The Mirror of Erised: a retrospective population-wide study of Czech all-cause mortality data by COVID-19 vaccination status.

Publication date: Jul 10, 2025

In this study, we investigated the association between COVID-19 vaccination status and all-cause mortality (ACM) rate in the population of the Czech Republic between January 2020 and December 2022. In this retrospective study based on official population-wide individual (record-level) data, we analyzed monthly ACM rates stratified by COVID-19 vaccination status, sex, and age. The ACM was compared to expected mortality based on pre-COVID data. The recipients of the Janssen vaccine were excluded from the study. The final dataset comprised N = 5,636,949 individuals from the Czech Republic, encompassing all residents born between 1925 and 1980 who were alive on January 1, 2020. Multiple peculiar patterns in ACM were revealed. The ACM of vaccinated individuals across several age cohorts was greatly diminished compared to the ACM of the unvaccinated, even in periods when virtually no COVID-19-related deaths were observed, suggesting a strong selection/indication bias. A similar drop in the ACM of newly vaccinated individuals was observed again during the booster campaign. With time from vaccination, the differences in ACM between groups with different vaccination statuses dwindled. Indication bias was observed at the beginning of the vaccination campaign when the frailest individuals were preferentially vaccinated. The population-wide data strongly suggest the presence of selection/indication bias, warranting careful interpretation of vaccination effectiveness estimates derived from observational studies.

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