so many people with mild symptoms, which are not being tested and therefore they are not reflected in the data,” he said.

Whether Germany will be able to keep its fatality rate way below those of other countries is unclear, but the country’s health officials are aware that things could change at any moment going forward.

“In Germany, we are at the very beginning of the epidemic,” Degen said. “We see more and more deaths and we don’t know how everything develops. And of course everything is done to further slow the spread at the moment in order to save medical capacities.”

HJ Mai is an award-winning journalist. He currently works as an editor for NPR’s Morning Edition.