Original article
The COVID-19 Disease Burden in Germany in 2020
Years of life lost to death and disease over the course of the pandemic
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Background: The SARS-CoV-2 pandemic presented major challenges to the health sector in 2020. The burden of disease arising from COVID-19 can be expressed as the number of years of life lost to disease or death. For example, death at age 40 involves a loss of far more years of life than death at age 80.
Methods: The disability-adjusted life years (DALY) lost to COVID-19 were calculated as the sum of the years of life lost through death (YLL) and the number of years lived with disability (YLD), on the basis of laboratory-confirmed notifiable cases of SARS-CoV-2 infection in Germany in 2020 (documented as of 18 January 2021). The methodology was based on that used in the Global Burden of Disease Study. Pre-existing diseases do not enter into the determination of YLL; rather, the residual life expectancy that is applied in this calculation corresponds to a mean age-specific level of morbidity.
Results: 305 641 years of life were lost to COVID-19 in Germany in 2020. The percentage of DALY lost by persons under 70 was 34.8% in men and 21.0% in women. 99.3% of the COVID-19 disease burden was accounted for by death (YLL). The daily average years of life lost due to death was lower for COVID-19 than for the major non-communicable diseases. Persons who died of COVID-19 lost a mean of 9.6 years of life; those who were under 70 when they died lost a mean of 25.2 years of life. Men lost more years of life than women (11.0 vs. 8.1 years).
Conclusion: The effects of COVID-19 on public health can be expressed through the burden of disease indicators. This method yields additional information that should be put to use early in the course of future outbreaks.
In 2020, living conditions around the world were markedly affected by the coronavirus SARS-CoV-2 and the disease it causes, COVID-19, as well as by the measures taken to contain it. The spread of the infection and of the resulting cases of severe disease and death had slowed down considerably by mid-year, only to come back with renewed force and severity in the autumn and winter months (1). Reliable information is essential so that the disease can be controlled and the risk for the population assessed. In addition to statistics on incidence, hospitalizations, and mortality, indicators of the burden of disease also need to be considered, as they summarize the impact of disease-related morbidity and mortality on population health (2, 3).
The goal of the research described in this article is to estimate the years of life lost to COVID-19 in Germany, with the aid of three indicators. The first of these is the years of life lost owing to death from the disease (“years of life lost,” YLL). YLL is a more comprehensive measure of the impact of a disease on population health than number of deaths, as death at a younger age involves the loss of more years of life that would otherwise have been left to live. The second indicator, “years lived with disability” (YLD), reflects the number of years of life in which the affected individuals suffer impaired health (morbidity) because of the disease; the manner in which YLD is calculated takes both the severity and the duration of the disease into account, so that this indicator reflects the impact of morbidity on population health more accurately than raw case numbers alone. The third indicator, “disability-adjusted life years” (DALY), is the sum of the first two. In the Methods and Results sections of this article, the three indicators—YLL, YLD, and DALY—will be addressed in that order.
Method
To calculate the disease burden, all laboratory-confirmed cases of SARS-CoV-2 in the year 2020 that had been reported to the Robert Koch Institute by 18 January 2021 were analyzed (eMethods 1). The definition of cases required documentation of the date of reporting and death (if applicable), the patient’s age and sex, and whether COVID-19 was one of the main causes of death (if the patient died) (4). Usually, there is a delay of two to three weeks in the reporting of SARS-CoV-2 cases, as well as in the documentation of clinical or vital outcomes. With regard to the latter, the data for 2020 are nearly complete. The calculation of the COVID-19 disease burden was based on previous work done in the project BURDEN 2020—The Burden of Disease in Germany at the National and Regional Level (5).
Years of life lost to death (YLL)
The number of years of life lost to death (YLL) is calculated as the sum of the statistical residual life expectancy (in years) of all deceased persons. The resulting YLL are attributed to the underlying causes of death. Pre-existing conditions in COVID-19 deceased are not taken into account in this calculation (eMethods 2 and 3). The analysis is based on the fatalities among the reported cases of SARS-CoV-2 (eFigures 1 and 2). To avoid overestimating the YLL, only fatalities for which COVID-19 was notified as one of the underlying causes of death are included (eMethods 1). The YLL due to other diseases, based on cause-of-death statistics from 2017 (the reporting year for the BURDEN 2020 study), were used to assess the relative contribution of COVID-19 to overall mortality. These reference diseases considered here were the five types of non-communicable disease (NCD) that caused the greatest YLL – ischemic heart disease; cancer of the trachea, bronchi, and lungs (in brief: lung cancer), stroke, chronic obstructive pulmonary disease (in brief: COPD), and colon and rectum cancer (in brief: colon cancer) – and, in addition, lower respiratory infections (eMethods 2). Absolute figures, YLL per 100 000 inhabitants, and average values per capita are presented. To capture the dynamics of the COVID-19 pandemic over time, the YLL was plotted day by day and as 7-day and cumulative averages. For comparison, daily averages were displayed for COVID-19 (2020) and for the other diseases (2017). The seasonality of lower respiratory tract infections in particular is thus levelled out.
Years lived with disability (YLD) and overall burden of disease (DALY)
Four parameters serve as the basis for the calculation of the number of years lived with disability (YLD) in persons with acute COVID-19 (eMethods 2):
- incident cases (SARS-CoV-2 infections excluding fatalities) (eMethods 1)
- severity distribution, classified as asymptomatic, mild, moderate, severe, or very severe disease course (eFigure 3, eTable 1)
- severity-specific weighting factors (disability weight): asymptomatic, 0; mild, 0.006; moderate, 0.051; severe, 0.133; and very severe/critical 0.655) (eTable 1); and
- the severity-specific duration of illness (eTable 1).
Potential late sequelae of COVID-19 are not considered. The summary measure DALY composed of YLL and YLD is presented in absolute and relative figuresby age, sex, and geographical region.
Sensitivity analyses
A sensitivity analysis was conducted to determine the excess mortality due to the pandemic and the degree to which the YLL from COVID-19 reflected a real increase in disease burden (eBox). Analyzing excess mortality in this manner also enables a comparison of the COVID-19 pandemic with earlier influenza waves. The reported case numbers and mortality figures for influenza are, in fact, marked underestimates, as influenza is generally diagnosed on clinical grounds alone and need only be reported to the authorities when the pathogen has been positively identified (6). It follows that it is difficult to make direct comparisons based on data from these sources. Another sensitivity analysis was used to assess the dependency of the YLD calculations on changes in the duration of illness.
Results
Underlying data
1 748 644 cases of laboratory-confirmed SARS-CoV-2 in the year 2020 had been reported to the Robert Koch Institute by 18 January 2021; the data elements used in the present analysis included the date of reporting and of death (in fatal cases), the age and sex of the patient, the severity of the disease, and the vital outcome (eMethods 1, eFigures 1 and 2). The patients included 920 277 women (52.6%) and 828,367 men (47.4%). There was a total of 38,641 fatalities, with COVID-19 reported as the cause of death in 31 638 (81.9%). Of the patients who died, 52.6% were men, and 89.0% were at least 70 years old.
Years of life lost to death (YLL)
A total of 303 608 years of life were lost to death from COVID-19 in Germany in 2020, of which 121 114 (39.9%) were lost by women and 182 494 (60.1%) by men. On average, each patient who died lost 9.6 years of life; women lost fewer years of life than men (8.1 vs. 11.0). The YLL per day had reached approximately 2300 by 8 April 2020, stayed at approximately that level until 17 April, and then sank to a very low level from late April onward, only to rise again in October (Figure 1). Assuming negligible seasonal variation in mortality caused by NCD, it can be inferred from the cause-of-death statistics that the number of YLL due to COVID-19 was, for a few days, higher than the number of daily average YLL caused in 2017 by the main types of NCD and by lower respiratory infections (Figure 1, red line). The cumulative averages suggest that, by December 2020, the burden of disease owing to deaths from COVID-19 had returned to a level below the daily averages from 2017 for these reference diseases (Figure 1, green line). From December onward, the cumulative average YLL due to COVID-19, and thus also the average YLL for the entire year (blue line), exceeded the YLL for lower respiratory infections from 2017, but was still below the YLL for the main types of NCD.
Among persons with COVID-19, the number of YLL due to the disease rose at first with advancing age. Men, except for those aged 90 and above, displayed a markedly larger absolute loss of years of life to COVID-19 than women. The YLL was markedly lower, in absolute terms, in persons of both sexes aged 90 and above, but it continued to rise with age in relative terms (Figure 2).
Reflecting the greater residual life expectancy in persons who died at a younger age, a considerable portion of the YLL due to COVID-19 in 2020 was accounted for by persons under age 70: 20.6% in women and 34.6% in men. These persons lost an average of 25.2 years of life (Table).
The sensitivity analysis reveals an estimated excess mortality from late February to early April 2020 (on the heels of the 2019/2020 influenza wave), and from late October 2020 onward (eFigure 4), particularly among persons aged 70 and above (eFigure 5). Between these two periods, the observed mortality was similar to the expected course of mortality, except for excess mortality owing to a heat wave in August 2020. Compared to previous years, the excess mortality in the spring of 2020 was approximately at the level of the 2019 influenza wave, and the excess mortality in the autumn of 2020 approximately at the level of the 2017/2018 influenza waves (eFigure 6). The reported deaths from COVID-19 and the calculated excess mortality generally agreed closely; yet, in times of especially increased mortality — in calendar weeks 14 and 15 (30 March - 13 April) and from calendar week 49 (30 November - 6 December) onward — the excess mortality exceeded the reported deaths from COVID-19 (eFigure 4).
Years of life lived with disability (YLD)
Persons who contracted COVID-19 in Germany in 2020 but did not die lost a total of 2033 years of life due to impaired health. Women suffered slightly fewer YLD than men (1005 vs. 1028). The number of YLD rose with age, then declined again in advanced age (Figure 3). Persons aged 50 to 59 were the most severely affected. These results reflect the age distribution of the reported cases (eFigure 1). Accordingly, in both men and women, more than 70% of YLD were accounted for by persons under age 70 (Table).
In relative terms, however, the number of YLD rose steadily with age because of the age-specific severity distribution (eFigure 3) and was greatest among persons aged 90 and above (Figure 3). Over the period of observation, 2.45 YLD arose per 100 000 persons. When considered separately for the two sexes, this figure was slightly lower for women than for men (2.39 vs. 2.51 YLD per 100 000 persons).
The sensitivity analyses revealed that the calculated YLD was sensitive to the assumed duration of illness. Assuming five days of illness at all levels of severity yielded a figure of 574 YLD (0.69 per 100 000 persons); the corresponding figure for an assumption of 15 days was 1723 YLD (2.08 per 100 000 persons) and, for 28.4 days, as in a study from South Korea (7), 3262 YLD (3.93 per 100 000 persons). Nonetheless, as most of the disease burden due to COVID-19 was accounted for by YLL, rather than YLD, the variability of YLD depending on the assumed duration of illness made little difference to the overall calculated burden of disease (DALY).
The overall burden of disease due to COVID-19 (DALY)
A total of 305 641 years of life were lost by the population of Germany in 2020 because of COVID-19 (DALY; 368.2 per 100 000 persons). 99.3% of the DALY were accounted for by YLL. However, YLD accounted for approximately 40% of DALY among persons with COVID-19 aged 10 to 19, but lessened with age to become less than 1% among persons aged 60 to 69. A considerable portion of the overall DALY was accounted for by persons under age 70 (Table).
The COVID-19 disease burden was higher in western and southern regions of Germany, and lower in the north and northeast. These regional differences persisted after standardization for age (Figure 4, eFigure 7). The disease burden was especially high in areas (“spatial planning regions,” Raumordnungsregionen, ROR) located in the states of Bavaria and Saxony. This was mainly due to the high case numbers experienced during the first and second waves of infection in Bavaria and Baden-Württemberg, and in the second wave in Saxony.
Discussion
An estimated total of 305 641 disability-adjusted life years (DALY) were lost to COVID-19 in Germany in 2020. 99.3% of this disease burden was accounted for by fatal cases (303 608 YLL), and 0.7% by years lived with disability (2033 YLD). The persons who died of COVID-19 lost a mean of approximately 9.6 years of life; more years of life were lost by men than by women (11.0 vs. 8.1 years). The percentage of years of life lost to death among persons under age 70 was 34.6% among men and 20.6% among women.
These differences between the sexes with respect to years of life lost reflect the fact that men died of COVID-19 more frequently than women and were also more likely to die before age 70 (8). This accords with the finding that, although women contract the infection somewhat more commonly, men are more likely to develop severe disease at a younger age (9). As younger persons have a longer residual life expectancy, this results in higher YLL figures for men than for women.
The dynamic temporal course of YLL and its decline over time were determined in part by pandemic control measures and seasonal effects (10). A new, noticeable rise in infections starting in August 2020 made little difference to the overall burden of disease (as measured in DALY) until early October, because it mainly affected younger persons and the percentage of mild disease courses was higher (Figure 1, eFigures 1 and 3) (11). The cumulative YLL due to COVID-19 in 2020 was lower than the usual number of years of life lost owing to other major causes of death, but the excess mortality analysis reveals that, by the end of the year, the COVID-19 pandemic in Germany had reached the approximate level of severity of a severe influenza wave.
The above comparison with the YLL due to other diseases in 2017 is, however, only a preliminary attempt to contextualize the COVID-19 disease burden. This manner of presenting the findings smooths out important seasonal variation in lower respiratory infections and also, to a lesser extent, in certain types of non-communicable disease (12). Moreover, persons with COVID-19 can die from multiple causes; the recording of only the main cause of death of the list of underlying causes, as is done in Germany, is problematic (13, 14). However, future analyses based, e.g., on cause-of-death statistics for 2020 will be able to reveal whether COVID-19 was given as the official cause of death in numbers comparable to the reported fatal cases of COVID-19. It will also become possible to determine the extent to which mortality from other causes may have changed, and thus also to determine whether the calculated excess mortality may actually have been affected in the opposite direction by other trends. The restrictions on interpersonal contact, for example, have been found to be associated with lower mortality from traffic accidents (15); meanwhile, a hesitancy to visit hospital emergency rooms may have increased mortality, for instance from cardiovascular diseases (16, 17).
In other studies of the COVID-19 disease burden, the residual life expectancy entering into the calculation of YLL was adjusted for pre-existing conditions (18). In the present study, however, as in the Global Burden of Disease study on which it was based, a disease-independent age-specific residual life expectancy was used for all persons who died at any particular age (19). The mean attainable residual life expectancy thus becomes the benchmark for the years of life lost. This yielded a quantification of the loss of life years that could, ideally, have been avoided by optimal prevention and treatment (eMethods 3).
The high relative contribution of YLL to the COVID-19 disease burden approximately corresponds to the high relative contribution of YLL to the disease burden from lower respiratory infections, according to the Global Burden of Disease study (20). However, the size of YLD is sensitive to the underlying assumptions of the method (eMethods 3). Moreover, due to underreporting the cases analyzed do not represent all actual cases of SARS-CoV-2 infection (3, 21), and the estimation of severity grades is fraught with uncertainty, as, for many patients, a description of symptoms is lacking (eMethods 1). Finally, evidence increasingly suggests that patients’ health may be impaired in the long term by hitherto unrecognized late sequelae of COVID-19 (22). Thus, the present study likely underestimates YLD to some extent (eMethods 3). In the near future, seroprevalence studies (23, 24) and clinical research will lead to a more accurate assessment of the frequency, severity-grade distribution, and late sequelae of COVID-19.
The present analysis is the first quantification of the COVID-19 disease burden in Germany. The impact of COVID-19 on population health, considering fatal cases, incident cases, severity grades, and duration of illness over the course of the pandemic, can be summarized in a few indicators and compared with other common diseases. It thereby becomes clear how the uncontrolled spread of the virus can temporarily affect population health. Moreover, the impact of COVID-19 on the health of younger persons, and its different effects in men and women, become clearer than from the number of reported cases alone. Calculating the disease burden thus yields additional information for the monitoring of current pandemics, which can also be put to use early on in the course of future outbreaks.
Acknowledgement
These analyses are based on joint previous work carried out in theproject BURDEN 2020—The Burden of Disease in Germany at the National and Regional Level by the BURDEN 2020 Study Group: Alexander Rommel, Elena von der Lippe, Annelene Wengler, Michael Porst, Aline Anton, Janko Leddin, Thomas Ziese (Robert Koch Institute), Helmut Schröder, Katrin Schüssel, Gabriela Brückner, Jan Breitkreuz (Scientific Institute of AOK, Dietrich Plass, and Heike Gruhl (German Environment Agency).
Note on funding
These analyses are based in part on previous work of the project BURDEN 2020—The Burden of Disease in Germany at the National and Regional Level. That study was supported by the Innovation Fund of the German Joint Federal Committee (project number 01VSF17007).
Conflict of interest statement
The authors state that they have no conflict of interest.
Manuscript submitted on 6 October 2020, revised version accepted on 3 February 2021.
Translated from the original German by Ethan Taub, M.D.
Corresponding author
Dr. rer. med. Alexander Rommel
Robert Koch Institute
Abteilung 2, Epidemiologie und Gesundheitsmonitoring
Nordufer 20, 13353 Berlin, Germany
RommelA@rki.de
Cite this as:
Rommel A, von der Lippe E, Plass D, Ziese T, Diercke M, an der Heiden M, Haller S, Wengler A, on behalf of the BURDEN 2020 Study Group: The COVID-19 disease burden in Germany in 2020—years of life lost to death and disease over the course of the pandemic. Dtsch Arztebl Int 2021; 118. DOI: 10.3238/arztebl.m2021.0147
►Supplementary material
eMethods, eTables, eFigures, eBox:
www.aerzteblatt-international.de/m2021.0147
Dr. rer. med. Alexander Rommel, Dr. rer. pol. Elena von der Lippe, Dr. med. Thomas Ziese,
Dr. rer. pol. Annelene Wengler
Department 3, Infectious Disease Epidemiology, Robert Koch Institute, Berlin: Michaela Diercke M.Sc., Dr. rer. nat. Matthias an der Heiden, Dr. med. Sebastian Haller
Department II 1 Environmental Hygiene, German Environment Agency, Berlin: Dr. PH Dietrich Plass
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