Early and Broad Testing Helps Explain Why COVID-19 Looks Less Lethal in Germany

One relative bright spot in the COVID-19 pandemic has been Germany, where the number of deaths as a share of confirmed cases—the crude case fatality rate, or CFR—is currently about 0.9 percent. Since the number of actual infections is likely to be several times larger than the official figures suggest, the true CFR in Germany may be somewhere near the lower end of the (very wide) range that U.S. public health officials consider reasonable based on current (very limited) data: 0.1 percent (the estimated CFR for the seasonal flu) to 1 percent (10 times as deadly as the seasonal flu).

By comparison, the crude CFR for COVID-19 is currently 1.8 percent in the United States, 4 percent in China, 6.4 percent in the U.K., 8.6 percent in Spain, and a jaw-dropping 11.4 percent in Italy. Is Germany doing something right, or has it just been lucky so far?

Writing from Berlin in The New York Times, German journalist Anna Sauerbrey notes that the country is “not in full lockdown,” although “gatherings of more than two people are banned,” while “schools, [nonessential] shops, restaurants and theaters are closed.” Sauerbrey argues that “early and persistent testing,” coupled with contact tracing and targeted quarantines of people who have been exposed to the virus, helps account for Germany’s success in curtailing the epidemic.

As of March 15, Germany had conducted 167,000 tests, compared to about 104,000 in the United States, a country with a population four times as large. Germany’s testing rate was not as high as South Korea’s (or Italy’s, for that matter). But it was higher than the rate in the vast majority of countries included in that tally.

“Between countries, there are several reasons why the death rate might vary, but they’re very small compared to the impact of how many people get tested,” Liam Smeeth, an epidemiologist at the London School of Hygiene and Tropical Medicine, told Time. “Germany very rapidly rolled out testing to a very large number of people, relative to the population.”

Wider testing not only helps limit transmission. It also reduces the gap between confirmed cases and total infections, which in turn reduces the crude CFR.

“Germany has also been better at protecting its older residents, who are at much greater risk,” Sauerbrey says. “States banned visits to the elderly, and policymakers issued urgent warnings to limit contact with older people. Many seem to have quarantined themselves. The results are clear: Patients over the age of 80 make up around 3 percent of the infected, though they account for 7 percent of the population. The median age for those infected is estimated to be 46; in Italy, it’s 63.”

The median age of the general population is actually a bit higher in Germany than in Italy. But in Germany a disproportionate number of people who have tested positive for the virus are young. Sauerbrey suggests that may have to do with infections that young people contracted while skiing in the Italian Alps or participating in pre-Lent carnival events.

Germany’s crude CFR has nearly doubled since last week, and it may climb further as the virus spreads and people who are already infected develop symptoms. But COVID-19 still looks far less lethal in Germany than it does in many other countries, a contrast that underlines the importance of early and wide testing—something the United States conspicuously failed to do.

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