Covid-19: A comparison between European countries
Covid-19 response: a comparison between European countries
Monday April 13th, 2020 by Francisca Oxley, Iris Indigo
In Europe, the countries with the highest number of cases are Spain, Italy, France, Germany and the UK. The current mortality rate for Covid-19 differs substantially between these countries. Germany in particular stands out positively in this respect. Its death rate is 2.2%, compared to the UK’s death rate of 12.2%. This is partially because Germany does a lot more rigorous testing and counts not only serious and severe cases, but also mild and asymptomatic cases. But that is not the only reason. So, what is Germany’s secret? And what can we learn from our European fellow countries? In this article, I will mainly focus on the UK (as our home country), Germany (as best in class) and Italy (as the first European country to experience a significant outbreak with a similar population size to the UK).
It’s interesting to note that all 5 countries had their first case in the same week towards the end of January. In the first week of the developing pandemic however, it was mainly Germany that was in the news as having an outbreak. Later, Germany got overtaken in number of cases and deaths by Italy and the focus of news outlets very much shifted to Italy at that point.
So, let’s look at Germany to start with. On January 27th, the CEO of the company Webasto informed the German authorities that one of his employees had tested positive for the Coronavirus. This lady, who was based in China, had come over to Germany to facilitate some workshops at the company’s headquarters. Over the next two weeks, 16 Coronavirus cases were identified, all linking back to “case #0”. All cases were admitted to hospital for further observation.
In England, two members of the same family who had recently been to China, tested positive on January 31st. Whilst contract tracing was definitely used to identify any potentially linked cases, not a low of information is available about this.
The same day, two Chinese tourists in Rome tested positive for Covid-19. Again, information about what exactly happened is sketchy, but a cluster of 16 confirmed cases was detected in Lombardy on 21st February with another cluster of 60 additional cases on February 22nd . It is likely that these confirmed cases were already “tip of the iceberg” stuff as by early March, the virus had spread to all regions of Italy. Most of the cases in other regions could be traced back to these two clusters.
The table above shows that Germany and Italy are pretty much on a par if you look at the number of tests per million citizens, with the UK scoring significantly lower.
Italy did a scientific study, in the small town of Vò. All 3,300 inhabitants were tested. The study began on March 6th and found at least 6 asymptomatic cases. They found that the isolation of asymptomatics is crucial to be able to control the virus spread. And although Italy was a bit complacent in the initial handling of the crisis, it was the first country in Europe to implement tough lockdown measures and deserves credit for that.
Development of test kits
Even before the first case was identified, a German scientist designed a test kit based on Sars and other coronaviruses. This protocol was made public by the WHO on January 17th. By the end of February, Germany (Landt) had produced 4 million kits with a capacity to produce 1.5 million test kits per week. Germany has been testing intensively from the start, with domestic labs able to perform 160,000 tests per week in March, up to 500,000 tests per week in April, with the aim to get to up to 1.4 million tests per week.
The British government declined to use the test that was developed by Germany. Instead, the government seemed to aim for herd immunity. Minor testing and contact tracing was stopped and “passive self-isolation" for symptomatic people was encouraged. This differed substantially from the WHO recommendations and created a torrent of questions from UK scientists. Even today, April 11th, the UKs position is you must have symptoms to be tested and NHS staff are still not systematically tested.
Italy has also been developing a test kit. DiaSorin, an Italian Biotech company, has developed a coronavirus test which gives results in one hour only.
Centralised versus decentralised health care:
Healthcare is decentralised in Germany: it means that each of the 16 federal states make their own decisions about testing and lockdown measures, resulting in for example schools remaining open longer in states less severely hit by the virus. That makes it hard for a country to act “in sync”. But it turns out it has got significant advantages as well: each of the regions understands the development of the disease in their own areas very well and can take decisions suitable for their own area. And it means that between 200 and 300 German laboratories have been involved in the rapid testing scheme since February. High rates of testing are seen by many at the only viable exit strategy.
The healthcare system in Italy is also highly decentralised, with most administrative and organisation powers in region. It is regarded as one of the best healthcare systems in the world, second only to France (by WHO ranking).
In the UK, initially, a diagnostic test was only available in 8 PHE (Public Health England) laboratories. It led to a lack of capacity and the test has now been rolled out to another 40 NHS labs. This doesn’t compare well to the approximately 250 laboratories that are available in Germany to perform these tests. More labs are being recruited at universities and research institutes in order to start testing NHS workers.
Ramping up critical care capacity:
The German government has used February and March to increase the number of intensive care beds. With 29.2 critical care beds per 100,000 people, they were already in a very strong position. This compares to 6.6 in the UK and 12.5 in Italy. The German government also ordered in March 16,500 units for ventilation and intubation from two German companies. They now have about 40,000 ventilators ready, whilst the UK has got 8,200 and Italy over 5,300 ventilators (Italy’s figure is from January, so is probably outdated). Although the UK has ordered another 30,000 from UK firms and 8,000 ventilators elsewhere, these either still need to be produced or haven’t arrived yet. It is fair to say that the UK was slow to acknowledge the urgency and need.
Germany was very well prepared for a pandemic in all ways: strategy, payment and reporting structures. The UK on the other hand...a government led pandemic exercise 4 years ago, predicted that an Asian respiratory virus would overwhelm the NHS. The exercise was never published and the lessons were not learned.
Heavily government-funded health insurance system
The setup of the health insurance system plays a role as well. In Germany, health insurance is heavily government-funded. In both the UK and Italy, the national health service is significantly underfunded.
So, a combination of factors is leading to a low death rate in Germany, and a substantially higher mortality rate in Italy and the UK. We can only hope that UK politicians will truly learns the lessons from this pandemic to save lives.