Posted 13 апреля 2020, 12:32
Published 13 апреля 2020, 12:32
Modified 24 декабря 2022, 22:36
Updated 24 декабря 2022, 22:36
What do we do better in this context? - experts asked themselves a question and answered it in a detailed way:
“COVID-19 is spreading more and more around the world: 1,450,087 people became infected (as of April 8, 4 p.m.), 83,472 died. Compared to mortality rates in Italy (12%), Spain, France and the UK (about 10%), China (4%) and the United States (2.5%), in Germany this figure is low at 1.5%. What distinguishes Germany from the other countries? This is the question that scientists and the media around the world are asking themselves", as the New York Times (NYT) recently stated.
“They talked about the “German anomaly”, said NYT Prof. Dr. Hendrik Streeck, director of the Institute of Virology at the University Hospital in Bonn. He was contacted by colleagues from the United States. “What are you doing differently?”, they asked me", - he says. "Why is your mortality rate so low?"
The fact that the mortality rate is lower than in other countries probably has several reasons. One of them may be that the patients enter the clinic early, when there is a threat of deterioration.
Corona-Taxi goes to quarantined patients
In Heidelberg, for example, the so-called Corona-Taxi allow patients with COVID-19 to receive early medical care. Medical students and nursing staff at the University of Heidelberg Hospital form a team of special taxis that visit patients with COVID-19 in quarantine after 8 days to take a smear and blood for analysis.
"At the end of the first week, a tipping point is coming," NYT Prof. explained. Dr. Hans-Georg Kräusslich , Head of the Department of Virology, Heidelberg University Hospital, one of Germany's leading research clinics. It is then that it becomes clear whether COVID-19 itself will subside or if symptoms worsen.
In the event of a threat of deterioration, patients are quickly taken to hospital. According to Stefan Kramer of the Rhein-Neckar County Health Department in Heidelberg, between 3 and 4 vehicles are currently in operation. “The number of Corona-Taxi depends on the number of patient visits. Since we visit all the people who are tested positively at least once on the eighth day, this can be well planned”, - Kramer explained in an interview with Medscape.
University Hospital and the Department of Public Health work closely together in the Corona-Taxi area. The idea arose when it became clear "that it is not so simple to provide medical care for all positively tested people". It has also been shown that early admission to the hospital can shorten the course of the disease", - says Kramer.
And now additionally the Test-Taxi
Another joint project is starting: Test-Taxi. Patients in nursing homes with suspected COVID-19 should be detected more quickly and diagnosed more reliably. “At the moment, one of these Test-Taxis is already working. We are analyzing demand and planning to purchase a second car”, - Kramer reports.
"Test taxi" allows you to quickly take a smear from often people with limited mobility in place. In the case of the outbreak of COVID-19, experts hope to get a general idea of it as soon as possible and begin to take action.
Extensive testing - at an early stage in the clinic
Could a lower mortality rate be somehow related to the fact that patients come to the clinic earlier? "This is still speculation at the moment and is likely to become more clear in a few weeks," Prof. said. Dr. Michael Pfeifer , president of the German Society of Pneumology and Respiratory Medicine (DGP).
However, he acknowledges that extensive and early testing for COVID-19 in Germany led patients to appear in clinics at an early stage of the disease. “It's easier to stabilize patients at an early stage of the disease,” he explains in an interview with Medscape.
From heavily affected US states, it is known that many patients come to the clinic only at a late stage of the disease.
Many young people are infected with COVID-19 - The Skiers' Epidemic
Despite the fact that the average age of deaths from COVID-19 in Germany is 82 years, the average age of patients here is lower than in many other countries, it is only 49 years old. In France, as recent national reports show, this figure is 62.5 years in France and 62 years in Italy.
Explanation of the difference: many early patients in Germany were infected with the virus in Austrian and Italian ski resorts and were relatively young and healthy, according to Kräusslich . The pandemic began in Germany as the “epidemic of skiers."
However, as COVID-19 spreads, more and more older people also become infected. Accordingly, the mortality rate also increased, which at the beginning of March amounted to 0.8%, as previously stated by the President of RCT Prof. Dr. Lothar M. Wieler .
Currently the 350,000 tests per week in Germany
The fact that many more people are tested in Germany than in most other countries also results in low mortality. This is because more people with few or no symptoms are also tested, which increases the number of known cases, but not the number of deaths. "This automatically reduces the mortality rate," says Kräusslich .
Germany currently runs over 350,000 tests per week - more than any other European country. In mid-January, a test was already developed at Charité Clinic in Berlin and instructions for it were published.
When the first case of COVID-19 arrived in Germany in February, tests were already conducted in laboratories across the country. "The reason we currently have so few deaths in Germany compared to the number of infected people is mainly due to the fact that we conduct an extremely large number of laboratory tests," says Prof. Dr. Christian Drosten , head of the virology department at Charité, whose team developed this test.
"If I know the diagnosis and can treat patients at an early stage - for example, by connecting them to a ventilator before their condition worsens - the chances of survival are much higher," Kräusslich confirms.
In order to accelerate testing of medical personnel, some clinics began to conduct block tests, with smears taken at the same time from 10 employees, and individual tests are carried out later only if the results of the group are positive.
At the end of April, a large-scale study of antibodies among the population is also planned to determine the extent to which group immunity is formed.
USA: Less Tests
The fact that more tests are being conducted in Germany than in the USA is also related to the fact that the costs of tests are covered by the health insurance funds. In the first weeks of the outbreak of COVID-19 in the United States this did not happen. Only last month Congress passed a law about the free testing.
Not only the cost of the test, but also the lack of medical insurance does not allow people in the US to visit a doctor. "It is unlikely that a young person who does not have health insurance will go to the doctor only because of a sore throat - but at the same time he runs the risk of infecting more than other people," says Streeck.
Streeck reports that in most countries, including the United States, testing is mostly limited to critically ill patients, so young people who have few or no symptoms are more likely to be unable to take the test.
Germany: Testing capacity is limited due to the lack of large reserves of reagents.
In Germany, as a rule, everything is different. The case of a symptomless young man who was tested in Bonn is reported because he attended a carnival event with those infected and was identified as "positive." He worked in a school that was closed after that, all the children and staff had to spend 2 weeks in home quarantine, and about 235 people were tested.
"Testing and tracking is a strategy that has been successful in South Korea, and we tried to learn from it," Streeck said. But lessons can be learned from earlier German mistakes: the strategy for identifying contacts should have been used even more actively, he says. For example, all those who returned to Germany from the Ischgl ski resort had to be found and tested.
However, in his April 7 NDR Corona-Udpate podcast, Drosten indicates that testing options are limited as reagents become increasingly scarce. "We have been in this state for a week or two, and it is becoming more painful at the moment when we notice in the laboratories that we order supplies for two weeks, and we receive all types of reagents for only three days." It’s like living hand-to-hand. Therefore, from his point of view, it is important to test only when it is really necessary.
Preparation of new intensive care facilities and intensive care unit registry
Another argument why Germany is in a good position: hospitals throughout the country have expanded their capabilities in the field of intensive care. At the same time, they started from a high level. Before COVID-19, Giessen University Hospital had 173 intensive care beds equipped with fans. Recently, the hospital increased the number of beds by 40, and the number of emergency staff on intensive care by 50%.
“Now we have enough capacity to receive patients from Italy, Spain and France,” says Prof. Dr. Susanne Herold , Head of the Clinical Infectology Department at Giessen University Hospital. "We are very strong in intensive care."
In January, there were about 28,000 intensive care beds in Germany with the option of connecting a fan, or 34 per 100,000 people. For comparison: in Italy - 12, in the Netherlands - 7. In Germany, there are currently 40,000 beds for intensive care.
An important part of preparing for the COVID-19 pandemic is the intensive care unit registry. There, from 1,100 to 1,200 intensive care units of German clinics must register their free capacities and, thus, provide better coordination on a daily basis.
German doctors have prepared for how to deal with a lack of intensive care resources, despite an increase in throughput. “It’s important that we have instructions for doctors to produce triage patients if necessary,” Streeck said. "But I hope we never have to use them."
Some experts are cautiously optimistic that social distancing can smooth out the curve of the spread of serious illnesses to such an extent that the healthcare system can survive a pandemic using the existing fund of intensive care beds and fans.
What is the role of the Сhancellor?
The New York Times also argues that German government communications during the crisis may have helped keep mortality low. The Chancellor, who has a natural science education, interacted clearly, calmly, and regularly during the crisis, when increasingly harsh social events were introduced in the country.
Constraints that are so essential for slowing the spread of the pandemic met up a weak political resistance and rejection and were largely respected. “Perhaps our greatest strength in Germany” - Kräusslich says, - "is the rational decision-making at the highest government level combined with the trust that the government enjoys among the people ..."