Germany's pandemic of contradictions
From "gold standard" to no standard
To call it a “transition phase” may be generous. It sure is a confusing one. As some European countries ease their way out of the pandemic (good idea TBD), Germany seems to be walking back and forth as it tries to find the exit.
That is evident in key contradictions the country confronts:
There is a persistent “vaccine gap,” as the country’s pandemic-explainer-in-chief, Christian Drosten, regularly says.
That means an exploding incidence rate, even if milder overall, can still lead to burdensome hospitalizations and ICU occupancy, especially among vulnerable groups.
The incidence rate is based on PCR tests, which last month the government said it would start to limit (official lingo: “prioritize”) to at-risk and essential groups, such as medical personnel.
At the same time, the government left open what it’s strategy or goals might be to reflect this change:
“The Federal Health Minister will, in coordination with state-level health ministers, draw up a modified testing regime and adjust the coronavirus test regulations accordingly.”
In other words, we’re changing the inputs but leaving the outputs as is until we figure out what’s next. Vague enough for you?
That was Jan. 24. The federal health ministry’s testing FAQs were last updated days before that. In pandemic terms, this is a lifetime.
In a small tweak last week, the health ministers (there are 16, one for each state, plus Karl Lauterbach at the federal level) agreed that PCRs would be prioritized, as already announced, but anyone previously eligible for a free one could still get it.
Call it a first-among-equals policy. Or, having your test and taking it, too.
It’s a contradiction no one seems to be able to explain, except to say that results from non-prioritized PCRs might take awhile to come back (there have already been delays due to overburdened labs, which was the grounds for the prioritization in the first place).
As frustrating as that may be for those waiting on a result (and possibly twiddling their thumbs in unofficial quarantine until then), it is even more problematic for the big picture. If delays in PCR reporting becomes a feature, not a bug, there is even less of a reason to trust the numbers we’re getting.
While the authorities responsible for collecting and reporting cases — the Robert Koch Institute for public health (RKI) and Germany’s sprawling network of local public health offices — do receive positive results from antigen rapid tests, an RKI spokesperson told me they don’t really count for anything. At least not yet.
“If and how antigen tests enter into the statistics going forward is currently under review.”
Officially, those with coronavirus-like symptoms or a positive result from an antigen rapid test are entitled to a free PCR. Even those with no symptoms, but alerted to a potential “increased risk” of exposure via the RKI’s contact tracing app, are theoretically able to get one. (That has contributed to hours-long lines at state-run testing centers.)
However, authorities have been gradually tweaking the wording on that:
The most recent version is what a health ministry (BMG) spokesperson previously told me verbatim.
The thing is, no one in Germany needs an app to go red or any other sort of special permission to get an antigen rapid test. Those are free anyway at test centers “at least” once a week (in real terms: about as often as you like), and it has been that way for months (save a confusing period last fall).
So, where are we? The government is saying most people in Germany de facto don’t get to have a thing the government’s own rules say we can have — and in some cases require, such as determining when you have to isolate (posted Feb. 3) — and is instead offering us something we get already anyway.
The test strategy has not been updated since Dec. 15 and includes all kinds of references to PCRs as well as a reminder that “extensive testing is an essential component of a comprehensive strategy to combat the pandemic: It enables the rapid and precise collection of the number and distribution of infected people in Germany. That is the basis of breaking infection chains and protecting the health system from collapse.”
Protecting critical infrastructure and keeping hospitals from being overrun is the entire point of where we’re at in the pandemic right now. (Though it should be noted that the RKI relies on health surveillance and hospitalization data, not just test results, for keeping tabs on what’s going on.)
Other than promising a “speedy” process (it’s now been almost two weeks), the BMG declined to comment on what changes may be coming to compensate for fewer PCRs, which in turn affects reporting.
“There is no reason for alarm. Practical solutions will be sketched out,” the spokesperson said.
That probably means shifting from PCRs to antigen rapid tests as the basis for isolation and calculating the incidence rate. The state of Berlin has already done this, putting new rules into effect on Saturday. (There is a bit of irony here, seeing that a few weeks ago Berlin state officials declined to implement the reduced quarantine time and testing out rules, citing a need to wait for the feds’ blessing. Just a few days thereafter, they did an abrupt 180, on the sound legal grounds that, well, other states were already doing it.)
OK, fine, so in with the rapid tests and out with the PCRs. There is nothing inherently bad or wrong about that. Except you can’t just swap one for the other — for both empirical and public communication reasons.
Since the beginning of the pandemic, the PCR test has been called the “gold standard” for detecting COVID-19. The process very rarely misses a case or presents a false result. Rapid tests, while still very good — especially given their cost, ease of use and lack of processing time — are more likely than a PCR to result in false positives (sending people unnecessarily into quarantine) or false negatives (lending a false sense of security that allows infectious people to unknowingly spread the virus).
Despite the empirical difference as well as how the tests have been explained to the public, the app — remember, it’s backed by the RKI and the federal government — “treats the rapid test exactly the same as the PCR test,” the BMG spokesperson said.
Never mind that the BMG’s own literature acknowledges that “antigen rapid tests are less reliable than PCR tests.”
So much for the value of gold. In fact, you can’t treat the tests the same without adjusting your risk tolerance.
Both PCR and antigen rapid tests can be useful, depending on what you want to do with them. While a PCR will tell you if you have the virus, a rapid test can be suitable for sussing out infectiousness, as it is more likely to come back positive while a person is most able to spread the virus.
“We need to talk about setting goals. And the public communication has been incomprehensible,” Tobias Kurth, an epidemiologist and director of the Institute of Public Health Berlin at Charité, told me. “When you do this — PCR only under certain circumstances — then you’re doing away with the objectives” as they’re currently envisaged.
“We need to base decisions on data and not just on ideas we’ve come up with,” he said, or because they are politically or economically expedient. The decision to prioritize PCR tests is based on existing demands on the system, not as part of a larger strategy to move the country out of the pandemic.
“It’s an open question if we want to take on more risk, but if so, then with data to determine that,” Kurth said. “What do we as a society want to achieve?”
The takeaway: Omicron is so bonkers contagious that it makes a joke of contact tracing and would put most of the country on the sofa if we keep on keeping on as we have. And for a virus that by this point and for most (three-times-the-charm vaxed) folks results in mild, or no, illness. It’s probably not unreasonable to tell young(ish), seemingly healthy and outwardly symptom-free people they can’t get a PCR just because of some Bluetooth data. But given stubborn vax rates and a pervasive allergy to liability and risk (a topic for another time), this is something that German Officialdom neither can nor is particularly eager to say in a bold way.
Thus, we find ourselves in-between. A “transition,” if you will.
(Ed. Given how often agencies update their pages, it’s entirely probable that many of the links above will soon lead to info that no longer supports some claims made here. What you read should be considered a snapshot of a forever moving target.)