The Coronavirus in Europe 'We're Not Prepared at All'

More people in Germany have been infected with the new coronavirus. A widespread outbreak could push the country's public health infrastructure to its limits, as doctors, agencies and hospitals are overwhelmed. But experts insist there's still no cause for panic. By DER SPIEGEL Staff
Respiratory masks in Germany are becoming harder to find, as is hand sanitizer.

Respiratory masks in Germany are becoming harder to find, as is hand sanitizer.

Foto: Julian Stratenschulte/ picture alliance/ dpa

Carnival in Gangelt-Langroich is a big deal. Bernd B. has been preparing for the celebration in his hometown on the Lower Rhine since last summer. The 47-year-old, who has managed a real estate company with his brother and six employees in a neighboring town since 1999, dances in the carnival association’s male ballet.

On Feb. 15, a Saturday, he attended a traditional carnival event called the Kappensitzung, in Langbroich’s community hall. The approximately 300 attendees partied until late in the evening. Bernd B. was likely already carrying the highly infectious Sars-Cov-2 coronavirus at that point.

About a week later, his condition deteriorated dramatically. On Shrove Monday, he drove about 30 kilometers (19 miles) with his wife to a hospital in the town of Erkelenz. When the two entered the clinic at 11:15 a.m., B. could hardly speak. He was put in intensive care and isolated. The doctors suspected influenza. But the test came back negative.

During the night, B.’s health continued to worsen and he had to be artificially respirated. At that point, it became clear to doctors that his symptoms pointed to the new coronavirus, even though, seemingly, B. had not visited China, South Korea, Italy or Iran in recent weeks. The doctors collected secretions from his lungs and on Shrove Tuesday, around noon, an ambulance brought the sample to the laboratory at Düsseldorf’s university hospital. At 5 p.m., a virologist called the doctors in Erkelenz to report that the sample had come back positive.

At 12:30 a.m. on Ash Wednesday, B. was transferred to an isolation ward at the university hospital in Düsseldorf and attached to an artificial lung. His state was critical. He was fighting for his life. His wife was also relocated with him. Her test had initially come back negative, but the virus was found in a second test on Wednesday.

The two were the first coronavirus patients in North Rhine-Westphalia.

The Beginning of an Epidemic

At almost the same time, the first cases in the southern German state of Baden-Württemberg appeared: A 25-year-old from the Göppingen region who had traveled to Milan had been infected, as well as a 24-year-old who had accompanied him on the trip. She then infected her 60-year-old father, a senior physician in the pathology department at the university hospital in Tübingen.

Because the pathologist had taken part in a meeting of senior physicians, a dozen doctors were tested and removed from the task of caring for patients.

The virus was confirmed in a 32-year-old man from the region of Rottweil, also in Baden-Württemberg. The man had previously traveled to the Italian town of Codogno in Lombardy. On Thursday afternoon, a test showed that a man in his early thirties from Kaiserslautern, in the western German state of Rhineland Palatinate, was sick with Covid-19. On Thursday evening, officials announced four more cases in Baden-Württemberg and one in Bavaria, Hesse and Hamburg, respectively. The latter was an employee at a university hospital located in the Eppendorf neighborhood.

There's no denying it: Covid-19, as the respiratory disease caused by the Sars-CoV-2 virus is called, has arrived in Germany. After weeks of playing down the issue, German Health Minister Jens Spahn said that we are "at the beginning of a coronavirus epidemic.” He said that it is "unclear if our current strategy of isolating the virus and ending chains of infection will continue to work.”

Employees in the Health Ministry speak of a "dynamic situation” that is changing by the hour. On Wednesday, Spahn organized a conference call with his counterparts in the state health ministries and asked them to update their pandemic plans. According to spokeswoman Susanne Glasmacher, employees of the Robert Koch Institute (RKI), have been working under intense pressure on a new "framing concept” that, unlike the national pandemic plan, focuses on the new coronavirus instead of influenza.

The American epidemiologist Jennifer Nuzzo: "In our view, no country on earth is fully prepared for this epidemic."

The American epidemiologist Jennifer Nuzzo: "In our view, no country on earth is fully prepared for this epidemic."

Foto: MATT ROTH / DER SPIEGEL

While the number of new infections is going down in China, the virus is now spreading in South Korea, Iran and Italy, and from there, around the world. In recent days, Iraq, Afghanistan, Bahrain, Georgia, Norway, Greece, Romania, Brazil, Austria and Switzerland have all reported their first cases.

Not If, but When

In the United States, Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases, had a clear message for Americans. She said the question is not whether the coronavirus will spread in the U.S., but when -- and how many Americans will fall seriously ill: "Disruption to everyday life might be severe.”

The authorities are still trying to slow the spread of the virus as much as possible around the world, and experts hope that the new virus can be kept in check until flu season is over so that at least two waves of infection don’t overlap. But it should be clear by now that authorities also need to plan for the medical treatment of thousands, maybe hundreds of thousands of infected people in Germany alone.

Events across Germany in recent days can be seen as a test run for what doctors, hospitals, health authorities, ministers and everyday citizens will face in the coming weeks. Is Germany really as well prepared as Health Minister Spahn has been claiming for weeks? Is the "vigilant calm” that he initially recommended really enough to overcome the crisis?

Is Germany equipped against a virus that could cause damage "far beyond a health emergency,” as Jeremy Farrar, the director of the Wellcome Trust, one of the world’s biggest health foundations, puts it? He believes the virus could cause a chain reaction with the "potential to reach the scale of the global financial crisis of 2008.”

On Wednesday afternoon, Erkelenz’s director of nursing, Stephan Demus, was sitting in his hospital’s otherwise empty cafeteria. He had barely slept the night before. Crucial questions remained unanswered, he said: With whom did Bernd B. and his wife have contact? And where did they get infected?

Both of their children and the family’s grandmother are currently quarantined at home. A phone line for citizens is being set up. Several employees at the Erkelenz hospital who came into contact with B. also had to be isolated at home and have now been instructed to maintain a diary about their health.

On Wednesday, thousands of people arrived in the clinic wanting to have themselves tested for the virus despite not having any symptoms. The phones at the reception and in the offices were ringing off the hook. "We were overwhelmed with requests. It’s insane,” Demus said.

Chains of Infection

Then came the next startling discovery: Bernd B.’s wife works in a daycare center. Officials ordered all schools and kindergartens in the area to close until Monday. "We cannot guarantee that we will be able to cut off the chains of infection,” Karl-Josef Laumann, the health minister of North Rhine-Westphalia, said on Wednesday at a press conference.

Authorities in Cologne were also alarmed. Bernd B. had recently visited the university hospital in Cologne twice, on Feb. 13 and 19, for a gastroscopy and an ultrasound. As a result, Johannes Niessen, the head of Cologne’s health authority, held a crisis meeting with doctors and other experts at the hospital that lasted late into the night.

According to the hospital computer’s appointment calendar, B. had contact with 10 hospital employees as well as 31 patients while he was being tested. That night, Niessen and his deputies called the 10 employees and asked them to stay home the next day. One of them initially believed it to be a carnival prank.

37 percent of all hospitals in Germany faced personnel shortages in their intensive care units in the first half of 2019.

Source: DKI

Reaching all of the patients will take even longer. "One of them,” Niessen said, "is now in Tripoli.”

As of Thursday night, all the tests in Cologne had come back negative. But the virus has clearly spread - and the carnival event attended by Bernd B. likely had something to do with it. An employee from Bernd B.’s real estate company and her partner have now tested positive for the coronavirus. A staff officer in the German air force at a barracks in the Wahn district of Cologne was also isolated and brought to an army hospital near the city of Koblenz. He had also been at the party attended by Bernd B. in Gangelt-Langbroich. The virus further infected a doctor from the nearby city of Mönchengladbach who was also there. Fourteen more Covid-19 cases in the district of Heinsberg, also nearby, were discovered on Thursday evening.

'Not Prepared at All'

If, at this point, the virus is infecting doctors and causing numerous hospital employees to be isolated, if the chain of infection is barely decipherable and those overseeing the outbreak are exhausted, what will happen when perhaps thousands of infected people are sitting in emergency rooms in the coming weeks?

Experts agree that horror scenarios like the one portrayed in films like "Outbreak” and "Contagion” are pure fantasy. The mortality rate for Covid-19, which is currently loosely estimated as being between 0.2 and 2.5 percent, is too low for that. On the other hand, a lethality of 0.2 percent is twice as high as that of the average seasonal flu, which kills hundreds and even thousands in Germany every year.

A mortality rate of 0.7 percent, which the WHO has found in the regions outside of Hubai, would be seven times as high.

"Every virus that is, like the Covid-19 pathogen, easily transmissible, that attacks the lungs and can lead to death, needs to be taken seriously,” says Florian Klein, the director of the Institute for Virology at the university hospital in Cologne. "Especially when, like with Sars-CoV-2, it is coming into contact with a population that is not immune.” And Heiko Schneitler, long-time head of the Düsseldorf health authority, says, "We still don’t know exactly why the new coronavirus kills which people.”

But according to Schneitler, preparations for the spread of such a completely new pathogen cannot be completed in two weeks or two months. "For that, you need more like 20 years.”

Germany, of all places, which spends more than almost any other country in Europe on its health services, has only middling pandemic preparations. In the Global Health Security Index, for example, international experts placed Germany in 14th place among 195 countries. When it came to "Emergency preparedness and response planning,” it ended up 67th.

"We're not prepared at all,” says Michael Kochen, the longtime president of the German College of General Practitioners and Family Physicians (DEGAM). "Where are the posters on the bus stops, subway stations and advertising columns telling people to regularly wash their hands and to cough into a handkerchief or their sleeve? Why is the website of the Robert Koch Institute (Germany's center for disease control) so confusing that you can barely find the important information?”

A Country's Best Defense

If any country can stem the spread of a new virus, it’s probably Singapore. Mount Elizabeth Hospital in the Novena neighborhood looks more like a five-star hotel than a hospital. The ramp leading to the opulent entryway is filled with expensive cars, and patients need to register and have their temperature taken before they are allowed to enter.

Leong Hoe Nam, 49, works on the seventh floor. He's one of the leading virologists in this Asian city-state. He lived through SARS in 2003. "But this time,” he says, "we are facing a bigger challenge. This virus needs to be managed in a completely different manner.”

He says the fight against the new pathogen is akin to a naval battle: "The big hospitals are our aircraft carriers in this new fight. They have the greatest strategic importance and need to be protected and shielded by health authorities and the practicing physicians.”

The same thing could theoretically also happen in Germany if the number of infected people increases. The first points of contact for most patients wouldn't be hospitals, which are only supposed to handle serious cases, but -- after a brief phone consultation -- general practitioners. The doctors, wearing breathing masks and protective clothing, would then take samples for a virus test and, depending on the severity of the symptoms, either send the patients to the hospital or into quarantine at home. This is what DEGAM, for instance, recommends.

Yet many general practitioners feel left in the lurch by health authorities and politicians. "And Health Minister Jens Spahn seriously believes that Germany is well prepared for a pandemic," says one cardiologist in Berlin. Apart from the online information, public health authorities haven't sent any memos or letters to registered doctors. "We are completely in the dark."

Medical health professionals are particularly concerned about the lack of FFP-3 fine-particle masks and protective suits. "In my opinion, the preparations are anything but optimal," says Frank Unger, a general practitioner in Berlin's Marzahn district. "I think that every practice should get a care package with 20 to 100 protective masks and protective suits," he says. "But that hasn't happened. Not even close. If we hadn't been proactive ourselves, we wouldn't have anything."

Seizures and Export Bans

In fact, masks and protective suits, which are largely made in China, are all but impossible to get in Germany at the moment.

Ming Gutsche, who was born in China, sells protective clothing and respirator masks via her company in Rastatt, in southern Germany, and says her 21 employees can barely cope with all the orders. At the end of January, she even had a few shady men pull up into her company parking lot in small vans, asking if they could buy her entire inventory. Gutsche threatened to call the police, saying she didn't want any "crisis buyers."

She's now distributing everything she has to her regular customers, which include hospitals, fire departments and pharmaceutical companies, via a quota system. But her stockpiles are shrinking.

The German Health Ministry is aware of the supply bottleneck. The few factories in Europe that manufacture protective masks and suits, the ministry noted in the minutes of a video conference with industry representatives, "couldn't possibly compensate" for the disruption in supply from China.

One long-standing supplier of Gutsche's is in Wuhan and churns out wares from 7 a.m. until 10 p.m. "But since the New Year's celebrations there, the factories are no longer allowed to send us anything," she says. "All of the product has been confiscated."

Even countries like Taiwan and South Korea have imposed export bans on protective clothing, according to the minutes from the Health Ministry. And products that are still available are only getting more expensive. A spokesperson for the German Hospital Federation says packs of 50 simple protective masks, which once went for a mere 3.95 euros ($4.36) are now being sold on Amazon for 150 euros.

Michael Koch still has a couple of breathing masks lying around in his basement at home. He works as a product manager at Medika Medizintechnik, a wholesaler for medical products. But his inventory, too, he says, will soon dry up. "Ninety percent of all articles such as masks, protective clothing, swabs or bandages come from China. Many of them even come directly from Hubei Province," the epicenter of the outbreak.

Such a shortage of supplies could pose a dangerous problem. Without adequate protective clothing, doctors and nursing staff will become infected with the coronavirus. Who would then take care of the patients, in hospitals that are already suffering from personnel shortages?

The issue is a top priority within the German government's crisis management team. "We are currently doing everything we can to take another look at what we have in stock in Germany," Spahn says. "And above all to legally ensure that nothing leaves the country, either by seizing it or banning its export."

Stretched Thin

If new coronavirus infections are limited to certain regions, hospitals could move staff between states. But: "If we have to treat several hundred thousand additional patients nationwide, there isn't a health care system in the world that wouldn't have a problem with that," says Susanne Johna, the head of the Marburger Bund, a doctor’s union, and the German Medical Association's pandemic commissioner. "We managed to stem the large flu epidemic two years ago with the same number of staff we have now," says Johna, who works as an internist at St. Joseph's Hospital Rheingau near Frankfurt. She argues, however, that the health care system has reached its limits.

Many people could also become infected in waiting rooms as they sit near oblivious carriers of the Sars-CoV-2 virus. That's why Andreas von Thüna, an internal medicine practitioner from the western German town of Brühl, prefers to make house calls in case of suspected infections. Many experts believe this is the right way forward. But this has yet to be systematically organized in Germany.

Great Britain, on the other hand, has been conducting a pilot project since the end of January in which people suspected of being infected are tested at home. Doctors in one London hospital came up with the idea after noticing ambulances had to be decontaminated for hours after transporting people suspected of having the virus.

Now those who test for the virus go to people's homes. Their protective clothing is discarded after each visit. In Wales, almost 95 percent of all people suspected of having the virus have now been offered home testing.

In the Global Health Security Index, the United Kingdom ranks first in Europe and second worldwide. The British Department of Health has long since reacted to the coronavirus outbreak and has put detailed instructions for general practitioners, laboratories and medical staff online.

In Germany, meanwhile, public health authorities are suffering from a lack of personnel. "In Cologne, we're well equipped," says Niessen, the head of the Cologne health authority. "But in many places, an experienced doctor earns on average 1,500 euros less a month than in a hospital."

Even in times of non-crisis, state health services are already hitting their limits, says Ute Teichert, chairwoman of the Federal Association of Physicians of Public Health Departments.

It's little consolation that even the U.S., which ranks first in the Global Health Security Index, is having trouble dealing with the crisis. The country is having trouble with its virus test.

Jennifer Nuzzo, an epidemiologist at the Center for Health Security at Johns Hopkins University in Baltimore and one of the authors of the Global Health Security Index, is a hard woman to reach these days. When she finally found time to talk to DER SPIEGEL on Wednesday, she wanted to first get one thing straight: "In our view, no country on earth is fully prepared for this epidemic."

By Jörg Blech, Kristina Gnirke, Hubert Gude, Veronika Hackenbroch, Nils Klawitter, Martin U. Müller, Christian Parth, Cornelia Schmergal, Christoph Schult, Samiha Shafy, Julia Smirnova, Frank Thadeusz and Bernhard Zand

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