1.4 Monitoring and surveillance
Role of public health offices
With rising infections rates in autumn 2020 and at levels not seen since the early days of Germany’s battle against COVID-19, public health offices are struggling to effectively use contact tracing to try and root out chains of infections. In many cases across the country soldiers from the Bundeswehr are assisting to get through individual case backlogs, which are time consuming and face the possibility that the information from infected persons is not 100% accurate, leading to further time investment to sort out all details. RKI still recommends that health offices pursue each individual contact. In Berlin, an area with among the highest infection rates in Germany in November 2020, public health offices do not have enough staff to effectively track and trace people in chains of infection. As of end of October, people with a positive test result are therefore called upon to go into domestic isolation as soon as possible, even without contacting the health authorities. They should also inform contact persons about the infection as soon as possible so that they can have themselves tested and go into quarantine. Institutions and locations where infected persons have spent time are also asked to inform contact persons such as children at school or fellow parents of younger children in kindergarten classes. To cope with rising number, public health offices only focus on people considered as part of a high-risk group — such as people who already have a previous illness, staff and patients in hospitals and nursing care or homeless people.
Following a federal-state decision, the contact tracing software SORMAS (Surveillance Outbreak Response Management and Analysis System) is to be introduced in all health authorities until end of February 2021. However, only between 21% and 40% of the 376 health authorities used SORMAS in early February 2021 (numbers of offices using the software vary by source of information).
The federal government continues to support the public health service (ÖGD). The program for more help is to be extended until the end of 2021. For example the number of "containment scouts" who help the authorities to track infection chains are to be increased from currently 1,500 to more than 2,000. If necessary, this number could be increased to up to 5,000 scouts. The recruiting of medical students who support the Public Health Service will be continued.
Notifications of testing results
As of January 1, 2021, laboratory notifications of positive COVID-19 tests must go through the German Electronic Reporting and Information System (DEMIS). All public health offices are connected to DEMIS and 88% of the offices were using it by the end of 2020, with other labs still using technologies like fax machines to report results.
Key role of public health offices and initiatives to strengthen their capacities
On April 20, the Minister of Health confirmed that Germany’s Public Health Service (ÖGD) will be supported with increased personnel and digital capacities. This is to fulfil the agreement between the federal and state governments from March 25, when they agreed to have at least one contact tracing team of five people in public health offices per 20,000 inhabitants. To supply more administrative support, especially with contact tracing, public employees from other areas of the bureaucracy will be transferred to help identify and control COVID-19 outbreaks. In areas that have been particularly affected, soldiers and officials of the armed forces will also be called in. In addition, the Ministry of Health is also financing training for medical students to support the health authorities in tracking contact persons, documentation and with data entry. Finally, digitalization is being upgraded to speed up reporting and communication channels. The 375 public health offices can expect financial support of EUR 50 million from the Ministry of Health in particular for upgrades in hardware and software. Digital symptom and tracking apps are also in development to control the disease’s spread. Currently, the symptoms are monitored by making phone and house calls daily, which is an organizational burden on local health authorities. In addition, the Robert-Koch-Institute will establish a contact office for the local public health offices with 40 additional employees.
Throughout Germany, the 375 public health offices are increasingly regarded as key in the fight against the virus. Since the outbreak, the local health offices’ capacities have been boosted by public employees from other areas of the bureaucracy transferred to help with COVID-19 contact tracing. Currently most public health offices work without any adapted software for contact tracing and case registration. Results of COVID-19 tests are communicated via faxes which ultimately lead to timely delays of test results between testing centres, medical practices and local health offices.
With the objective to increase the personnel in public health offices on April 15 (up to one contact tracing team of five people per 20,000 inhabitants), the federal Minister of Health aims to provide support with 105 mobile contact tracing teams each consisting of five containment scouts. Until end of April, 263 of the 375 public health offices stated personal requirements. Until early May, 376 containment scouts could be hired. In total 496 containment scouts are needed to support the public health offices. The containment scouts are primarily students and are centrally recruited by the Robert-Koch-Institute (RKI) since the end of March 2020.
On May 14, results of a survey of public health offices, carried out by media, were presented. The survey evaluated if public health offices are able to meet supposed staffing levels (up to one contact tracing team of five people per 20,000 inhabitants, see above). Nearly half (46%) of all German public health offices (375) responded. Results showed that only 24% of the participating offices met the staffing requirements, while 67% of public health offices did not reach these targets until mid-May.
Despite the governments agreement to have contact tracing teams of five people per 20,000 inhabitants at public health offices, several federal states sit below that level at the end of September. For example, Bavaria, with 13 million inhabitants, should have 650 tracing teams available. They currently have 288 teams in use. Likewise, the states of Baden-Württemberg, Hessen and Saarland are below their target numbers. Bremen is an example of a federal state that is currently meeting this level.
On April 22, the Robert Koch Institute updated the clinical criteria for considering testing for COVID-19. Tests of person with mild respiratory symptoms do not longer depend on available test capacity. Currently, testing capacity is sufficient to test persons with mild symptoms. In addition, with the end of the season of colds and flu, a higher detection rate is expected. The expanded testing criteria are also necessary with the lift some of the lockdown measures in Germany since April 20 and further easing of social distancing restrictions in the coming weeks (see Section 1.2 Transition measures: physical distancing).
Laboratory testing for COVID-19 should be performed for suspected cases according to the following criteria (22 April 2020):
1. Acute respiratory tract infection and having been in close contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of symptoms.
2. Clinical or radiologic characteristics of viral pneumonia in the context of increased number of pneumonias in care facilities or hospitals.
3. Clinical or radiologic characteristics of viral pneumonia with no indication of any other cause, without contact with confirmed COVID-10 case.
4. Acute respiratory tract infection and a) activity in care, medical practice or hospital, b) high-risk patients or c) without any known risk factors.
On November 3, the RKI adapted the test criteria for SARS-CoV-2 infections to the autumn and winter season in order to prevent overloading medical practices, laboratories, parents and care facilities. A SARS-CoV-2 test must be carried out by ambulatory physicians if at least one of the following criteria is met (3 November 2020):
1. Severe respiratory symptoms (e.g. acute bronchitis or pneumonia, respiratory distress or fever),
2. Acute hypo- or anosmia or hypo- or ageusia (disturbance of the sense of smell and taste),
3. Unexplained disease symptoms and close contact (less than 1,5 metres distance for at least 15 minutes) with a confirmed COVID-19 case or
4. Acute respiratory symptoms of any severity and one of the following criteria: Membership in a risk group, work in nursing, medical practice, hospital, increased probability of exposure, contact in the household or in a cluster of persons with acute respiratory disease (ARD) of unknown cause and an increased COVID-19 7-day incidence (> 35/100,000 inhabitants) in the district, during the period of the symptoms there was the possibility (exposure setting) of further dissemination to many more persons, continued close contact with many people or with vulnerable risk patients, clinical deterioration with existing symptoms.
Contact tracing app, software and other surveillance tools
Since early March, the government has launched the development of a voluntary smartphone app using Bluetooth to trace possible chains of Covid-19 contagion. The app will warn smartphone users if they have come into contact with anyone infected with the virus. Disputes over the methods and possible centralisation of data storage, as well as ambiguities regarding responsibilities have led to delays. The original app was set to store users’ contact tracing data on a central server but those plans were shelved in the face of public pressure. On April 26, the government announced that it will instead develop an app that compiles data in a decentralised and anonymous fashion. The objective is that the new app allows the country to move away further from lockdown measures without triggering an exponential increase in new Covid-19 infections. The launch of the new app is expected by mid-June. On May 1, it was decided that the COVID-19 tracing app should be based on a decentralized software architecture that was developed jointly by Deutsche Telekom and SAP. The Fraunhofer-Gesellschaft and the Helmholtz-Zentrum CISPA are on hand to advise on the development.
In the meantime, however, the Robert-Koch-Institute (RKI) is already testing an app that uses data from fitness trackers. On April 7, the RKI, in partnership with healthtech startup Thryve, launched the app ‘Corona-Datenspende’ (Corona Data Donation) for voluntary consensual use by the German public to help monitor the spread of COVID-19 and analyse the effectiveness of measures taken against the pandemic. The data donation app was designed to be used with a range of smartwatches and fitness trackers to share anonymised health data for scientific purposes. It collects information to help see if COVID-19 symptoms could also be derived from vital data, like a pulse. Until May 6, 509,000 users are already using this app.
Since early April, the COVID-19 Mobility Project analyses mobility flows in Germany over time to assess social distancing using mobile phone data collected by mobile phone providers (https://www.covid-19-mobility.org/). It was developed by the Project Group Computational Epidemiology at the Robert Koch Institute in Berlin and the Research on Complex Systems Group (ROCS) at the Institute for Theoretical Biology and IRI Life Sciences at Humboldt University of Berlin. The collected data is commercially available and also used for other purposes. Also, no identifying or personal information are collected, it is only possible to know the amount of people moving from one antenna area to another. The COVID-19 Mobility Project does not identify or confirm cases and contacts; however, it supplements the “standard” contact tracing approaches by informing the success of self-isolation measures at the population, rather than individual, level.
Since April 20, the public health office in Berlin's central district 'Mitte' has started using the software app SORMAS ("Surveillance, Outbreak Response Management and Analysis System") to help with contact tracing duties. The system, which was originally developed in 2014 in response to the Ebola outbreak in West Africa, should help make the process more efficient, as previously employees relied on Excel spreadsheets to keep tabs on tracing infected persons. Normally 20 people work there for the protection against epidemics - at the moment there are 160. The introduction of SORMAS is planned in all twelve districts of city of Berlin.
In the hope of staying ahead of fast-spreading coronavirus mutations, the German government wants to follow other countries’ examples and use more genetic sequencing to pinpoint newly emerging variants. As of January 19, Germany is making it mandatory for laboratories to do more genome sequencing and share information with public authorities. At least 5% of all positive tests are supposed to be sequenced.
Outpatient monitoring system in Schleswig-Holstein
The northern state of Schleswig-Holstein has created a unique outpatient monitoring system where doctors and health authorities implemented a system to detect disease complications early and prevent the need for inpatient treatment while ensuring hospital capacities. Doctors contact and get updates twice a day from the infected who are isolated at home, while public health offices can concentrate on tracking contacts and arranging isolations. The monitoring system, which is in place since early April, aims to detect and prevent complications of COVID-19 diseases and ultimately reduce hospital admissions. According to Schleswig-Holstein's Minister of Health, 1,606 infected persons have been included in the monitoring so far, of which 1,196 have recovered. 103 have been hospitalized, and 35 have died. At present, 206 people are still being treated. General practitioners, lung specialists, digital translators (not all patients speak German), a mobile team of anaesthesiologists and health authorities have all been working from the system’s interactive database to provide proper care.
Definition of infection rate thresholds as early warning systems for new outbreaks
On May 6, when the government announced the second phase of easing far-reaching restrictions on public life that took effect in mid-March, it also defined an ‘emergency break’ to reinstate a lockdown in a region. Once infection rates spread to more than 50 new cases per 100,000 people in a given area within seven days, new lockdowns would be put in place in the respective region.
On May 12, the state government of Berlin has adopted a much stricter early warning system. The Senator for Health and the head of state justified that the population density of Berlin required a separate policy. The city-state will utilize a traffic light system’ combining the three factors of “R” value, the number of available hospital beds and the total number of new infections. If there are 20 new infections per 100,000 inhabitants within seven days, the traffic light will change to yellow, and in case of 30 new infections, it will switch to red. If the reproduction number is 1.1 on at least three consecutive days, the traffic light turns yellow and at a rate of 1.3, it turns red (on May 12, the reproduction number was 0.79 in Berlin and 1.13 nationwide). Finally, if 15% of all ICU beds are being used by COVID-19 patients, traffic light turns to yellow and at 25% it turns to red (currently 9% of ICU beds in Berlin are occupied). If two of these indicators are yellow, the new situation will be evaluated. If two indicators turn red, reinstatement of lockdown measures will be considered.
Second Act for protecting the Population in the Event of an Epidemic Situation of National Importance
On May 14, the federal parliament passed the ‘Second Act for protecting the Population in the Event of an Epidemic Situation of National Importance’. From now on, the law requires health authorities to report negative laboratory test results. Health authorities must also report if someone is considered cured as well as the likely location of infection. The data is transmitted anonymously to the RKI. The law also approves support for the 375 public health offices that will receive EUR 50 billion from the federal government, in particular to enhance digitalisation (see above). Each public health office therefore has a financing share of EUR 100,000 to EUR 150,000 at its disposal for this purpose. The details will be set out in administrative agreements.
On June 16, the German federal government launched the new Corona-Warn-App www.coronawarn.app/en/. The app helps to notify users as quickly as possible if they have been exposed to a person diagnosed with COVID-19 and to trace and identify infection chains of COVID-19. It is based on technologies with a decentralized approach, notifying users if they have been exposed to COVID-19 via Bluetooth and enabling them to retrieve test results electronically. The Bluetooth technology measure the distance and duration of the encounter between people who have installed the app. The smartphones "remember" encounters if the criteria determined by the RKI on distance and time are met (people who have been in the vicinity of the infected person for a period of at least 15 minutes within the last 14 days). The devices then exchange temporary encrypted random IDs. If people using the app test positive for COVID-19, they can inform other users on a voluntary basis. Then the random IDs of the person diagnosed with COVID-19 are made available to all people who are using the Corona-Warn-App.
The interfaces are provided by Google and Apple. The app must therefore be downloaded in the official Google and Apple app stores and only runs on smartphones which have at least Android 6 or iOS (13.5). The app was developed by SAP and Deutsche Telekom at a cost of around EUR 20 million and overseen by cyber security experts from German research institutes. The Robert Koch Institute issues the new app on behalf of the federal government. The latter stresses that the use of the app is voluntary and cannot be used as entry permission to public places.
The introduction of the COVID-19 warning app has taken its time compared to other countries. The delay was due to issues of data protection and data privacy the government wanted to be ensured. Unlike other coronavirus apps, the German warning app does not detect user locations. Transparency is key to both protect the app's end-users and to encourage adoption. To increase people's trust in the app and guarantee transparency, the developers have published the app's source code in advance.
How does the new app work?
The Corona-Warn-App recognizes only which other app users are currently in the vicinity. The phones send each other short-term identification numbers. The actual contact data is only stored locally on the users' respective smartphones and it is encrypted in such a way that even the phone owners cannot view it. The data is automatically deleted after two weeks.
If a testing lab supports the electronic process, users can use the QR code they received during the test to retrieve their results. In case of a positive test result, a specially generated QR code with the test result is sent to that person. This code then needs to be scanned into the person's smartphone. Upon this, an alert can be transmitted by the phone by sending anonymized data of people who have come into contact with the infected person to a central server. A push message is sent automatically to all those people, i.e., people who have been in the vicinity of the infected person for a period of at least 15 minutes within the last 14 days. People who receive a warning will obtain recommendations on how to proceed: for example, to have a test themselves and putting themselves in quarantine.
However, not all laboratories and public health offices are equipped with the necessary digital infrastructure to send test results to the system and generate QR codes. Hence, people who have been tested by such laboratories and found to be infected must contact a telephone hotline. Those calling the hotline will have to answer test questions to ensure that they have indeed been tested positive. However, questions and answers must not allow any conclusions to be drawn about the person's identity. The call center is meant to be able to handle about 1,000 calls per day.
As of June 19, about 9.6 million people downloaded the new app, according to the Robert Koch Institute. As of July 9, the Corona warning app has been downloaded 15,4 million people and the app sent out its first warning alerts on June 24.
As of August 4, more than 16.4 million people had downloaded the app and it has been made available for download in all EU member states as well as Turkey, Switzerland, Norway and the UK. Versions of the app in Arabic, Polish, Romanian, Bulgarian and Russian languages are being develop as well.
As of September 23, 5,000 people infected with COVID-19 have been able to warn their anonymous contacts via the Corona Warn App. The Federal Health Minister urged users to register if they test positive in the app as only half of the app’s users testing positive thus far send a warning. The app has been downloaded more than 18 million times in Germany, representing the amount of downloads for all other European warning apps combined.
Starting on October 19, an update of Germany’s Corona-Warn-App (version 1.5) made it possible to exchange contact and risk assessment warnings to official warning apps from other countries. As a first step, Germany, Ireland and Italy will exchange warnings, with the goal of having at least 16 national apps linked together by the end of the year. Further, the Warn-App is extended by a Symptom Diary in which positive-tested persons can voluntarily enter symptoms of illness iin order to be able to make the warning of contacts even more precisely.
Laboratory testing for COVID-19 should be performed for suspected cases according to the following criteria (regularly updated by RKI) (see also section 3.2):
1. Acute respiratory tract infection and having been in close contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of symptoms;
2. Clinical or radiologic characteristics of viral pneumonia in the context of increased number of pneumonias in care facilities or hospitals.
3. Clinical or radiologic characteristics of viral pneumonia with no indication of any other cause
4. Any acute respiratory tract infection and a) activity in care, medical practice or hospital, b) high-risk patients or c) without any known risk factors (testing for COVID-19 only if sufficient capacity)
A person suspected to have COVID-19 needs to be quarantined if there is a high risk of infection: either a) if within the last two weeks the person had close contact with a person who has contracted COVID-19 (close contact means either that the person spoke with the sick person for at least 15 minutes or was coughed or sneezed on at a time when the sick person was infectious i.e. two days before the first symptoms), or b) whenever the public health office at local authority level places a person under quarantine.
A person does not have to be quarantined if in the past two weeks he or she was in the same room as a person with COVID-19 but had no close contact. However, persons working with people who have pre-existing diseases (workers in hospital, elderly care, etc.) should by all means inform their company medical officer. Every person, however, should perform daily self-inspection for symptoms of disease.
Any person who is healthy but has had contact with a family member, friend or acquaintance who, in turn, had contact with a laboratory-confirmed COVID-19 patient, does not have to be quarantined. In this case, the person is not a contact person, has no increased risk of contracting COVID-19 and cannot infect anyone else either. If, however, the person is showing (light) symptoms of acute respiratory tract infection, he or she should have a test. If it is not possible to receive a test, the person should self-isolate at home, avoid any contacts with a distance less than 2 meters and respect hand hygiene and respiratory etiquette.
Extensive contact tracing is implemented by public health offices at local authority level. Someone who had close contact with a person with confirmed COVID-19 (see definition above) is registered and informed about the virus and possible symptoms. The contact person must be quarantined (see above). The 375 public health offices in Germany play a central role in monitoring and surveillance of the disease. They provide information and counselling on COVID19, they assess whether person need to be tested for COVID-19, perform tests (at home, often relying on support from students in medical training), and monitor medical conditions and quarantine of COVID-19 cases by phone. The RKI is currently training students to help with contact tracing.
If a person has been in a high-risk area (defined and regularly updated by the RKI) during the last 14 days and the public health office is aware, the person receives information and the individual risk is assessed and necessary measures are defined. If the person who has spent time in a risk area does not show any symptoms, it is recommended to avoid unnecessary contact with others and stay at home, if possible. Should symptoms develop within 14 days, a doctor should be consulted after calling in advance to announce the visit.
According to figures from the Robert Koch Institute released on May 12, 2,786 residents of residential facilities (including facilities for care of older, disabled, or other persons in need of care, homeless shelters, community facilities for asylum-seekers, repatriates and refugees as well as other mass accommodation and prisons) had died from COVID-19. This is about 37% of all COVID-19 deaths at that time. Retirement and nursing homes are strongly affected by the pandemic also in Germany. In many places, facilities are in lack of protective equipment. In addition, the lack of health and care professionals in residential facilities throughout the last years exacerbates the situation. Since mid-April, RKI teams support outbreak containment measures with a focus on outbreaks in retirement and health care homes as well as hospitals in several federal states.
With the pandemic enduring, care homes have created ways for residents to see and speak with relatives for the first time by using virus-proof containers, garden sheds, telephone boxes or other solutions. They are placed in front of the main buildings and have two entrances and a plastic window to separate both sides on the inside. A microphone is built in so that people can talk to each other, and curtains hang on windows. Residents and their guests have a limited to time slot to interact and then the room is disinfected before the next pair enters.
Since May 11, in several federal states such as Bremen, Hesse, Bavaria and Saxony-Anhalt, visitors are once again permitted in retirement homes and senior care facilities. Residents are permitted an hour-long visit with one visitor per day (in some states only one fix reference person), as long as that person wears a mask.
Since mid-October 2020, new rapid antigen tests can be widely used, especially in hospitals and nursing homes, according to an ordinance by Federal Ministry of Health (see also Section 1.5 Transition measures: Testing). This should help to better protect residents, staff and visitors. To this end, facilities must develop a test concept upon which the public health department determines how many tests can be purchased and financed at the cost of the health insurance companies. In nursing homes, up to 20 tests per month per resident are possible.