High variability of COVID-19 case fatality rate in Germany.

BACKGROUND: During the first wave of the COVID-19 pandemic a high case fatality rate (CFR) was noticed worldwide including also Germany where the first European cases have been observed. The WHO recommended immediate intubation for patients with dyspnoea which has since been revised after reviewing the initial clinical outcome. The objective of this study is to analyze CFR and assess if there is an advantage of a more conservative management of COVID-19 induced hypoxemia. METHODS: PCR confirmed COVID-19 infections and death counts were obtained for all German districts from 27 Jan 2020 until 15 Feb 2021 using official reports of Robert Koch Institute Berlin, Germany. A moving average CFRt was constructed by dividing disease related deaths two weeks after a given index day by the number of infections two weeks prior to that date. In addition to a local comparison also mortality outcomes in other German speaking countries were compared. RESULTS: The mean CFR is estimated to be 2.92% based on 71.965 fatalities and 2.465.407 cases. There was a large regional scattering of CFRs across the German districts. Differences of the mortality pattern were observed also at state level and preserved across different sex and age groups while being largely independent of case numbers. Although Munich city had higher infection rates, more patients died during the first wave in Hamburg (OR 1.6, 95% CI 1.3-1.9) which was mirrored also by higher death risk at Hamburg intensive care units (OR 2.0, 95% CI 1.3-3.1). While the majority of Munich hospitals favoured a conservative management of hypoxemia including high flow nasal cannula (HFNC), Hamburg hospitals followed a more aggressive scheme of early mechanical ventilation (MV). Austria and Switzerland experienced higher CFRs than Germany during the first wave but after changing their treatment guidelines, both countries experienced lower CFRs during the second wave. CONCLUSION: Using retrospective public health data, different case fatality rates have been observed across Germany. A more conservative management of COVID-19 induced Adult Respiratory Distress Syndrome (ARDS) is justified also by epidemiological data.

[The early phase of the COVID-19 pandemic in Bavaria, Germany]. / Die frühe Phase der COVID-19-Pandemie in Bayern.

INTRODUCTION: The effect of non pharmacological interventions (NPIs) during an epidemic disease outbreak is well accepted dating back to historical events. NPIs involve numerous measurements like hygiene rules or contact restriction that are applied during given situations, while so far only limited quantitative data exist to rate the overall effectiveness. METHODS: Using the official counts of Robert Koch Institute in Berlin/Germany, press reports and Twitter messages, the early phase of the current COVID-19/Sars-CoV2 in Bavaria is being reconstructed. RESULTS: The first cases have been observed in Munich by the end of January 2020. While the initial outbreak could be sufficiently covered using isolation and quarantine measurements, the consecutive early spreading falls into three phases, starting with winter school holidays at the end of February, a number of beer festivals in the following week, and general elections on March, 15. The disaster plan on March, 16 indicates the end of the early phase. Using the official case counts, a rather coherent picture evolves although representative epidemiological studies are still missing. The epidemic started with a few cases during the winter holidays, increased exponentially afterwards including significant more cases by beer festivals and another significant excess of cases following the election that occurred in Bavaria only. Compared to other German countries, Bavaria reached the highest prevalence which could not be reversed by even the most restrictive containment measurements. CONCLUSION: To be effective, NPIs need to applied early, if possible even before the beginning of the exponential phase.