Why is the coronavirus mortality rate so much lower in Germany?

Is there something about being Germany which protects the body against coronavirus Covid-19? Probably not, I would guess. In which case why do the latest figures from the Robert Koch Institute show that the country has a case fatality rate (CFR) of 0.3 per cent, while the World Health Organisation (WHO) figures from Italy seem to show a CFR of 9 per cent? To say there is a vast gulf between those figures is an understatement. If nine per cent of people who catch Covid-19 are going to die from it we are facing a calamity beyond parallel in the modern world. If only 0.3 per cent of people who catch it die from it, this pandemic may yet turn out to be no worse than seasonal flu, which as I have explained here before is estimated by the US Centers for Disease Control to kill between 291,000 and 646,000 people a year without the world really noticing. According to John Hopkins University, which is collating fatalities data, 15,308 have died to date.

So which is closer to the real situation, Italy’s experience or Germany’s? Various theories have been put forward for Germany’s low death rate: for example that many of those who have tested positive for Covid-19 are young people who had returned from skiing holidays in Italy. The age profile for those who have tested positive in Germany is certainly much lower than in Italy: a median of 46-years-old as opposed to 63 in Italy. Some have expressed the fear that young German skiers will slowly infect their parents and grandparents’ generation, and that the death rate will steadily rise as the disease works its way through more vulnerable elderly people.

Germany is almost certainly behind Italy in this epidemic. But the main difference between Germany and Italy lies in those countries’ respective attitudes towards testing. Germany has carried out far more enthusiastic testing of the general population – there does not seem to be a central figure for this, but the German Doctors’ Association has estimated that 200,000 people across the country have been tested. In Britain, it is 64,000 people. On the other hand, German hospitals do not routinely test for the presence of coronavirus in patients who are dying or who have died of other diseases. Italy, by contrast, is performing posthumous coronavirus tests on patients whose deaths might otherwise have been attributed to other causes.

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This matters hugely to the Case Fatality Rate for each country. As explained here before, CFR is not to be confused with the genuine Mortality Rate. The former is simply the number of deaths divided by the number of recorded cases. The latter is the number of deaths divided by the actual number of people who have been infected by the disease. Trouble is, nobody knows the latter figure because no country has tested its entire population to see who has or has had the disease. What we do know is that large numbers of people who have been confirmed as having the disease only have mild symptoms – 45 per cent according to Italy’s National Institute for Health. One in 10 have no symptoms at all. There must be many others who have been infected but haven’t been tested and therefore who do now show up as confirmed cases.

It stands to reason that the more people who are tested, the more accurate a picture we will have of the mortality rate, the transmission rate and other metrics which will determine the eventual path of this pandemic. To underline the uncertainties behind the data from which policy is currently being made, the Royal Society of Hygiene and Tropical Medicine the other day estimated the number of people in Britain who already have or have had Covid-19 at between 6,000 and 23 million. That is a pretty broad spread with hugely different implications. If only 6,000 have the disease in Britain, socially-distancing the population or locking down society might have a purpose. If 23 million have the disease, it is pointless – it already has ripped its way through the population but without killing more than a tiny percentage.

What we really need is a huge effort to test a large randomised sample of the population to see how widespread the infection is. Hopefully, that will soon happen. But in the meantime, I am minded to think that the more accurate picture of Covid-19 comes from the country which has conducted the most tests: Germany.