YOUNG EAP BLOG

COVID-19 SERIES (#9)

SARS-CoV-2 in Germany

The first case of COVID-19 in Germany was reported on 28th of January 2020. A man from Bavaria (Starnberg) had work-related contact with a Chinese colleague who is assumed to be the source of his infection. She participated in a seminar at the company office south of Munich and only became aware about her COVID-19 infection after her return to China a few days later. Two days after the seminar, the 33-year old male German employee started to feel unwell for two days and stayed home, then returned to work and learned about the infection of his Chinese colleague which was communicated on the same day. He was tested positive for SARS-COV-2 on the same day, and three of his co-workers were tested positive the following day. Hence, the company headquarter closed for two weeks. At least 14 SARS-COV-2 positive cases among employees and family members were reported, some asymptomatic and some with mild symptoms. This first agglomeration of COVID-19 infections was meticulously tracked by the local public health service that employed quarantine measures, which successfully contained the spread. However, the infection spread rapidly thereafter, particularly after the winter holidays in February when many families returned to Germany from skiing holidays in Austria and Northern Italy, and the virus was widely distributed.

The first uncontrolled outbreak of the Coronavirus began on February 27, 2020 in Heinsberg (North Rhine-Westphalia) where an infected couple transmitted the virus to potentially hundreds of other people on a carnival festivity attended by about 300 participants. On February 28, 32 infected persons were already reported from three main infection agglomerations across Germany: Heinsberg in North Rhine-Westphalia, Munich and Baden-Wurttemberg. At the end of February, the German Minister of Health Jens Spahn announced a special session of the health committee and asked for broad cooperation as well as a united European action to prevent spreading of the virus. In the beginning of March, companies started to encourage and organize working from a home office, and large-scale events (such as the book fair in Leipzig) were cancelled. The first COVID-19 related death in a German citizen occurred in a 60-year old man who travelled to Egypt, where he died on March 8. The following day, a 78-year old man and an 89-year old woman are the first two deaths reported in North Rhine-Westphalia, Germany.

From March 10 onwards, first states banned events with more than 1000 attendees, on March 16 the borders to France, Austria and Switzerland were partly closed and schools and kinder gardens shut down, and the national danger level was raised to “high” a day later. On March 18, chancellor Dr. Angela Merkel (a trained physicist) rose to speak to the nation via television for the first time outside her regular new year’s speech in the 15 years of her chancellorship (1). A restraining order was imposed over all of Germany on March 23, ruling that people were only allowed to meet one other person from a different household, and restaurants, cafes, bars and shops were closed except for being able to offer take away foods. In contrast to some other European countries, German citizens were always allowed to leave their house provided they kept a distance of at least 1.5 meters to others who were not members of their households. The federal government approved a huge financial package of 156 Billion Euros to support the German economy and provided a generous package to fund partial continued payment of employees without work so their work contracts were not ended. In addition, the 16 states also provided a variety of support measures to companies and employees.

Beginning at the end of April, shops up to a size of 800qm were allowed to reopen, while a mandatory facial mask wearing was introduced for public transportation and shops (where keeping the recommended distance of 1.5 meters is not always possible). First schools re-opened on May 4 for pupils of older age whereas day care remains closed for longer. Large public events are banned until August 31.  

 

Governmental institutions and their role in the Corona crisis

The prime institution providing scientific advice on biomedicine and public health to the federal government is the Robert Koch Institute (RKI) in Berlin.  Its tasks comprise: ‘

  • Identification, surveillance and prevention of diseases, including infectious diseases
  • Monitoring and analysing term public health trends in Germany
  • Epidemiological and medical analyses and evaluation of highly pathogenic and highly contagious diseases that are of great significance to the general public
  • Provision of scientific advice for health-related political decision-making
  • Sharing information with political decision-makers, the scientific and the general public
  • Executive tasks defined by special laws, in particular with regard to preventing infection, legislation on stem cell research, and attacks using biological agents
  • Federal health reporting‘ (2).

The RKI has analysed data on the SARS-CoV-2 spread in Germany from day one and formulated recommendations for action. Geographic areas of high risk were defined and guidelines for the dealing with suspected cases were provided. These have been provided to the federal ministry of health and to the 16 states, who based on German law have the authority and responsibility to implement infection protection. The RKI also created a dashboard in cooperation with Esri Germany (3) visualizing current epidemiological data on COVID-19 and thus making it more accessible to the public. Education on hygienic measures was performed by the federal centre for health education (4) and the federal ministry of health (5).

 

The German action plan

Germany has been very lucky with its availability of testing capacity and of hospital and intensive care unit (ICU) beds. Based on reported data from 176 laboratories, the RKI reported 3.147.771 tests for SARS-CoV-2 were performed countrywide until early May, with some 6.3 % positive results (6). Although the number of undetected cases may be considerable, the broad testing along with the relatively early lockdown measures helped to contain the spread of infection. Prior to the COVID-19 epidemic, Germany had about 28.000 ICU beds or about 34 ICU beds per 100.000 inhabitants, compared to the European mean of 11.5 per 100.000 inhabitants (7). In response to the COVID-19 epidemic, hospitals were required to cancel elective care and interventions which markedly reduce the need for ICU capacity for non-Covid-19 patients, and large tertiary care hospitals increased and often doubled their ICU capacity by converting post-surgical recovery rooms and intermediate care facilities into fully equipped ICU units. The RKI jointly with the German interdisciplinary association for intensive care and emergency medicine (DIVI e.V.) (8) developed a nation-wide platform for real-time monitoring of available ICU capacities to allocate required resources (9). However, even when the number of COVID-19 patients peaked, there was never a shortage of hospital and ICU care capacity. Therefore, also the guidelines developed by DIVI on triage for access to ICU when need would exceed capacity did not need to be applied (10).

 

Public Health and Primary Care Services

In a pandemic situation, a sudden and special need for public health services arise. In Germany the Public Health Service is under the authority of the states and is generally organized by public health offices at the county and city level, usually led by a medical officer. Their activities are diverse and include counselling and support for families with infants and pre-school children, counselling and support for pregnant women and mothers, serial examinations in day cares and school entry examinations, dental examinations, surveillance and monitoring in the areas of hospital, environmental and epidemic hygiene, counselling and support for people with psychiatric disorders and people with chronic diseases or disability as well as risk of disability, health reporting, and provision of advice to political decision makers.  

During the COVID-19 epidemic, the public health offices are required by law to be informed on positive test results of patients in order to conduct tracking of contact persons, aiming to contain the spread of infection by tracing contact persons of every infected person and imposing usually quarantine at home. This is a very demanding task, considering that it can easily be 150 contact persons of one infected patient that need to be tracked, particularly since many public health offices tend to be understaffed. The staff of many offices has therefore been upgraded by transferring public servants from other departments and by hiring temporary staff e.g. medical students who were trained online by RKI to trace patient contacts. Tracking is often done by phone calls with every single suspected contact person, which is very time consuming. During the course of the conversations with the infected and the contact persons, and due to the dynamic of the crisis, special situations occur that may require flexible adaptions of the process. For example, families living in small apartments may not be able to keep social distancing within their household which may have an impact on the duration of quarantine, or some infected people may initially forget to mention a contact person that may then lead to a further round of contact tracing. Additionally, there are legal issues that have to be identified and clarified during the course of the process. Due to the federal structure of the public health system, different approaches may be applied in neighbouring countries which may irritate people who receive different instructions under similar conditions. The response to the COVID-19 crisis was very much supported by a well-established system of countrywide coverage by primary care physicians, including paediatricians delivering primary care to children and adolescents. The majority of COVID-19 patients can be monitored and treated by their primary care doctor, which enables most of them to stay at home, while they can still be transferred to hospital in time in case, they need an escalation of the level of care. This well-functioning system reduces the burden on hospitals and the number of infectious patients that need to be cared for in hospital settings.

 

Increasing appreciation of academic medicine and of holding capacity

The enormous challenges that have arisen from the epidemic and the need to take numerous unprecedented decisions directed great attention to science-based advice provided by academic medicine. The visibility and appreciation of scientific research in biomedicine and of individual researched has dramatically increased. A Science Communicator Award was dedicated by the German Research Council (DFG) to Professor Christian Drosten, Director of the Institute of Virology of Charité Berlin, who has been working on Corona viruses for more than two decades (11). He started to share his knowledge on Corona viruses and on SARS-CoV-2 in a regular podcast produced by a public radio station, which has become hugely popular. A characteristic of this series is that it is based on current scientific publications and providing the public with greater understanding of research methodology and remaining uncertainty in biomedical science.  

 

Children and COVID-19 in Germany

COVID-19 is widely discussed among paediatricians in Germany. Schober et al. (12) recently published an article on the many different challenges children are facing in the light of the Corona pandemic. Due to the closure of educational institutions 1,6 billion learners were not schooled until the end of April 2020 worldwide (UNESCO: COVID-19 Educational Disruption and Response 2020), (12), (13). Children have a right to education according to the UN-Convention on the Rights of the Child, Art. 28 (14). Thus, the closure of educational institutions has to be based on scientific knowledge that we will further have to obtain in order to be able to gradually reopen those institutions again in dependence of the development of infections. As observed in other countries, relatively little numbers of children have been infected with SARS-CoV-2 in Germany, suffering from mild to no symptoms in most cases, though the reasons for this are not fully understood yet. However, also a small number of children with severe disease courses and with a Kawasaki-like manifestation have been observed. Along Schober et al. the current data therefore suggests that closed educational institutions do not primarily protect children themselves from the disease but serve the containment of the pandemic and protection of more vulnerable population groups (12). Studies from Iceland where schools were not closed (15) and from the severely affected municipality of Vo in Italy (16) showed no infections among children under the age of ten (12), (15), (16) and a large-scale Chinese study suggests that only five percent of the children need supplementary oxygen and less than one percent develop organ failure (17). These numbers may be overrated due to the testing of largely symptomatic children (12). So far only very few individual cases of deaths from COVID-19 in children have been reported (18).

 

Figure 1: Electronically reported COVID-19 cases/100,000 population in Germany by age group and sex (n=161,869) for cases with information available (03/05/2020, 12:00 AM), (19)

Children and their families are currently facing a multitude of social and psychological challenges with schools and kinder gardens being closed and parents teaching their children from home while working in home office at the same time themselves. The Leopoldina, the German National Academy of Sciences since 2008 (20), published a third ad hoc statement on suggested measures for Germany, underlining the rise of social inequalities caused by the decline of care, teaching and learning opportunities for children due to the Corona crisis (21). Paediatricians therefore ask for more research on the epidemiological relevance of children as transmitters of the virus especially among pre- and asymptomatic children. The WHO-China Joint Mission Team reported in February 2020 that of note, people interviewed could not recall episodes in which transmission occurred from a child to an adult in Wuhan (22). Following studies showed that only in one percent of the examined household clusters children were the Index cases (12), (23-25). There is rising data that children not only suffer less frequently from COVID-19 and with milder symptoms but also seem to be transmitters of the disease less often (12). Drosten et al. showed that children had a quantitively comparable viral load in the upper airways to adults (26) though most of the tested children were symptomatic which is why the conclusion that children may be as infectious as adults is not evident (12). Due to the observations that have been made to date, the use of closed educational institutions has to be further investigated and critically evaluated (27) especially against the background of its secondary harm to children and their families (12).

The special interests of children in the current situation again underline the importance of the needed implementation of children’s fundamental rights into the German constitutional law. Currently there are rising political debates on the liberty rights of children and adults and the proportionality against the background of the restrictions that were introduced in the light of the pandemic by the German government. With kinder gardens and schools being closed and parents working from home families are facing an unprecedented stress level. At least in Germany citizens were always allowed to leave the house with the family to go out for a walk in the nature. Still every human being and especially children need physical and social interaction, mental stimulation and somebody to pay full attention to them. With rising numbers of female workers this situation sharpens family conflicts since many mothers feel set back as they are most of the time still the ones to take more care of their children causing relationships to become more turbulent, not to mention families confronted with uncertain economic situations. Cases of domestic violence are expected to rise and child well-being is endangered. At the same time the work for youth welfare offices has become more difficult. The current situation with no development support from kinder gardens and schools and the higher media consumption that takes place at home has additional negative impacts especially for children with speech disorders and those with German as a second language. For children with no siblings the missing child-child interaction is severe, as well as for single parent households. Paediatricians fear a traumatic loss experience for some children with the abrupt end to the interaction with friends, educators and teachers. The current situation clarifies the importance that educational institutions have for children’s psychological well-being due to a structure and regular interaction that they provide. Since many parents feel unsettled about the current situation this is leading to the cancellation of standard vaccines and preventive development check-ups also making the work for child protection more difficult. The delay of important diagnostic measures is in some places seen to create problems in the development and treatment of patients. The adaption of primary care office settings providing a structure to treat potentially infectious patients separately from non-infectious patients might be of help, as might telemedicine and video consultations.

German paediatric societies join to gather important clinical experiences and insights into the new disease, these are for example released on the paediatric society’s website (28) and groups on Facebook with clinicians have been formed for professional exchange. Another example is a survey that is conducted by the German Society for Paediatric Infectious Diseases (DGPI) that evaluates the course of the disease of hospitalized children with COVID-19. The goal of this survey is ‘Quality Improvement of Clinical Care’ with access to all clinicians to the obtained data (29).

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References

  1. https://www.bundeskanzlerin.de/bkin-de/mediathek/-this-is-a-historic-task-and-it-can-only-be-mastered-if-we-face-it-together–1732476
  2. https://www.rki.de/EN/Content/Institute/institute_node.html
  3. https://experience.arcgis.com/experience/478220a4c454480e823b17327b2bf1d4
  4. https://www.infektionsschutz.de/coronavirus/
  5. https://www.zusammengegencorona.de/en/
  6. https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/2020-05-13-de.pdf?__blob=publicationFile
  7. Rhodes A et al: The variability of critical care bed numbers in Europe. Intensive Care Med (2012) Oct;38(10): 1647-53
  8. https://www.divi.de/ueber-uns/ueber-die-divi
  9. https://www.intensivregister.de/#/intensivregister
  10. https://www.divi.de/aktuelle-meldungen-intensivmedizin/covid-19-klinisch-ethische-empfehlungen-zur-entscheidung-ueber-die-zuteilung-von-ressourcen-veroeffentlicht
  11. https://www.dfg.de/en/service/press/press_releases/2020/press_release_no_11/index.html
  12. Schober T et al.: Dtsch Arztebl 2020; 117(19): A 990–4
  13. https://en.unesco.org/covid19/educationresponse
  14. https://www.ohchr.org/en/professionalinterest/pages/crc.aspx
  15. Gudbjartsson DF, et al.: Spread of SARS-CoV-2 in the Icelandic population. N Engl J Med 2020. Doi: 10.1056/NEJMoa2006100
  16. Lavezzo E, et al.: Suppression of COVID-19 outbreak in the municipality of Vo, Italy. medRxiv 2020.2004.2017.20053157. Doi: 10.1101/2020.04.17.2005315z.
  17. Dong Y, et al.: Epidemiology of COVID-19 among children in china. Pediatrcs 2020. Doi: 10.1542/peds.2020-0702.
  18. Mallineni SK, et al.: Coronavirus disease (COVID-19): Characteristics in children and considerations for dentists providing their care. Int J Paediatr Dent 2020, Doi: 10.1111/ipd.12653.
  19. https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/2020-05-04-en.pdf?__blob=publicationFile
  20. https://www.leopoldina.org/en/about-us/
  21. https://www.leopoldina.org/uploads/tx_leopublication/2020_Leopoldina-Stellungnahmen_zur_Coronavirus-Pandemie.pdf
  22. https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
  23. Ma H H, Tian J, Zhou X et al.: Visualizing the novel coronavirus (COVID-19) in children: What we learn from patients at Wuhan Children´s Hospital. The Lancet infectious Diseases 2020. Doi: 10.2139/ssrn.3556676.
  24. Zhu Y, et al.: Children are unlikely to have been the primary source of household SARS-CoV-2 infections. medRxiv 2020, 2020.2003.2026.20044826. Doi: 10.10.1101/2020.03.26.20044826
  25. Xu X, Liu X, Wu Y, et al.: Close contacts and household transmission of SARS-Cov-2 in China: a content analysis based on local Health Commissions. Public dosclosures. medRxiv 2020, 2020, 2003.2002.20029868.
  26. https://zoonosen.charite.de/fileadmin/user_upload/microsites/m_cc05/virologie-ccm/dateien_upload/Weitere_Dateien/analysis-of-SARS-CoV-2-viral-load-by-patient-age.pdf
  27. Anderson RM, Heesterbeek H, Klinkenberg D, et al.: Ho will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020;395:931-4.
  28. https://www.dgkj.de/fachinformationen-corona-virus
  29. https://dgpi.de/covid-19-survey-der-dgpi/

About the authors

Prof. Dr. med Berthold Koletzko (Germany) – is Professor of Paediatrics at LMU – University of Munich, Germany and head, Div. Metabolic & Nutritional Medicine, Hauner Children’s Hospital, Univ. of Munich.

Lena Maizière (Germany) – is a member of Young EAP and Paediatric Resident

 

 

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