Czech Republic and low COVID-19 mortality in the heart of Europe: possible explanations

Three months after the onset of the explosive spread of COVID-19 disease in Europe, the Czech Republic is among the few European countries with only a very limited burden of this serious infection and low case fatality rates (Figures 1 and 2). The country is very active in PCR testing, including all suspicious contacts for SARS-CoV-2 virus, and hospitals test most incoming patients. There is an ongoing discussion, about how to explain the difference compared with most the other European countries.4

Figure 1.

Total confirmed COVID-19 deaths per population in European countries.

Figure 2.

Case fatality rates in European countries.

We attempted to assess several possible reasons for the mild course of COVID-19 in our country that could be helpful for epidemic control in other countries or for the future. The possible explanations are listed in Tables 1and2.

Table 1.

Possible explanation for the low COVID-19 burden in the Czech Republic

Healthcare services	Political decisions	Czech population
Hospitals restructured quickly (before the first death in the country occurred) to prepare for the COVID-19 epidemic.	Strict government regulations declared 8 days after the first confirmed case and 13 days before the first COVID-19 death.	Lack of face protection masks quickly resolved by thousands of volunteers, who produced large amounts of textile masks in a few days
Hospital beds 6.6 per 1000 inhabitants is twice more than in Italy, Spain, or the UK (Table 2).	Very early state border closure	People trust the healthcare system and do not hesitate to visit a facility as such a visit does not result in any financial burden
Public health and epidemiology services in every region immediately started tracing all positive patients.	Obligatory face protection mask wearing since day 1	While watching the news from Italy in early March, fear spread among the population and social distancing, hand washing, and facemask wearing started soon after.
Healthcare is free and widely available.		90% of population live in places with <500 000 citizens. The only large city of >1 million (Prague) has no densely populated ‘ghetto’.
Over 2000 medical students as volunteers at all possible levels (first contact, population testing, hospitals, etc.)

Table 2.

Hospital beds per 1000 inhabitants

Country	Hospital beds per 1000 people
Germany	8
Austria	7.4
Hungary	7
Czech Republic	6.6
Poland	6.6
France	6
Belgium	5.6
Switzerland	4.5
Greece	4.2
Portugal	3.4
The Netherlands	3.3
Italy	3.2
Spain	3
UK	2.5
Sweden	2.2

Source: https://ourworldindata.org/coronavirus.

Lockdown timing

We believe that the single most important factor was the early decision to close schools, public events, and even state borders. The Third Faculty of Medicine was the first institution in the country that cancelled a public event. Facing the onset of COVID-19 hospital admissions in Prague (after the return of thousands of Prague families from skiing in Northern Italy), we decided to cancel our annual medical students’ ball (1200 expected attendees) on 5 March. This was followed 5 days later by the decision of the Czech government to close schools and public events with >50 attendees.

This lockdown was ordered 13 days before the first COVID-19 death in the country, and its timing was most probably (along with the border closure) crucial for the subsequent low rates of COVID-19 in the country. The importance of lockdown timing is supported by data from other countries that closed schools (along with other ‘lockdown measures’) before the first COVID-19 death in the given country: Hungary, Norway, Finland, Slovakia, Denmark, and Portugal. Also, Greece closed schools just the day after the first death. In contrast, lockdown in countries suffering most from COVID-19 was done much later—more than 6 weeks after the first proven case (Italy, Spain, the UK, Belgium, and France); see Table 3.

Table 3.

Relationship between lockdown timing and COVID-19 mortality

Country	No. of COVID-19 deaths per million at 6 weeks after the first COVID-19 death in the country	No. of days between the first COVID-19 case in the country and closure of schools	No. of days between the first COVID-19 death in the country and closure of schools
Greece	11.61	15	1
Czech Republic	22.88	8	–13
Hungary	28.98	6	–5
Norway	33.20	15	0
Finland	42.00	42	–10
Denmark	73.72	15	–4
Portugal	92.97	13	–2
France	166.51	51	30
UK	234.86	49	14
Italy	254.08	38	15
Spain	404.09	45	11
Belgium	540.31	39	2

Source: https://ourworldindata.org/coronavirus.

Facemasks

Furthermore, Czech citizens were extremely disciplined not only in using facemasks but even in producing textile facemasks at home in large numbers during the initial phase, when publicly available supplies were close to zero. From almost the first day of the lockdown the majority of the population was wearing facemasks. During the course of the pandemic, textile facemasks even became a fashion item (colours matching clothes). The importance of this simple protective measure is supported by a metanalysis² showing a 47% reduction of infection spreading with facemask use and a 38% reduction with regular hand hygiene.

Public health and epidemiology system

The country has a long tradition of regional stations for public health (hygiene) and epidemiology. Every county (with 0.5–1 million inhabitants) is served by one such station led by a professional with board certification in public health and epidemiology. These professionals organized many activities from the very beginning, especially tracing and systematic quarantine of all contacts.

Thousands of medical students: volunteers

The first day (!) after the lockdown of schools, the medical students of the Third Faculty of Medicine (Charles University) organized jointly with students from all the seven other medical schools in the country several thousands of volunteers to help in all healthcare facilities (hospitals, hygiene stations, emergency medical services, etc.). This greatly facilitated the extremely fast transformation of the healthcare services to be ready for COVID-19.

Hospital admissions for COVID-19

The experience of all Czech hospitals during this period is very similar: in early March (after the first COVID-19 hospital admissions occurred in the country) every large hospital transformed at least one of its departments into a COVID clinic. This transformation took place very quickly (within 7–10 days) including dedicated staff assigned from other departments to these new clinics. Simultaneously, most elective procedures (especially those requiring intubation and mechanical ventilation) were immediately postponed. Thus, the healthcare services were well prepared for a COVID-19 tsunami, which however did not occur. Most of the capacity of these improvised COVID clinics remained empty. By early May, these clinics are returning to their original function, and hospitals are resuming all elective procedures. The peak number of COVID-19 patients treated in Czech hospitals was 446 (42 per million on 9 April 2020); currently it has decreased to 239, i.e. currently (May 9) only 23 patients per million population are in Czech hospitals with COVID-19.

BCG vaccine

Another possible explanation was suggested by Berg et al.³ and Miller et al.⁴ According to these two analyses, the countries with a long history of compulsory BCG vaccination (as in the Czech Republic) have a lower burden of COVID-19 disease, including milder cases with lower mortality.

Conclusions

Based on the alarming information from Italy, the Czech Republic was very quick and effective in implementing the above-described measures. All parties (healthcare professionals, politicians, and the population in general) acted swiftly and responsibly, thus the country was fortunate during the first 3 months of this pandemic due to the combination of all the described facts.

The future may provide some additional explanations. At the time of writing, the country is returning back to normal in a stepwise manner.

References

References are available as Supplementary material at European Heart Journal online.