COVID-19 in Europe has settled into a pattern that looks far more like seasonal flu than a rolling emergency, but the virus has not disappeared and its consequences are still accumulating. Excess mortality across 29 European countries dropped to about 2% above expected levels in 2023, down from peaks above 10% in 2020 and 2021. Hospitalizations and deaths now follow a predictable winter surge, booster uptake has fallen to single digits in most countries, and genomic surveillance has contracted sharply. The pandemic chapter may be closed, but the virus continues to circulate, mutate, and cause measurable harm, particularly among older adults and people with chronic conditions.
How the Death Toll Changed Year by Year
A spatio-temporal analysis covering 29 European countries estimated roughly 1.64 million excess deaths over the four pandemic years (2020–2023), about 8% more than the expected baseline. The worst years were 2020 and 2021, each carrying around half a million excess deaths. By 2022 the figure dropped to about 444,000, and by 2023 it fell to roughly 109,000, or just over 2% above what would have been expected without the pandemic.1The Lancet Regional Health – Europe. Impact of COVID-19 on total excess mortality and geographic disparities in Europe, 2020–2023: a spatio-temporal analysis That steep decline tracks broadly with rising population immunity and widespread vaccination, though disentangling the two is difficult.
The geographic picture was uneven throughout. In absolute terms, Italy, Poland, and Germany recorded the highest total excess deaths over the four years. In relative terms, Bulgaria, Lithuania, and Slovakia were hit hardest, with age-standardized excess death rates two to three times those of Western European countries. Eastern Europe as a whole experienced roughly 13% excess mortality over 2020–2023, compared with 6–8% in other regions. In 2021 alone, Eastern European excess mortality reached about 29%, a staggering gap that coincided with lower vaccination coverage and lower per-capita healthcare spending in those countries.1The Lancet Regional Health – Europe. Impact of COVID-19 on total excess mortality and geographic disparities in Europe, 2020–2023: a spatio-temporal analysis
An interesting wrinkle emerged in Germany: during the winter of 2022–2023, the peak excess mortality was actually driven by influenza rather than COVID-19. The standardized mortality ratio during that influenza wave exceeded the ratio of any SARS-CoV-2 wave Germany had experienced, with the highest average weekly excess deaths of any wave in the study period.2PubMed Central. All‑cause excess mortality in Germany peaked during the late‑2022 influenza period, exceeding peaks during SARS‑CoV‑2 waves (2020-2023) This finding underscores how COVID-19’s relative burden has shifted. It is still a leading cause of respiratory illness across Europe, but it no longer towers above everything else the way it did in 2020.
The Seasonal Pattern That Has Emerged
One of the clearest developments is that COVID-19 now behaves like a seasonal respiratory disease. A modeling study of both the United States and Europe found a distinct annual pattern, consistent across cases, hospitalizations, and deaths, running from roughly November through April each year. The seasonal bump in hospitalizations amounted to about 75 additional admissions per million people during winter months, while winter mortality added about two extra deaths per million. These trends held across all countries evaluated.3Scientific Reports. Seasonal trends in COVID-19 cases, hospitalizations, and mortality in the United States and Europe
Surveillance data from Spain’s 2024–2025 winter season illustrate how European health systems are now tracking COVID-19 alongside influenza and RSV as part of a single integrated respiratory surveillance framework. Hospitals systematically test patients admitted with acute respiratory infections for all three pathogens, generating side-by-side burden estimates rather than treating COVID-19 as a standalone crisis.4PubMed Central. Burden of Severe Disease Associated With Influenza, SARS-CoV-2 and RSV in Spain During the 2024-2025 Winter Season This shift from emergency-mode surveillance to routine respiratory monitoring is the clearest institutional signal that Europe has moved past the acute pandemic phase. Public health agencies across the EU and EEA have been explicitly working toward this transition, refocusing strategies on preventing and managing severe outcomes rather than attempting to stop all transmission.5PubMed Central. Public health considerations for transitioning beyond the acute phase of the COVID-19 pandemic in the EU/EEA
Why Booster Uptake Is So Low
As of early 2025, every EU/EEA country recommends an annual COVID-19 booster for older adults, with the lower age cutoff ranging from 60 to 65 depending on the country. The vaccine and its administration are free of charge in nearly all member states. Despite this, median booster coverage during the 2024–2025 season was just 8.7% among adults aged 60 and older, and 8.5% among those 80 and older, with enormous variation between countries (from under 1% to over 80% in the oldest age group).6PubMed Central. Advancing Vaccination Strategies for Older Adults: Insights of the Adult Immunization Board Meeting
These numbers represent a dramatic collapse from earlier in the pandemic. Among six middle-income European countries and areas tracked between 2022 and 2024, the share of people who had received a COVID-19 vaccine in the past 12 months fell from 25% down to 3%. Most of those countries had not updated their guidelines to recommend annual vaccination, and only two had updated vaccines available.7PubMed Central. COVID‐19 Hospitalizations, Vaccine Uptake, Vaccination Guidelines, and Vaccine Availability in Six Middle‐Income Countries and Areas in Europe, May 2022–April 2024
Focus group research in Spain offers a window into why. Participants described the vaccine as less necessary, saying they believed it could not stop transmission and that the risk of severe illness was much lower than early in the pandemic.8PubMed Central. Hesitancy towards the COVID-19 booster vaccination: a thematic analysis from a focus group study in Spain Vaccination fatigue, safety concerns, and a general sense that the pandemic is “over” all play a role. Health authorities have responded by promoting co-administration with influenza vaccines and simplifying logistics, but the gap between recommendation and uptake remains one of the most conspicuous challenges in European public health right now.
The East-West Divide
The disparity between Eastern and Western Europe runs deeper than raw death counts. Research into COVID-19 vaccine hesitancy found that Eastern European countries faced far higher levels of vaccine skepticism and outright refusal during the mass vaccination campaigns of 2021. The driving factors were not primarily about the vaccines themselves but about institutional trust: distrust of national governments and of medical professionals as credible sources of health information was much more prevalent in Eastern Europe and accounted for a large share of the hesitancy gap.9PubMed Central. What accounts for the variation in COVID-19 vaccine hesitancy in Eastern, Southern and Western Europe?
Lower government healthcare spending per capita in Central and Eastern European countries also contributed to worse outcomes. During the second year of the pandemic, countries with the highest per-capita health expenditures (predominantly in Northern and Western Europe) showed weak or even negative relationships between COVID-19 surges and non-COVID excess deaths, suggesting their health systems absorbed the shock. In Central and Eastern Europe, where spending was lowest, the biggest weekly swings in non-COVID deaths were observed, pointing to strained health systems that could not maintain care quality across the board.10Comparative Economic Research. Central and Eastern Europe. Mortality and Health Spending during the First Year of the COVID–19 Pandemic. Comparing Central, Eastern and Western Europe
These structural inequalities have not gone away. The same institutional trust deficits and funding gaps that widened the East-West mortality divide during the pandemic’s worst years now complicate annual booster campaigns, routine surveillance, and long-COVID management in the region.
What Hybrid Immunity Actually Provides
Most Europeans now carry some combination of vaccine-derived and infection-derived immunity. The question that matters practically is how much protection that “hybrid immunity” gives, and for how long. A systematic review and meta-regression found that hybrid immunity (from prior infection plus primary-series vaccination) protected against severe disease or hospitalization at about 96% effectiveness three months after infection, and that protection held remarkably steady, projecting at around 97% at 12 months. Protection against reinfection was a different story: about 69% at three months, sliding to roughly 42% by 12 months.11The Lancet Infectious Diseases. Protective effectiveness of previous SARS-CoV-2 infection and hybrid immunity against the omicron variant and subvariants: a systematic review and meta-regression
In practical terms, this means that most people in Europe have strong residual protection against ending up in the hospital from COVID-19, but reinfections remain common. Serological data confirm how widespread infection has become: among people with no known prior infection, the probability of detectable antibodies to the virus’s nucleoprotein (a marker that indicates natural infection rather than vaccination) reached about 82% within four weeks of a positive test. Among those who already had a prior infection, the figure was 94%.12Scientific Reports. Assessment of hybrid population immunity to SARS-CoV-2 following breakthrough infections of distinct SARS-CoV-2 variants by the detection of antibodies to nucleoprotein The population-level antibody landscape is now heavily layered, with most people carrying immunity from multiple exposures.
Reinfection is not harmless, however. A large study found that compared with a single infection, reinfection roughly doubled the risk of death and tripled the risk of hospitalization, and contributed additional risks of pulmonary, cardiovascular, kidney, neurological, and other complications. These risks persisted into the post-acute phase and held regardless of vaccination status.13PubMed Central. Acute and postacute sequelae associated with SARS-CoV-2 reinfection The finding complicates the comfortable narrative that repeated COVID-19 infections are just mild colds for most people.
Long COVID and Its Economic Shadow
Long COVID remains one of the most consequential legacies of the pandemic across Europe. A recent global meta-analysis estimated the pooled prevalence of long COVID in Europe at about 39%, though this figure encompasses a wide range of definitions and study designs.14PubMed Central. Global Prevalence of Long COVID, Its Subtypes, and Risk Factors: An Updated Systematic Review and Meta-analysis Even with the understanding that milder cases dominate, the absolute numbers are large enough to create a measurable economic drag.
An OECD analysis concluded that long COVID imposes a consistent burden on labor markets across member and EU states. People affected by long COVID are significantly more likely to leave employment, reduce working hours, or experience sustained declines in work ability. The specific numbers vary by country and study, but the direction of evidence is uniform: long COVID translates into productivity losses with real economic consequences.15OECD Publishing. Addressing the Costs and Care for Long COVID: The Long Shadow of the Pandemic For European health systems already managing aging populations and strained budgets, long COVID represents an ongoing cost that will take years to fully materialize and measure.
How Europe Tracks the Virus Now
The surveillance infrastructure for COVID-19 in Europe has evolved considerably. Traditional clinical testing has declined as most countries stopped mass testing programs. In its place, wastewater-based surveillance has become a mainstay. A survey of ten European countries found that their wastewater systems covered between 25% and 99% of the national population, and eight out of ten also used wastewater to track variant distribution. All ten countries reported that the findings were valuable for public health decision-making.16PubMed Central. A survey of the representativeness and usefulness of wastewater-based surveillance systems in 10 countries across Europe in 2023 Wastewater monitoring provides a population-level signal that does not depend on individuals seeking tests, making it especially useful now that most people who get COVID-19 never get tested at a clinic.
Genomic surveillance, by contrast, has contracted sharply. High-income countries submitted 25 times fewer SARS-CoV-2 sequences per million population in 2024 than they did in 2022. The absolute numbers dropped from a peak of 577 million submissions to under 50 million in 2024.17PubMed Central. Inequities and global declines in SARS-CoV-2 genomic data availability hinder response to emerging variants This decline matters because genomic data is how scientists spot new variants early. If a variant with significant immune escape emerged tomorrow, the current surveillance network would likely detect it more slowly than it would have in 2022. Researchers have flagged this as a blind spot with global repercussions, since high-income countries historically provided the bulk of the world’s sequencing data.
Children and COVID-19 Vaccination in Europe
European countries took widely varying approaches to vaccinating children against COVID-19, and the policy landscape remains fragmented. The core tension is straightforward: the risk of severe illness from COVID-19 in children was always low, and it dropped further with the Omicron variant and rising population immunity from prior infection. That low baseline risk means even small adverse effects from vaccination warrant serious weighing. The most notable concern is a relatively elevated risk of myocarditis following second doses of mRNA vaccines in adolescent males, though the clinical course of those cases has generally been mild.18PubMed Central. Vaccination against COVID-19 – risks and benefits in children Several European countries have scaled back or discontinued routine COVID-19 vaccination recommendations for healthy children, while maintaining them for children with underlying health conditions.
SARS-CoV-2 in European Wildlife
An overlooked dimension of COVID-19’s persistence is its presence in animal populations. A Swiss study investigating free-ranging wildlife found serological evidence of SARS-CoV-2 exposure in red foxes (about 3% prevalence), Eurasian lynx, and European wildcats. Two of the positive foxes showed neutralizing activity against Omicron subvariants. No active viral infections were detected in any animal tested, and the researchers concluded there was no evidence of reservoir formation.19PubMed Central. Investigations on the potential role of free-ranging wildlife as a reservoir of SARS-CoV-2 in Switzerland These were the first reports of SARS-CoV-2 antibodies in free-ranging red foxes, lynx, and wildcats anywhere in the world.
The relevance for European public health is indirect but real. If SARS-CoV-2 were to establish a stable animal reservoir in European wildlife, the virus could circulate and mutate outside the reach of human vaccination campaigns, potentially generating novel variants that spill back into human populations. The Swiss findings are reassuring in that no active reservoir was found, but they confirm that the virus has reached wild carnivore species through spillover from humans or domestic animals. Ongoing monitoring of wildlife is one piece of the broader One Health approach that European countries are adopting, recognizing that respiratory viruses do not respect species boundaries.