[Influenza pandemic deaths in Germany from 1918 to 2009. Estimates based on literature and own calculations].

Background And Objective: Estimation of the number of deaths as a consequence of the influenza pandemics in the twentieth and twenty-first centuries (i.e. 1918-1919, 1957-1958, 1968-1970 and 2009) is a challenge worldwide and also in Germany. After conducting a systematic literature search complemented by our own calculations, values and estimates for all four pandemics were collated and evaluated.

Method: A systematic literature search including the terms death, mortality, pandemic, epidemic, Germany, 1918, 1957, 1968, 2009 was performed. Hits were reviewed by title and abstract and selected for possible relevance. We derived our own estimates using excess mortality calculations, which estimate the mortality exceeding that to be expected. All identified values were evaluated by methodology and quality of the database. Numbers of pandemic deaths were used to calculate case fatality rates and were compared with global values provided by the World Health Organization.

Results: For the pandemic 1918-1919 we identified 5 relevant publications, 3 for the pandemics 1957-1958 and 1968-1970 and 3 for 2009. For all four pandemics the most plausible estimations were based on time series analyses, taken either from the literature or from our own calculations based on monthly or weekly all cause death statistics. For the four pandemics these estimates were in chronological order 426,600 (1918-1919), 29,100 (1957-1958), 46,900 (1968-1970) and 350 (2009) excess pandemic-related deaths. This translates to an excess mortality ranging between 691 per 100,000 (0.69 % in 1918-1919) and 0.43 per 100,000 (0.00043 % in 2009). Case fatality rates showed good agreement with global estimates.

Conclusion: We have proposed plausible estimates of pandemic-related excess number of deaths for the last four pandemics as well as excess mortality in Germany. The heterogeneity among pandemics is large with a variation factor of more than 1000. Possible explanations include characteristics of the virus or host (immunity), social conditions, status of the healthcare system and medical advances.