Excess mortality due to COVID-19 in Germany Stang, Andreas; Standl, Fabian; Kowall, Bernd ...
Journal of infection/The Journal of infection,
11/2020, Letnik:
81, Številka:
5
Journal Article
Recenzirano
Odprti dostop
•The management of the SARS-Cov-2 pandemic in Germany was named a success story.•A statistically sound estimate of excess mortality has not been made for Germany.•The excess mortality during the ...first wave of the pandemic is 8071 cases.•After age adjustment, there were 4926 fewer deaths than expected.•Several factors explain the comparatively mild course of the pandemic in Germany.
The first wave of the SARS-CoV-2 pandemic in Germany lasted from week 10 to 23 in 2020. The aim is to provide estimates of excess mortality in Germany during this time.
We analyzed age-specific numbers of deaths per week from 2016 to week 26 in 2020. We used weekly mean numbers of deaths of 2016–2019 to estimate expected weekly numbers for 2020. We estimated standardized mortality ratios (SMR) and 95% confidence intervals.
During the first wave observed numbers of deaths were higher than expected for age groups 60–69, 80–89, and 90+. The age group 70–79 years did not show excess mortality. The net excess number of deaths for weeks 10–23 was +8,071. The overall SMR was 1•03 (95%CI 1•03–1•04). The largest increase occurred among people aged 80–89 and 90+ (SMR=1•08 and SMR=1•09). A sensitivity analysis that accounts for demographic changes revealed an overall SMR of 0•98 (95%CI 0•98–0•99) and a deficit of 4,926 deaths for week 10–23, 2020.
The excess mortality existed for two months. The favorable course of the first wave may be explained by a younger age at infection at the beginning of the pandemic, lower contact rates, and a more efficient pandemic management.
Excess mortality is a suitable indicator of health consequences of COVID-19 because death from any cause is clearly defined contrary to death from Covid-19. We compared the overall mortality in 2020 ...with the overall mortality in 2016 to 2019 in Germany, Sweden and Spain. Contrary to other studies, we also took the demographic development between 2016 and 2020 and increasing life expectancy into account.
Using death and population figures from the EUROSTAT database, we estimated weekly and cumulative Standardized Mortality Ratios (SMR) with 95% confidence intervals (CI) for the year 2020. We applied two approaches to calculate weekly numbers of death expected in 2020: first, we used mean weekly mortality rates from 2016 to 2019 as expected mortality rates for 2020, and, second, to consider increasing life expectancy, we calculated expected mortality rates for 2020 by extrapolation from mortality rates from 2016 to 2019.
In the first approach, the cumulative SMRs show that in Germany and Sweden there was no or little excess mortality in 2020 (SMR = 0.976 (95% CI: 0.974-0.978), and 1.030 (1.023-1.036), respectively), while in Spain the excess mortality was 14.8% (1.148 (1.144-1.151)). In the second approach, the corresponding SMRs for Germany and Sweden increased to 1.009 (1.007-1.011) and 1.083 (1.076-1.090), respectively, whereas results for Spain were virtually unchanged.
In 2020, there was barely any excess mortality in Germany for both approaches. In Sweden, excess mortality was 3% without, and 8% with consideration of increasing life expectancy.
The aim of this study was to evaluate the COVID-19 vaccination acceptance of emergency medical services (EMS) personnel as front-line health care workers (HCW) in Germany. Several studies have shown ...low willingness for vaccination (e.g., seasonal influenza) among HCWs and EMS personnel.
We created a web-based survey. The questions were closed and standardized. Demographic data were collected (age, sex, federal state, profession). Experience with own COVID-19 infection, or infection in personal environment (family, friends) as well as willingness to vaccinate was queried.
The sample includes
= 1296 participants. A willingness to be vaccinated exists in 57%, 27.6% participants were undecided. Our results show a higher propensity to vaccinate among the following groups: male gender, higher medical education level, older age, own burden caused by the pandemic (
< 0.001).
Due to the low overall acceptance of vaccination by HCWs, we recommend that the groups with vaccination hesitancy, in particular, be recruited for vaccination through interventions such as continuing education and awareness campaigns.
Background and Purpose:
Large vessel occlusion (LVO) recognition scales were developed to identify patients with LVO-related acute ischemic stroke (AIS) on the scene of emergency. Thus, they may ...enable direct transport to a comprehensive stroke centre (CSC). In this study, we aim to validate a smartphone app-based stroke triage with a shortened form of the Field Assessment Stroke Triage for Emergency Destination (FAST-ED).
Methods:
This retrospective validation study included 2815 patients with confirmed acute stroke and suspected acute stroke but final diagnosis other than stroke (stroke mimics) who were admitted by emergency medical service (EMS) to the CSC of the Neurological University Hospital Essen, Germany. We analysed the predictive accuracy of a shortened digital app-based FAST-ED ( ‘FAST-ED App’) for LVO-related AIS and yield comparison to various other LVO recognition scales.
Results:
The shortened FAST-ED App had comparable test quality (Area under ROC = 0.887) to predict LVO-related AIS to the original FAST-ED (0.889) and RACE (0.883) and was superior to Cincinnati Prehospital Stroke Severity (CPSS), 3-Item Stroke Scale (3-ISS) and National Institute of Health Stroke Scale (NIHSS). A FAST-ED App ⩾ 4 revealed very good accuracy to detect LVO related AIS (sensitivity of 77% and a specificity 87%) with an area under the curve c-statistics of 0.89 (95% CI: 0.87–0.90). In a hypothetical triage model, the number needed to screen in order to avoid one secondary transportation in an urban setting would be five.
Conclusion:
This validation study of a shortened FAST-ED assessment for a smartphone-app guided stroke triage yields good quality to identify patients with LVO.
ZusammenfassungHintergrundMit dem Beschluss des Gemeinsamen Bundesausschusses (G‑BA) erfolgt eine Umstrukturierung der innerklinischen Notfallmedizin durch Bildung von zentralen Notaufnahmen und ...einer gestuften Notfallversorgung. Zusätzlich wurde die Zusatzweiterbildung Klinische Akut- und Notfallmedizin etabliert.ZielZiel dieser Arbeit ist es zum einen, die UnfallchirurgInnen auf diese Strukturveränderung aufmerksam zu machen. Zum anderen möchten wir ein Meinungsbild evaluieren und die Stellung der Unfallchirurgie in der Notfallmedizin diskutieren.MethodeIm Rahmen des TNT2021 (Jahreskongress von TraumaNetzwerk DGU®, Sektion Notfall-, Intensivmedizin und Schwerverletztenversorgung und Traumaregister DGU®) erfolgte eine webbasierte Onlineumfrage zur Erfassung der Meinung der TeilnehmerInnen zur Stellung der Unfallchirurgie in der Notfallmedizin.ErgebnisseVon 143 KongressteilnehmerInnen haben 98 (67 %) an der Umfrage teilgenommen. Die Mehrzahl der TeilnehmerInnen war männlich (n = 78; 80 %), über 40 Jahre alt (n = 62; 63 %) und in einer beruflichen Position mit Personalverantwortung (n = 73; 75 %). Eine präklinische notfallmedizinische (MW: 84,8; SD: 18,7) und intensivmedizinische (MW: 78,3; SD: 20,4) Ausbildung erscheint wichtig. Andererseits erscheint den Befragten die anschließende Tätigkeit in diesen Bereichen weniger wichtig (präklinische Notfallmedizin: MW: 65,1; SD: 28,0; Intensivstation: MW: 53,7; SD: 30,3). Die Tätigkeit in einer Notaufnahme wird höher bewertet (MW: 87,0; SD: 18,7). Hoch ist die Zustimmung, dass die/der Trauma-LeaderIn ein/e UnfallchirurgIn sein sollte (MW 87,9; SD: 19,7).DiskussionEin hohes Aufkommen von unfallchirurgischen Notfallpatienten sowie die Versorgung von Schwerverletzten in ausgewiesenen Traumazentren zeigen, dass eine unfallchirurgische Expertise in einer Zentralen Notaufnahme (ZNA) obligatorisch ist. Zur Sicherstellung eines hohen Qualitätsstandards für unfallchirurgische Notfallpatienten sind zudem leitende Positionen anzustreben.
Background and Purpose:
Considering the highly time-dependent therapeutic effect of endovascular treatment in patients with large vessel occlusion–associated acute ischemic stroke, prehospital ...identification of large vessel occlusion and subsequent triage for direct transport to a comprehensive stroke center offers an intriguing option for optimizing patient pathways.
Methods:
This prospective in-field validation study included 200 patients with suspected acute ischemic stroke who were admitted by emergency medical service to a comprehensive stroke center. Ambulances were equipped with smartphones running an app-based Field Assessment Stroke Triage for Emergency Destination scale for transmission prior to admission. The primary measure was the predictive accuracy of the transmitted Field Assessment Stroke Triage for Emergency Destination for large vessel occlusion and the secondary measure the predictive accuracy for endovascular treatment.
Results:
A Field Assessment Stroke Triage for Emergency Destination ⩾4 revealed very good accuracy to detect large vessel occlusion–related acute ischemic stroke with a sensitivity of 82.4% (95% confidence interval = 65.5–93.2), specificity of 78.3% (95% confidence interval = 71.3–84.3), and an area under the curve c-statistics of 0.89 (95% confidence interval = 0.85–0.94). Field Assessment Stroke Triage for Emergency Destination ⩾4 correctly identified 84% of patients who received endovascular treatment 73.5% specificity (95% confidence interval = 66.4–79.8) with an area under the curve c-statistics of 0.82 (95% confidence interval = 0.74–0.89). In a hypothetical triage model of an urban setting, one secondary transportation would be avoided with every fifth patient screened.
Conclusion:
A smartphone app-based stroke triage completed by emergency medical service personnel showed adequate quality for the Field Assessment Stroke Triage for Emergency Destination to identify large vessel occlusion–associated acute ischemic stroke. We demonstrate feasibility of the use of a medical messaging service in prehospital stroke care. Based on these first results, a randomized trial evaluating the clinical benefit of such a triage system in an urban setting is currently in preparation.
Clinical Trial Registration: https://clinicaltrials.gov Unique identifier: NCT04404504.
(1) Background: The COVID-19 vaccination has caused uncertainty among employees and employers regarding vaccination reactions and incapacitation. At the time of our study, three vaccines are licensed ...in Germany to combat the COVID-19 pandemic (BioNTech/Pfizer (Comirnaty), AstraZeneca (Vaxzevria), and Moderna (Spikevax). We aim to assess how often and to what extent frontline healthcare workers had vaccination reactions after the first and second vaccination. The main focus is on the amount of sick leave after the vaccinations. (2) Methods: We create a web-based online questionnaire and deliver it to 270 medical directors in emergency medical services all over Germany. They are asked to make the questionnaire public to employees in their area of responsibility. To assess the association between independent variables and adverse effects of vaccination, we use log-binomial regression to estimate prevalence ratios (PR) with 95% confidence intervals (95%CI) for dichotomous outcomes (sick leave). (3) Results: A total of 3909 individuals participate in the survey for the first vaccination, of whom 3657 (94%) also provide data on the second vaccination. Compared to the first vaccination, mRNA-related vaccine reactions are more intense after the second vaccination, while vaccination reactions are less intense for vector vaccines. (4) Conclusion: Most vaccination reactions are physiological (local or systemic). Our results can help to anticipate the extent to which personnel will be unable to work after vaccination. Even among vaccinated HCWs, there seems to be some skepticism about future vaccinations. Therefore, continuous education and training should be provided to all professionals, especially regarding vaccination boosters. Our results contribute to a better understanding and can therefore support the control of the pandemic.
Background: Stroke mimics are common in the emergency department (ED) and early detection is important to initiate appropriate treatment and withhold unnecessary procedures. We aimed to compare the ...frequency, clinical characteristics and predictors of non-neurological and neurological stroke mimics transferred to our ED for suspected stroke. Methods: This was a cross-sectional study of consecutive patients with suspected stroke transported to the ED of the University Hospital Essen between January 2017 and December 2021 by the city’s Emergency Medical Service. We investigated patient characteristics, preclinical data, symptoms and final diagnoses in patients with non-neurological and neurological stroke mimics. Multinominal logistic regression analysis was performed to assess predictors of both etiologic groups. Results: Of 2167 patients with suspected stroke, 762 (35.2%) were diagnosed with a stroke mimic. Etiology was non-neurological in 369 (48.4%) and neurological in 393 (51.6%) cases. The most common diagnoses were seizures (23.2%) and infections (14.7%). Patients with non-neurological mimics were older (78.0 vs. 72.0 y, p < 0.001) and more likely to have chronic kidney disease (17.3% vs. 9.2%, p < 0.001) or heart failure (12.5% vs. 7.1%, p = 0.014). Prevalence of malignancy (8.7% vs. 13.7%, p = 0.031) and focal symptoms (38.8 vs. 57.3%, p < 0.001) was lower in this group. More than two-fifths required hospitalization (39.3 vs. 47.1%, p = 0.034). Adjusted multinominal logistic regression revealed chronic kidney and liver disease as independent positive predictors of stroke mimics regardless of etiology, while atrial fibrillation and hypertension were negative predictors in both groups. Prehospital vital signs were independently associated with non-neurological stroke mimics only, while age was exclusively associated with neurological mimics. Conclusions: Up to half of stroke mimics in the neurological ED are of non-neurological origin. Preclinical identification is challenging and a high proportion requires hospitalization. Awareness of underlying etiologies and differences in clinical characteristics is important to provide optimal care.
Knowledge regarding the sustainability of immune responses after COVID-19 vaccination is important, e.g., to decide whom and when to booster. Thus, we analyzed antibody titers in firefighters six ...months after vaccination with the mRNA-based vaccine Comirnaty. SARS-CoV-2 spike-binding antibodies (bAb) were quantified and compared to peak responses determined in healthcare workers (HCW). For the firefighters, neutralizing antibodies (nAb) were also analyzed. Six months after the second vaccine dose, all analyzed firefighters had detectable bAb, and 91% exhibited nAb titers above 1:16. However, actual titers six months after vaccination were over 12-fold lower than in the HCW control group four weeks after vaccination. bAb and nAb responses showed a significant correlation, and age correlated inversely with antibody responses. Unexpectedly, participants with a body mass index over 25 had higher neutralization titers after six months. All participants with very low neutralization titers were offered booster vaccination. The booster vaccination improved the extent and sustainability of antibody responses.
•All participants showed detectable antibody responses six months after vaccination.•Age correlated inversely with antibody responses.•Neutralizing antibody titers appear to correlate positively with BMI.•Booster vaccination increased longevity of antibody responses.
Abstract
Background and Aims
Arterial hypertension is one of the most common diseases of the cardiovascular system worldwide and is still the cause of most deaths in Germany. Data on interactions of ...the endothelin-system with the renin-angiotensin- and the sympathoadrenergic system in the regulation of systemic hemodynamics in humans are lacking. In our present investigation we study the effects of Endothelin A-, Alpha1- and Angiotensin II-type-1-receptor antagonization on the systemic pressor effects of intravenous Endothelin-1-application in young, healthy men. In addition, we analyzed the effects of the genetic variations of the GNB3 C825T-polymorphism on hemodynamic changes. GNB3 825CT/TT-allele-carriers are considered to have a higher risk for multiple diseases with structural, vascular degeneration, such as arterial hypertension, diabetes mellitus and obesity.
Method
21 healthy male volunteers were included in this double- blind, randomized, placebo-controlled cross-over study and were studied on four days. Endothelin-1 (ET-1) (0.5, 1, 2.5, 5 ng/kg/min for 20 min each) was given intravenous 2.0 hours after oral application of either placebo or Doxazosin, 3.5 hours after oral application of Candesartan (Candesartan 8 mg) or in the presence of a continuous infusion of the ET-A-selective antagonist BQ123 (60 μg/min). Blood pressure (BP) and heart rate (HR) were recorded and total peripheral resistance (TPR) was measured using impedance cardiography. ET-1-dose-response curves were analyzed with ANOVA. Data are presented as mean ± SD. Since we suspected an effect of the GNB3 C825T-polymorphism we divided the overall collective into 2 sub-collectives according to the GNB3 C825T-genotypes (n = 21, GNB3 825CC: n = 10, GNB3 825CT/TT: n = 11). Our analyses considered the overall collective and compared the sub-collectives intraday and interday.
Results
ET-1 increased systolic blood pressure (SBD) (p ≤ 0,01), diastolic blood pressure (DBD) and mean arterial pressure (MBP) as well as total peripheral resistance (TPR) (each p ≤ 0,001) with decreasing heart rate (HR5) (p ≤ 0,05). Elevation of blood pressure existed in both sub-collectives (GNB3 825CC: SBD & MBD: p ≤ 0,01, DBP & TPR: p ≤ 0,05, GNB3 825CT/TT: DBD, MBD & TPR: p ≤ 0,01, SBP p ≤ 0,05).
Antagonization of ETA-receptors reversed the effect in the overall collective as well as in the sub-collectives. Both, Doxazosin, as well as Candesartan led to a decrease in blood pressure, however, dose-response relationship was influenced more by doxazosin (DBD: p ≤ 0,001, MBD: p ≤ 0,01) than by candesartan (all values: p > 0,05). For both drugs, blood pressure and TPR remained elevated under maximum ET-1-application compared to baseline measurement. Blood pressure dependent heart rate changes were observed in the overall collective and in GNB3 825CC-allele-carriers under sole ET-1-therapy (p ≤ 0.05) (Fig. 1). Candesartan reversed the effect of ET-1 on the sub-collectives (p > 0.05). GNB3 825CT/TT-allele-carriers showed no reduction in heart rate under ET-1-application, but with accompanying candesartan therapy (p ≤ 0.01) (Fig. 2). The genotype collectives thus behaved oppositely to the drugs in this respect.
Conclusion
In summary, ET-1 increased systolic, diastolic and mean arterial blood pressure as well as systemic vascular resistance. Doxazosin, Candesartan and BQ123 led to a decrease in blood pressure. Blood pressure and TPR remained elevated under maximum ET-1 application plus Candesartan or Doxazosin. The heart rate changes of the genotype-separated sub-collectives were opposite when ET-1 was administered compared to ET-1 and Candesartan.
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