COVID-19 Pandemic in the Czech Republic: Substantial Decline of the Demand for Pediatric Healthcare Services

Since December 2019, the SARS-CoV-2 virus, a beta coronavirus which can cause the coronavirus disease 2019 (COVID-19) has been spreading around the world. SARS-CoV-2 is highly infectious, thereby the entire population is generally susceptible. This virus spread throughout almost the entire world quite rapidly. At the time of writing this article, COVID-19 has been confirmed in most countries including the Czech Republic (CZ). The main routes of transmission are respiratory droplets and patient-to-patient contact.

Compared with the general population, pediatric cases are milder, less prevalent and most of them have been linked epidemiologically to cases in known adults (Hong H et al., Pediatr Neonatol 2020; 61: 131–132; Armann JP et al., Dtsch Arztebl Int 2020; 117: 373–374). On the other hand, pandemic-related measures impacted general pediatric care. This situation has led to reductions in emergency room visits and thereby, a decreased number of referrals for hospitalization (Tartari F et al., J Eur Acad Dermatol Venereol 2020; 10.1111/jdv.1655). Taking this into account, pediatric care providers have had to make adjustments. Some of pediatric units were adapted to accommodate adult patients (Philips K et al., J Pediatr 2020; S0022–3476(20)30564–3). The COVID-19 pandemic has triggered an expansion in telemedicine across the world as well (Berg E et al., J Pediatr Gastroenterol Nutr 2020; 10.1097/MPG.0000000000002749). These factors could lead to a lower number of overall hospital admissions and, similarly, to a change in the spectrum of inpatient diagnoses.

In CZ, on the 1^st of March, 2020, the first case of COVID-19 was confirmed. During the 75 days that followed, a total of 356,515 individuals were tested, 8,480 had positive COVID-19 polymerase chain reaction tests (Ministry of Health of the Czech Republic 2020). In the pediatric population (≤15 years), 512 (6.2%) patients were detected, fortunately, no deaths were reported (Ministry of Health of the Czech Republic 2020). A lot of government restrictions were performed, e. g. school closures (from the 11^th of March, 2020), limited possibilities of travelling due to border closures (from the 16^th of March, 2020), and the mandatory wearing of face masks or covering of the nose and mouth in the general population (from the 18^th of March, 2020). During this time, we observed a lower number of pediatric patients and a different distribution of diagnoses than per usual. Therefore, the aim of this study was to analyze the number of inpatients/outpatients and spectrum of inpatients before and during the COVID-19 pandemic.

Firstly, we performed a multi-center retrospective study based on the anonymous analysis of numbers of inpatients and outpatients from pediatric departments in nine regional Czech hospitals in four consecutive months (January, February, March and April) in the years 2019 and 2020. The number of admissions in all four months was stable in 2019, ranging around 1692 to 1808 per month. In 2020, there is a notable decline in admitted patients with January having the highest number of 1760 patients and April having the lowest number of patients – 842. The same trend was observed in outpatients when comparing data from 2019 and 2020 ([Fig. 1]).

Fig. 1 The total number of emergency outpatients and inpatients in nine Czech hospitals with available data.

Secondly, we analyzed clinical reports from admitted patients at the Department of Pediatrics of the Motol University Hospital in Prague (a tertiary care centre), in order to identify if spectrum of diagnoses of hospitalized patients were different before and during the pandemic. The period of data analysis was reported from March 2019 (reference period) and March 2020 (pandemic period). The total number of admitted patients were 437 and 327 respectively, with a median age of 7.5 years (range 0–19) and 10 years (range 0–19) respectively. Therefore, we were able to compare the spectrum of diagnoses in acute and planned admissions in both monitored periods ([Table 1]).

Table 1 Inpatient diagnoses over the analyzed period (March 2019, March 2020) at the Department of Pediatrics of the Motol University Hospital in Prague.

Group	Diagnosis/indication to admission	Number of inpatients (n)
		March 2019	March 2020
Pneumology	Acute respiratory diseases (laryngotracheitis, bronchitis, bronchopneumonia, others)	74	32
	Other acute respiratory states (aspiration, hemoptysis, exacerbation of chronic disease, and others)	14	5
	Chronic respiratory diseases (cystic fibrosis, bronchiale asthma, primary ciliary dyskinesia, and others)	8	11
	Setting of noninvasive ventilation	4	7
Gastroenterology	Inflammatory bowel disease (endoscopy, biological therapy)	60	70
	Gastroenteritis	35	8
	Other acute gastrointestinal states (pancreatitis, foreign body ingestion, acute constipation, abdomen pain, biliary atresia, autoimmune hepatitis, exacerbation of chronic disease, and others)	26	13
	Other endoscopy	5	10
	Percutaneous endoscopic gastrostomy	3	3
Nephrology	Miscellaneous nephropathies, urolithiasis, kidney transplant	15	3
	Urinary tract infection	9	8
	Chronic kidney disease, renal biopsy	5	12
Endocrinology	Diabetes mellitus (education, therapy adjustment)	17	13
	Diabetes mellitus (manifestations, other acute complications)	10	4
	Endogenous hypoglycemia	2	0
	Other endocrine diseases	9	7
Others	Nonaccidental poisoning and other acute psychiatric states	12	10
	Accidental poisoning	6	1
	Other acute states (parainfective rhabdomyolysis, fever of unknown origin, Kawasaki disease, collapse, anemia, anaphylaxis and others)	71	32
	Other planned hospitalizations (magnetic resonance imagination in general anesthesia, infantile hemangiomas for propranolol therapy, scoliosis for postoperative care, and others)	52	78
Total number of acute admitted patients (n)		274	116
Total number of planned admitted patients (n)		163	211
Median and range of visit duration in acute admissions (days)		3 (1–29)	4 (1–30)
Median and range of visit duration in planned admissions (days)		1 (1–22)	2 (1–45)

We observed a 25% decline of all inpatients during the period of the pandemic. Interestingly, this is similar to the inpatients – outpatients’ situation in other Czech hospitals ([Fig. 1]). We can speculate that the main reason for the decline in the number of urgent admissions in the CZ is the increased focus on hygiene, social distancing practises, school closures, limited possibilities of travelling due to border closures, and the mandatory wearing of face masks or covering of the nose and mouth in the general population. This can lead to a reduction of the incidence of infective diseases (mainly gastroenteritis and other viral infections), however in the most affected areas, a decline of these diseases in the adult population has not yet been reported (Comelli I et al., Acta Biomed 2020; 91: 45–49). On the other hand, it is possible that, due to the priority and focus on COVID-19, first-line health care providers could have missed, or been delayed in the correct diagnosis and treatment of febrile patients with respiratory or gastrointestinal symptomatology (Harahsheh AS et al., J Pediatr 2020; S0022–3476(20)30556–4).

The decline in planned admissions was expected because children with chronic disease present a fragile group, where COVID-19 could be an aggravating factor, especially for patients with bronchial asthma or diabetes mellitus (Abrams EM et al., J Pediatr 2020; S0022–3476(20)30528-X; Ho C et al., J Pediatr 2020: S0022–3476(20)30571–0). The ongoing pandemic could lead to planned admissions being postponed, when possible, either by the side of the parents (due to parent anxiety) or by the initiative of the consulting physician (due COVID-19 precautionary measures, shortage of staff, shortage of beds etc.). However paradoxically, our data showed an increasing trend in the number of planned admissions. Therefore, we can conclude that the main reason for the decline in the number of inpatients is the decrease of acute admissions. In other European countries, similar observations have been reported as well (Dann L et al., Arch Dis Child 2020; archdischild-2020–319654; Roland D et al., Lancet Child Adolesc Health 2020; 4: e32–e33).

Parent’s wariness, anxiety and lack of transportation options, pertaining to the COVID-19 pandemic could play a role in the lack of visits to emergency departments as well. This could lead to the late diagnosis of potentially life-threatening conditions. Therefore, it is important to prevent or reduce parents’ and childrens’ worry, fear, and stress which can lead to the excessive “coronaphobia” (Jiao WY et al., J Pediatr 2020; S0022–3476(20)30336-X; Lazzerini M et al., Lancet Child Adolesc Health 2020; 4: e10–e11). However, in our tertiary care centre, we observed only two cases of delayed diagnosis due to the COVID-19 pandemic and related restrictions and patients’ fear (one child with manifestation of diabetes mellitus with severe ketoacidosis and one child with manifestation of Crohn’s disease).

We can conclude that the main reason for the decline in the number of inpatients is the decrease of acute admissions. Similarly, we could speculate that government restrictions (mainly social distancing practices and mandatory wearing of facial coverings/masks) could have led to the reduced incidence of infective diseases in the Czech pediatric population. The difference in planned and acute admissions shows that infants and children with chronic diseases are dependent on hospital treatment regardless of a lockdown. Thus, it is important to prevent and reduce parents’ and childrens’ “coronaphobia” and emphasize appropriate and timely care for sick children. Finally, our data may be helpful toward political discussions concerning financial compensations for health care providers.

Publication History

Article published online:
26 October 2020