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Covid-19: Why Germany’s case fatality rate seems so low

BMJ 2020; 369 doi: (Published 07 April 2020) Cite this as: BMJ 2020;369:m1395

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Re: Covid-19: Why Germany’s case fatality rate seems so low

Dear Editor
If the early statistical indicators for mortality rates in Germany are borne out (following due analysis and correction for differences in reporting methodology) there is one glaring difference in how the German population habitually responds to viral symptoms.

Here in the UK, Paracetamol (Acetominophen) is widely available across the counter, even in supermarkets, and in Germany it is a prescription-only medicine (PoM).

Even incidental paracetamol usage is widespread in the UK and questions concerning potentially negative effects of antipyretic drugs remain largely unanswered, in terms of suitable prospective clinical studies conducted during viral pandemics.

The quote below, from the Journal of Thermal Biology, alludes to the possibility of a dysregulated cytokine cascade following antipyretic treatment. This phenomenon would be in keeping with the clinical presentation in some rapidly deteriorating cases. For most cases, individual susceptibility is undoubtedly multifactorial. However, in the absence of other predisposing illnesses, we must surely record what notional self-prescribed medication has been used in those patients showing high clinical susceptibility.

If it is considered possible that negative systemic effects from paracetamol arise, even within a single time-critical phase of the natural disease process, it follows that even modest self-prescribing must be clearly recorded for every admission, so that we are ultimately able to formulate a lucid research question and progress to a well-designed clinical study.

For the time being the question is whether suppression of fever may impact on:

'the temporal modulation of the stimulus induced generation of TNF-α, IL-1β and IL 6, early during the innate immune response, thereby obviating the risk of the potential harmful effects that could result from their dysregulated co-expression.'
'Fever: pathological or physiological, injurous or beneficial?' Journal of thermal biology Vol. 28, Issue 1, January 2003, Pages 1-13

Until such time as differences in mortality rates between different countries is explained purely by differences in reporting pathways and data-handling, we should consider that systemic differences in the treatment choices immediately available to patients may play a role in recovery times, rates of hospitalisation and fatality rates.


Competing interests: No competing interests

12 April 2020
Russell S. Malcolm
Speciallty Doctor
60 Great Ormond St, London WC1N 3HR