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Calculated Shard: 129 (from laksa139)

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curl -X POST \
  'http://laksa129.int.ahrefs:8124/' \
  -H 'Content-Type: text/plain' \
  -H 'X-ClickHouse-Database: crawler3' \
  -H 'Authorization: Basic YXBpOg==' \
  -d 'SELECT getAhrefsURLFromUnparsed(src_unparsed) AS found_url, ifNull(toUnixTimestamp(download_stamp), 0) AS crawl_time, ifNull(toUnixTimestamp(props_url_first_seen), 0) AS first_indexed_time, download_http_code AS http_code, src_unparsed AS src_unparsed, src_root_hash AS src_root_hash, history_drop_reason AS history_drop_reason, meta_title AS meta_title, meta_descriptions AS meta_descriptions, attrs_boilerpipe_text AS attrs_boilerpipe_text, attrs_markdown AS attrs_markdown, attrs_readable_markdown AS attrs_readable_markdown, meta_canonical AS meta_canonical FROM crawler3.page_info_local FINAL PREWHERE (src_root_hash, src_unparsed) IN ((getAhrefsRootHashFromUnparsed(getAhrefsUnparsedNoserviceFromURL(\'https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/\')), getAhrefsUnparsedNoserviceFromURL(\'https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/\'))) FORMAT JSONEachRow'

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{"found_url":"https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/","crawl_time":1771459842,"first_indexed_time":0,"http_code":200,"src_unparsed":"gov,nih!nlm,ncbi,pmc,\/articles\/PMC7068164\/ s443","src_root_hash":"7295144728021232729","history_drop_reason":null,"meta_title":"First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020 - PMC","meta_descriptions":["In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany ..."],"attrs_boilerpipe_text":"Abstract\nIn the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China. Median case age was 42 years; 25 were male. Late detection of the clusters’ index cases delayed isolation of further local cases. As at 5 March, there were 4,250 cases.\nKeywords:\nCOVID-19, Novel coronavirus, SARS-COV-2, SARS, coronavirus disease 2019\nA cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 [\n1\n]. On 12 January 2020, Chinese authorities shared the sequence of a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from some clustered cases [\n2\n]. Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19). As at 21 February 2020, the virus had spread rapidly mostly within China but also to 28 other countries, including in the World Health Organization (WHO) European Region [\n3\n-\n5\n]. Here we describe the epidemiology of the first cases of COVID-19 in this region, excluding cases reported in the United Kingdom (UK), as at 21 February 2020. The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission.\nSurveillance in the WHO European Region\nOn 27 January 2020, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe asked countries to complete a WHO standard COVID-19 case report form for all confirmed and probable cases according to WHO criteria [\n6\n-\n8\n]. The overall aim of surveillance at this time was to support the global strategy of containment of COVID-19 with rapid identification and follow-up of cases linked to affected countries in order to minimise onward transmission. The surveillance objectives were to: describe the key epidemiological and clinical characteristics of COVID-19 cases detected in Europe; inform country preparedness; and improve further case detection and management. Data collected included demographics, history of recent travel to affected areas, close contact with a probable or confirmed COVID-19 case, underlying conditions, signs and symptoms of disease at onset, type of specimens from which the virus was detected, and clinical outcome. The WHO case definition was adopted for surveillance: a confirmed case was a person with laboratory confirmation of SARS-CoV-2 infection (ECDC recommended two separate SARS-CoV-2 RT-PCR tests), irrespective of clinical signs and symptoms, whereas a probable case was a suspect case for whom testing for SARS-CoV-2 was inconclusive or positive using a pan-coronavirus assay [\n8\n]. By 31 January 2020, 47 laboratories in 31 countries, including 38 laboratories in 24 European Union and European Economic Area (EU\/EEA) countries, had diagnostic capability for SARS-CoV-2 available (close to 60% of countries in the WHO European Region), with cross-border shipment arrangements in place for many of those lacking domestic testing capacity. The remaining six EU\/EEA countries were expected to have diagnostic testing available by mid-February [\n9\n].\nEpidemiology of first cases in the European Region\nAs at 09:00 on 21 February 2020, 47 confirmed cases of COVID-19 were reported in the WHO European Region and one of these cases had died [\n4\n]. Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis.\nThe first three cases detected were reported in France on 24 January 2020 and had onset of symptoms on 17, 19 and 23 January respectively [\n10\n]. The first death was reported on 15 February in France. As at 21 February, nine countries had reported cases (\nFigure\n): Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 – not included further).\nFigure.\nEpidemic curve of reported COVID-19 cases by date of symptom onset, or date of notification, WHO European Region, as at 21 February 2020 (n = 38)\na,b\nCOVID-19: coronavirus disease 2019; WHO: World Health Organization.\na\nFour cases were reported by Germany with unknown date of onset and unknown symptomatology. Belgium and France reported one asymptomatic case each. These cases are displayed according to their date of notification.\nb\nThe figure does not include nine cases reported in the United Kingdom.\nThe place of infection (assessed at national level based on an incubation period presumed to be up to 14 days [\n11\n], travel history and contact with probable or confirmed cases as per the case definition) was reported for 35 cases (missing for three cases), of whom 14 were infected in China (Hubei province: 10 cases; Shandong province: one case; province not reported for three cases). The remaining 21 cases were infected in Europe. Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France [\n12\n,\n13\n]. Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain. Cases linked to the Haute Savoie cluster were also detected in the UK, including the index case of this cluster, who was infected in Singapore before travelling to France [\n14\n]. The index cases for the cluster in Bavaria was reported to be infected in China [\n15\n].\nThe median age of the 38 cases was 42 years (range: 2–81 years) and 25 were male (\nTable\n). The proportion of male cases was higher among cases acquired in Europe (14 males of 21 cases) compared with those acquired in China (8 males of 14 cases) although the difference was not statistically significant (chi-squared test: p = 0.6). There was no difference in median age by sex (males: 45 years; females: 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe: 47 years; acquired in China: 38 years, p = 0.2).\nTable. Characteristics of confirmed COVID-19 cases, WHO European Region, as at 21 February 2020 (n = 38)\na\n.\nCharacteristics\nNumber of cases overall\nNumber of cases infected in Europe\nNumber of cases infected in China\np value\nb\nAge range in years\n    0–17\n4\n3\n0\n0.08\n    18–49\n24\n13\n9\n    50–64\n7\n5\n2\n    ≥ 65\n3\n0\n3\nSex\n    Male\n25\n14\n8\n0.6\n    Female\n13\n7\n6\nHospitalised\n    Yes\n35\n21\n14\nND\n    No\n2\nND\nND\n    Unknown\n1\nND\nND\nSymptoms\nc\n(31 cases with available information)\n    Asymptomatic\n2\nND\nND\nND\n    Fever\n20\nND\nND\n    Cough\n14\nND\nND\n    Weakness\n8\nND\nND\n    Headaches\n6\nND\nND\n    Sore throat\n2\nND\nND\n    Rhinorrhoea\n2\nND\nND\n    Shortness of breath\n2\nND\nND\nMean days from onset to hospitalisation\n(29 cases)\n3.7\n4.6\n2.5\nND\nMean days from onset to first positive laboratory test\n(16 cases)\n5.1\n6.5\n5.2\nND\nCOVID-19: coronavirus disease 2019; ND: not determined or known; WHO: World Health Organization.\na\nThe Table does not include nine cases reported in the United Kingdom.\nb\nChi-squared test for difference in distributions between cases infected in Europe and those infected in China.\nc\nA single case could have more than one symptom. Only symptoms reported by two or more cases shown.\nAll but two cases were hospitalised (35 of 37 where information on hospitalisation was reported), although it is likely that most were hospitalised to isolate the person rather than because of severe disease. The time from onset of symptoms to hospitalisation (and isolation) ranged between 0 and 10 days with a mean of 3.7 days (reported for 29 cases). The mean number of days to hospitalisation was 2.5 days for cases imported from China, but 4.6 days for those infected in Europe. This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six took only a mean of 2 days to be hospitalised.\nSymptoms at the point of diagnosis were reported for 31 cases. Two cases were asymptomatic and remained so until tested negative. The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively. Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness. Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1). Fever was reported as the sole symptom for nine cases. In 16 of 29 symptomatic cases, the symptoms at diagnosis were consistent with the case definition for acute respiratory infection [\n16\n], although it is possible that cases presented additional symptoms after diagnosis and these were not reported.\nData on pre-existing conditions were reported for seven cases; five had no pre-existing conditions while one was reported to be obese and one had pre-existing cardiac disease. No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases.\nAll hospitalised cases had a benign clinical evolution except four, two reported in Italy and two reported in France, all of whom developed viral pneumonia. All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died. The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days. The duration of hospitalisation was reported for 16 cases with a median of 13 days (range: 8–23 days). As at 21 February 2020, four cases were still hospitalised.\nLaboratory diagnosis\nAll cases were confirmed according to specific assays targeting at least two separate genes (envelope (E) gene as a screening test and RNA-dependent RNA polymerase (RdRp) gene or nucleoprotein (N) gene for confirmation) [\n8\n,\n17\n]. The specimen types tested were reported for 27 cases: 15 had positive nasopharyngeal swabs, nine had positive throat swabs, three cases had positive sputum, two had a positive nasal swab, one case had a positive nasopharyngeal aspirate and one a positive endotracheal aspirate.\nDiscussion\nAs at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia. However the situation is rapidly developing, with a large outbreak recently identified in northern Italy, with transmission in several municipalities and at least two deaths [\n18\n]. As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region [\n19\n].\nIn our analysis of early cases, we observed transmission in two broad contexts: sporadic cases among travellers from China (14 cases) and cases who acquired infection due to subsequent local transmission in Europe (21 cases). Our analysis shows that the time from symptom onset to hospitalisation\/case isolation was about 3 days longer for locally acquired cases than for imported cases. People returning from affected areas are likely to have a low threshold to seek care and be tested when symptomatic, however delays in identifying the index cases of the two clusters in France and Germany meant that locally acquired cases took longer to be detected and isolated. Once the exposure is determined and contacts identified and quarantined (171 contacts in France and 200 in Germany for the clusters in Haute-Savoie and Bavaria, respectively), further cases are likely to be rapidly detected and isolated when they develop symptoms [\n15\n,\n20\n]. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six were hospitalised after a mean of 2 days. Locally acquired cases require significant resources for contact tracing and quarantine, and countries should be prepared to allocate considerable public health resources during the containment phase, should local clusters emerge in their population. In addition, prompt sharing of information on cases and contacts through international notification systems such as the International Health Regulations (IHR) mechanism and the European Commission’s European Early Warning and Response System is essential to contain international spread of infection.\nAll of the imported cases had a history of travel to China. This was consistent with the epidemiological situation in Asia, and supported the recommendation for testing of suspected cases with travel history to China and potentially other areas of presumed ongoing community transmission. The situation has evolved rapidly since then, however, and the number of countries reporting COVID-19 transmission increased rapidly, notably with a large outbreak in northern Italy with 3,089 cases reported as at 5 March [\n18\n,\n19\n]. Testing of suspected cases based on geographical risk of importation needs to be complemented with additional approaches to ensure early detection of local circulation of COVID-19, including through testing of severe acute respiratory infections in hospitals irrespectively of travel history as recommended in the WHO case definition updated on 27 February 2020 [\n21\n].\nThe clinical presentation observed in the cases in Europe is that of an acute respiratory infection. However, of the 31 cases with information on symptoms, 20 cases presented with fever and nine cases presented only with fever and no other symptoms. These findings, which are consistent with other published case series, have prompted ECDC to include fever among several clinical signs or symptoms indicative for the suspected case definition.\nThree cases were aged 65 years or over. All required admission to intensive care and were tourists (imported cases). These findings could reflect the average older age of the tourist population compared with the local contacts exposed to infection in Europe and do not allow us to draw any conclusion on the proportion of severe cases that we could expect in the general population of Europe. Despite this, the finding of older individuals being at higher risk of a severe clinical course is consistent with the evidence from Chinese case series published so far although the majority of infections in China have been mild [\n22\n,\n23\n].\nThis preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region. Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution.\nWith increasing numbers of cases in Europe, data from surveillance and investigations in the region can build on the evidence from countries in Asia experiencing more widespread transmission particularly on disease spectrum and the proportion of infections with severe outcome [\n22\n]. Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population. Serological studies are vital to understand the proportion of cases who are asymptomatic. Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death. Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose. In addition, a number of countries in Europe are adapting and, in some cases, already using existing sentinel primary care based surveillance systems for influenza to detect community transmission of SARS-CoV-2. This approach will be used globally to help identify evidence of widespread community transmission and, should the virus spread and containment no longer be deemed feasible, to monitor intensity of disease transmission, trends and its geographical spread.\nAdditional research is needed to complement surveillance data to build knowledge on the infectious period, modes of transmission, basic and effective reproduction numbers, and effectiveness of prevention and case management options also in settings outside of China. Such special studies are being conducted globally, including a cohort study on citizens repatriated from China to Europe, with the aim to extrapolate disease incidence and risk factors for infection in areas with community transmission. Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level.\nAcknowledgements\nWe are grateful for the essential work of a large number of public health experts, clinical microbiologists, practitioners and clinicians who have been involved in the investigations at national and regional level including all the professionals of the Canarian Health Service and the Balearic Islands Health Service. We acknowledge the work of ECDC data manager, particularly Zsolt Bartha, and country cooperation teams in rapidly establishing the online reporting system in TESSy by 26 January 2020. We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea. ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19. WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management.\nFunding statement: No specific funding.\nThe authors alone are responsible for the views presented in this manuscript and they do not necessarily reflect the views, decisions or policies of the institutions with which the authors are affiliated.\nConflict of interest:\nNone declared.\nAuthors’ contributions:\nEB and BC developed the surveillance system and reporting protocol. GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript. GS performed the analysis. GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript. JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript. MD, CC, VE, AG, AB, PS, MJSM, ANR, YVD, RoM, MBr, MBe, SBu, JS, LF, ALe, CS, AM, DLB, BC, SBS, SBe, SvdW, MV, BL, FR, EN, IC, ALa, MSC, FP, RiM, CM, MVR, NB, LS, SJ, KTW, MP were involved in national clinical, microbiological and public health investigations as well as data collection and reporting. All authors provided input to the outline, multiple versions of the manuscript and gave approval to the final draft.\nReferences\n1.\nWuhan City Health Committee (WCHC). Wuhan Municipal Health and Health Commission's briefing on the current pneumonia epidemic situation in our city 2019. [Accessed 14 Jan 2020]. Available from:\nhttp:\/\/wjw.wuhan.gov.cn\/front\/web\/showDetail\/2019123108989\n2.\nEuropean Centre for Disease Prevention and Control (ECDC). Rapid Risk Assessment: Outbreak of acute respiratory syndrome associated with a novel coronavirus, Wuhan, China; first update – 22 January 2020. Stockholm: ECDC; 2020. 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Available from:\nhttp:\/\/www.euro.who.int\/en\/countries\n6.\nEuropean Centre for Disease Prevention and Control (ECDC). 2019 novel coronavirus (nCoV) disease data Reporting Protocol Version 1, 27 Jan 2020.\n7.\nWorld Health Organization (WHO). Coronavirus disease (COVID-19) technical guidance: Surveillance and case definitions. Geneva: WHO; 2020. Available from:\nhttps:\/\/www.who.int\/emergencies\/diseases\/novel-coronavirus-2019\/technical-guidance\/surveillance-and-case-definitions\n8.\nEuropean Centre for Disease Prevention and Control (ECDC). European surveillance for human infection with novel coronavirus (2019-nCoV) 2020. Stockholm: ECDC. [Accessed 30 Jan 2020]. Available from:\nhttps:\/\/www.ecdc.europa.eu\/en\/european-surveillance-human-infection-novel-coronavirus-2019-ncov\n9.\nReusken CBEM, Broberg EK, Haagmans B, Meijer A, Corman VM, Papa A, et al. 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Available from:\nhttps:\/\/www.who.int\/docs\/default-source\/coronaviruse\/wuhan-virus-assay-v1991527e5122341d99287a1b17c111902.pdf?sfvrsn=d381fc88_2\n18.\nEuropean Centre for Disease Prevention and Control (ECDC). Outbreak of novel coronavirus disease 2019 (COVID19): situation in Italy – 23 February 2020. Stockholm: ECDC; 2020. Available from:\nhttps:\/\/www.ecdc.europa.eu\/en\/publications-data\/outbreak-novel-coronavirus-disease-2019-covid-19-situation-italy\n19.\nWorld Health Organization Regional Office for Europe (WHO\/Europe). COVID-19 situation in the WHO European Region. Copenhagen: WHO\/Europe. [Accessed 5 Mar 2020]. Available from:\nhttps:\/\/who.maps.arcgis.com\/apps\/opsdashboard\/index.html#\/ead3c6475654481ca51c248d52ab9c61\n20.\nLebensmittelsicherheit BLfGu, Robert Koch Institute \nBeschreibung des bisherigen Ausbruchsgeschehens mit dem neuartigen Coronavirus SARS-CoV-2 in Deutschland (Stand: 12. Februar 2020). [Description of the novel coronavirus SARS-CoV-2 outbreak in Germany (as at 12 February 2020)]. German.\nEpidemiologisches Bulletin.\n2020;7:3-4.\n[\nGoogle Scholar\n]\n21.\nWorld Health Organization (WHO). Global Surveillance for COVID-19 disease caused by human infection with novel coronavirus (COVID-19). Geneva: WHO; 2020. [Accessed 4 Mar 2020]. Available from:\nhttps:\/\/www.who.int\/docs\/default-source\/coronaviruse\/20200121-global-surveillance-for-2019-ncov.pdf?sfvrsn=9d82f528_4&download=true\n22.\nThe Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. China: Chinese Center for Disease Control and Prevention; 2020. [Accessed 18 Feb 2020]. Available from:\nhttp:\/\/weekly.chinacdc.cn\/en\/article\/id\/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51\n[\nPMC free article\n] [\nPubMed\n]\n23.\nThe Novel Coronavirus Pneumonia Emergency Response Epidemiology T. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020.\nChina CDC Weekly.\n2020;2(8):113-22.\n[\nPMC free article\n] [\nPubMed\n] [\nGoogle Scholar\n]","attrs_markdown":"[Skip to main content](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#main-content)\n\n![](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/us_flag.svg)\n\nAn official website of the United States government\n\nHere's how you know\n\nHere's how you know\n\n![](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/icon-dot-gov.svg)\n\n**Official websites use .gov**   \n A **.gov** website belongs to an official government organization in the United States.\n\n![](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/icon-https.svg)\n\n**Secure .gov websites use HTTPS**   \n A **lock** ( Locked padlock icon) or **https:\/\/** means you've safely connected to the .gov website. 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Organisation Regional Office for Europe, Copenhagen, Denmark\n\nFind articles by [Dmitriy Pereyaslov](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Pereyaslov%20D\"[Author])\n\n2, [Cornelia Adlhoch](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Adlhoch%20C\"[Author])\n\n### Cornelia Adlhoch\n1European Centre for Disease Prevention and Control, Stockholm, Sweden\n\nFind articles by [Cornelia Adlhoch](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Adlhoch%20C\"[Author])\n\n1, [Jukka Pukkila](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Pukkila%20J\"[Author])\n\n### Jukka Pukkila\n2World Health Organisation Regional Office for Europe, Copenhagen, Denmark\n\nFind articles by [Jukka Pukkila](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Pukkila%20J\"[Author])\n\n2, [Richard Pebody](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Pebody%20R\"[Author])\n\n### Richard Pebody\n2World Health Organisation Regional Office for Europe, Copenhagen, Denmark\n\nFind articles by [Richard Pebody](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Pebody%20R\"[Author])\n\n2, [Sonja Olsen](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Olsen%20S\"[Author])\n\n### Sonja Olsen\n2World Health Organisation Regional Office for Europe, Copenhagen, Denmark\n\n29These authors have contributed equally to the manuscript\n\nFind articles by [Sonja Olsen](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Olsen%20S\"[Author])\n\n2,29, [Bruno Christian Ciancio](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Ciancio%20BC\"[Author])\n\n### Bruno Christian Ciancio\n1European Centre for Disease Prevention and Control, Stockholm, Sweden\n\n29These authors have contributed equally to the manuscript\n\nFind articles by [Bruno Christian Ciancio](https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=\"Ciancio%20BC\"[Author])\n\n1,29\n\n- Author information\n- Article notes\n- Copyright and License information\n\n1European Centre for Disease Prevention and Control, Stockholm, Sweden\n\n2World Health Organisation Regional Office for Europe, Copenhagen, Denmark\n\n3Robert Koch Institute, Berlin, Germany\n\n4Santé Publique France – Direction des maladies infectieuses, Saint-Maurice, France\n\n5Centre national de référence Virus des infections respiratoires, dont la grippe, Institut Pasteur, Paris, France\n\n6Centre national de référence Virus des infections respiratoires, dont la grippe, Hospices civils de Lyon, Lyon, France\n\n7Istituto Superiore di Sanita, Rome, Italy\n\n8Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, Rome, Italy\n\n9Coordination Centre for Health Alerts and Emergencies. Spanish Ministry of Health, Madrid, Spain\n\n10Servicio de Epidemiología, Dirección General de Salut Pública, Islas Baleares, Spain\n\n11Federal Service for Surveillance on Consumer Rights Protection and Human Well-being (Rospotrebnadzor), Moscow, Russia\n\n12Department of Infectious Disease Prevention and Control, Common Community Commission, Brussels-Capital Region, Brussels, Belgium\n\n13Chief Physician, Infection control unit, Lapland Hospital District, Rovaniemi, Finland\n\n14County Medical Officer, Jönköping Region, Jönköping, Sweden\n\n15Santé publique France – Direction des régions, Cellule régionale Nouvelle Aquitaine, Bordeaux, France\n\n16Santé publique France – Direction des régions, Cellule régionale Ile-de-France, Paris, France\n\n17Santé publique France – Direction des régions, Cellule régionale Auvergne-Rhône-Alpes, Lyon, France\n\n18National Centre for Microbiology, WHO-National Influenza Centre, Institute of Health Carlos III. Madrid, Spain\n\n19National Centre of Epidemiology, CIBERESP, Institute of Health Carlos III. Madrid, Spain\n\n20Dirección General de Salut Pública, Islas Baleares, Spain\n\n21State Research Center of Virology and Biotechnology “Vector”, Rospotrebnadzor, Moscow, Russia\n\n22St. Pierre Hospital, Brussels, Belgium\n\n23Laboratory of Clinical Virology, Department of Microbiology and Immunology, Rega Institute, KU Leuven - University of Leuven, Leuven, Belgium\n\n24Epidemiology of infectious diseases, Sciensano, Brussels, Belgium\n\n25Expert Microbiology Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland\n\n26Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland\n\n27Public Health Agency of Sweden, Solna, Sweden\n\n28Jönköping Region, Jönköping, Sweden\n\n29These authors have contributed equally to the manuscript\n\nCorrespondence: Gianfranco Spiteri (Gianfranco.spiteri@ecdc.europa.eu)\n\nReceived 2020 Feb 24; Accepted 2020 Mar 5.\n\nThis article is copyright of the authors or their affiliated institutions, 2020.\n\nThis is an open-access article distributed under the terms of the Creative Commons Attribution (CC BY 4.0) Licence. You may share and adapt the material, but must give appropriate credit to the source, provide a link to the licence, and indicate if changes were made.\n\n[PMC Copyright notice](https:\/\/pmc.ncbi.nlm.nih.gov\/about\/copyright\/)\n\nPMCID: PMC7068164 PMID: [32156327](https:\/\/pubmed.ncbi.nlm.nih.gov\/32156327\/)\n\n## Abstract\nIn the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China. Median case age was 42 years; 25 were male. Late detection of the clusters’ index cases delayed isolation of further local cases. As at 5 March, there were 4,250 cases.\n\n**Keywords:**  COVID-19, Novel coronavirus, SARS-COV-2, SARS, coronavirus disease 2019\n***\nA cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 \\[[1](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r1)\\]. On 12 January 2020, Chinese authorities shared the sequence of a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from some clustered cases \\[[2](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r2)\\]. Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19). As at 21 February 2020, the virus had spread rapidly mostly within China but also to 28 other countries, including in the World Health Organization (WHO) European Region \\[[3](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r3)\\-[5](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r5)\\]. Here we describe the epidemiology of the first cases of COVID-19 in this region, excluding cases reported in the United Kingdom (UK), as at 21 February 2020. The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission.\n\n## Surveillance in the WHO European Region\nOn 27 January 2020, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe asked countries to complete a WHO standard COVID-19 case report form for all confirmed and probable cases according to WHO criteria \\[[6](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r6)\\-[8](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r8)\\]. The overall aim of surveillance at this time was to support the global strategy of containment of COVID-19 with rapid identification and follow-up of cases linked to affected countries in order to minimise onward transmission. The surveillance objectives were to: describe the key epidemiological and clinical characteristics of COVID-19 cases detected in Europe; inform country preparedness; and improve further case detection and management. Data collected included demographics, history of recent travel to affected areas, close contact with a probable or confirmed COVID-19 case, underlying conditions, signs and symptoms of disease at onset, type of specimens from which the virus was detected, and clinical outcome. The WHO case definition was adopted for surveillance: a confirmed case was a person with laboratory confirmation of SARS-CoV-2 infection (ECDC recommended two separate SARS-CoV-2 RT-PCR tests), irrespective of clinical signs and symptoms, whereas a probable case was a suspect case for whom testing for SARS-CoV-2 was inconclusive or positive using a pan-coronavirus assay \\[[8](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r8)\\]. By 31 January 2020, 47 laboratories in 31 countries, including 38 laboratories in 24 European Union and European Economic Area (EU\/EEA) countries, had diagnostic capability for SARS-CoV-2 available (close to 60% of countries in the WHO European Region), with cross-border shipment arrangements in place for many of those lacking domestic testing capacity. The remaining six EU\/EEA countries were expected to have diagnostic testing available by mid-February \\[[9](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r9)\\].\n\n## Epidemiology of first cases in the European Region\nAs at 09:00 on 21 February 2020, 47 confirmed cases of COVID-19 were reported in the WHO European Region and one of these cases had died \\[[4](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r4)\\]. Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis.\n\nThe first three cases detected were reported in France on 24 January 2020 and had onset of symptoms on 17, 19 and 23 January respectively \\[[10](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r10)\\]. The first death was reported on 15 February in France. As at 21 February, nine countries had reported cases ([Figure](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#f1)): Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 – not included further).\n\n### Figure.\nEpidemic curve of reported COVID-19 cases by date of symptom onset, or date of notification, WHO European Region, as at 21 February 2020 (n = 38)a,b\n\nCOVID-19: coronavirus disease 2019; WHO: World Health Organization.\n\na Four cases were reported by Germany with unknown date of onset and unknown symptomatology. Belgium and France reported one asymptomatic case each. These cases are displayed according to their date of notification.\n\nb The figure does not include nine cases reported in the United Kingdom.\n\n[![Figure](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/blobs\/4718\/7068164\/4cc44a9b6f2f\/2000178-f1.jpg)](https:\/\/www.ncbi.nlm.nih.gov\/core\/lw\/2.0\/html\/tileshop_pmc\/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=7068164_2000178-f1.jpg)\n\n[Open in a new tab](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/figure\/f1\/)\n\nThe place of infection (assessed at national level based on an incubation period presumed to be up to 14 days \\[[11](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r11)\\], travel history and contact with probable or confirmed cases as per the case definition) was reported for 35 cases (missing for three cases), of whom 14 were infected in China (Hubei province: 10 cases; Shandong province: one case; province not reported for three cases). The remaining 21 cases were infected in Europe. Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France \\[[12](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r12),[13](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r13)\\]. Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain. Cases linked to the Haute Savoie cluster were also detected in the UK, including the index case of this cluster, who was infected in Singapore before travelling to France \\[[14](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r14)\\]. The index cases for the cluster in Bavaria was reported to be infected in China \\[[15](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r15)\\].\n\nThe median age of the 38 cases was 42 years (range: 2–81 years) and 25 were male ([Table](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#t1)). The proportion of male cases was higher among cases acquired in Europe (14 males of 21 cases) compared with those acquired in China (8 males of 14 cases) although the difference was not statistically significant (chi-squared test: p = 0.6). There was no difference in median age by sex (males: 45 years; females: 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe: 47 years; acquired in China: 38 years, p = 0.2).\n\n### Table. Characteristics of confirmed COVID-19 cases, WHO European Region, as at 21 February 2020 (n = 38)a.\n| Characteristics | Number of cases overall | Number of cases infected in Europe | Number of cases infected in China | p valueb |\n|---|---|---|---|---|\n| Age range in years |   |   |   |   |\n| 0–17 | 4 | 3 | 0 | 0\\.08 |\n| 18–49 | 24 | 13 | 9 |   |\n| 50–64 | 7 | 5 | 2 |   |\n| ≥ 65 | 3 | 0 | 3 |   |\n| Sex |   |   |   |   |\n| Male | 25 | 14 | 8 | 0\\.6 |\n| Female | 13 | 7 | 6 |   |\n| Hospitalised |   |   |   |   |\n| Yes | 35 | 21 | 14 | ND |\n| No | 2 | ND | ND |   |\n| Unknown | 1 | ND | ND |   |\n| Symptomsc (31 cases with available information) |   |   |   |   |\n| Asymptomatic | 2 | ND | ND | ND |\n| Fever | 20 | ND | ND |   |\n| Cough | 14 | ND | ND |   |\n| Weakness | 8 | ND | ND |   |\n| Headaches | 6 | ND | ND |   |\n| Sore throat | 2 | ND | ND |   |\n| Rhinorrhoea | 2 | ND | ND |   |\n| Shortness of breath | 2 | ND | ND |   |\n| Mean days from onset to hospitalisation (29 cases) | 3\\.7 | 4\\.6 | 2\\.5 | ND |\n| Mean days from onset to first positive laboratory test (16 cases) | 5\\.1 | 6\\.5 | 5\\.2 | ND |\n\n[Open in a new tab](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/table\/t1\/)\n\nCOVID-19: coronavirus disease 2019; ND: not determined or known; WHO: World Health Organization.\n\na The Table does not include nine cases reported in the United Kingdom.\n\nb Chi-squared test for difference in distributions between cases infected in Europe and those infected in China.\n\nc A single case could have more than one symptom. Only symptoms reported by two or more cases shown.\n\nAll but two cases were hospitalised (35 of 37 where information on hospitalisation was reported), although it is likely that most were hospitalised to isolate the person rather than because of severe disease. The time from onset of symptoms to hospitalisation (and isolation) ranged between 0 and 10 days with a mean of 3.7 days (reported for 29 cases). The mean number of days to hospitalisation was 2.5 days for cases imported from China, but 4.6 days for those infected in Europe. This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six took only a mean of 2 days to be hospitalised.\n\nSymptoms at the point of diagnosis were reported for 31 cases. Two cases were asymptomatic and remained so until tested negative. The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively. Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness. Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1). Fever was reported as the sole symptom for nine cases. In 16 of 29 symptomatic cases, the symptoms at diagnosis were consistent with the case definition for acute respiratory infection \\[[16](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r16)\\], although it is possible that cases presented additional symptoms after diagnosis and these were not reported.\n\nData on pre-existing conditions were reported for seven cases; five had no pre-existing conditions while one was reported to be obese and one had pre-existing cardiac disease. No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases.\n\nAll hospitalised cases had a benign clinical evolution except four, two reported in Italy and two reported in France, all of whom developed viral pneumonia. All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died. The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days. The duration of hospitalisation was reported for 16 cases with a median of 13 days (range: 8–23 days). As at 21 February 2020, four cases were still hospitalised.\n\n## Laboratory diagnosis\nAll cases were confirmed according to specific assays targeting at least two separate genes (envelope (E) gene as a screening test and RNA-dependent RNA polymerase (RdRp) gene or nucleoprotein (N) gene for confirmation) \\[[8](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r8),[17](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r17)\\]. The specimen types tested were reported for 27 cases: 15 had positive nasopharyngeal swabs, nine had positive throat swabs, three cases had positive sputum, two had a positive nasal swab, one case had a positive nasopharyngeal aspirate and one a positive endotracheal aspirate.\n\n## Discussion\nAs at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia. However the situation is rapidly developing, with a large outbreak recently identified in northern Italy, with transmission in several municipalities and at least two deaths \\[[18](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r18)\\]. As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region \\[[19](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r19)\\].\n\nIn our analysis of early cases, we observed transmission in two broad contexts: sporadic cases among travellers from China (14 cases) and cases who acquired infection due to subsequent local transmission in Europe (21 cases). Our analysis shows that the time from symptom onset to hospitalisation\/case isolation was about 3 days longer for locally acquired cases than for imported cases. People returning from affected areas are likely to have a low threshold to seek care and be tested when symptomatic, however delays in identifying the index cases of the two clusters in France and Germany meant that locally acquired cases took longer to be detected and isolated. Once the exposure is determined and contacts identified and quarantined (171 contacts in France and 200 in Germany for the clusters in Haute-Savoie and Bavaria, respectively), further cases are likely to be rapidly detected and isolated when they develop symptoms \\[[15](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r15),[20](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r20)\\]. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six were hospitalised after a mean of 2 days. Locally acquired cases require significant resources for contact tracing and quarantine, and countries should be prepared to allocate considerable public health resources during the containment phase, should local clusters emerge in their population. In addition, prompt sharing of information on cases and contacts through international notification systems such as the International Health Regulations (IHR) mechanism and the European Commission’s European Early Warning and Response System is essential to contain international spread of infection.\n\nAll of the imported cases had a history of travel to China. This was consistent with the epidemiological situation in Asia, and supported the recommendation for testing of suspected cases with travel history to China and potentially other areas of presumed ongoing community transmission. The situation has evolved rapidly since then, however, and the number of countries reporting COVID-19 transmission increased rapidly, notably with a large outbreak in northern Italy with 3,089 cases reported as at 5 March \\[[18](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r18),[19](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r19)\\]. Testing of suspected cases based on geographical risk of importation needs to be complemented with additional approaches to ensure early detection of local circulation of COVID-19, including through testing of severe acute respiratory infections in hospitals irrespectively of travel history as recommended in the WHO case definition updated on 27 February 2020 \\[[21](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r21)\\].\n\nThe clinical presentation observed in the cases in Europe is that of an acute respiratory infection. However, of the 31 cases with information on symptoms, 20 cases presented with fever and nine cases presented only with fever and no other symptoms. These findings, which are consistent with other published case series, have prompted ECDC to include fever among several clinical signs or symptoms indicative for the suspected case definition.\n\nThree cases were aged 65 years or over. All required admission to intensive care and were tourists (imported cases). These findings could reflect the average older age of the tourist population compared with the local contacts exposed to infection in Europe and do not allow us to draw any conclusion on the proportion of severe cases that we could expect in the general population of Europe. Despite this, the finding of older individuals being at higher risk of a severe clinical course is consistent with the evidence from Chinese case series published so far although the majority of infections in China have been mild \\[[22](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r22),[23](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r23)\\].\n\nThis preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region. Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution.\n\nWith increasing numbers of cases in Europe, data from surveillance and investigations in the region can build on the evidence from countries in Asia experiencing more widespread transmission particularly on disease spectrum and the proportion of infections with severe outcome \\[[22](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r22)\\]. Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population. Serological studies are vital to understand the proportion of cases who are asymptomatic. Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death. Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose. In addition, a number of countries in Europe are adapting and, in some cases, already using existing sentinel primary care based surveillance systems for influenza to detect community transmission of SARS-CoV-2. This approach will be used globally to help identify evidence of widespread community transmission and, should the virus spread and containment no longer be deemed feasible, to monitor intensity of disease transmission, trends and its geographical spread.\n\nAdditional research is needed to complement surveillance data to build knowledge on the infectious period, modes of transmission, basic and effective reproduction numbers, and effectiveness of prevention and case management options also in settings outside of China. Such special studies are being conducted globally, including a cohort study on citizens repatriated from China to Europe, with the aim to extrapolate disease incidence and risk factors for infection in areas with community transmission. Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level.\n\n## Acknowledgements\nWe are grateful for the essential work of a large number of public health experts, clinical microbiologists, practitioners and clinicians who have been involved in the investigations at national and regional level including all the professionals of the Canarian Health Service and the Balearic Islands Health Service. We acknowledge the work of ECDC data manager, particularly Zsolt Bartha, and country cooperation teams in rapidly establishing the online reporting system in TESSy by 26 January 2020. We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea. ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19. WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management.\n\nFunding statement: No specific funding.\n\nThe authors alone are responsible for the views presented in this manuscript and they do not necessarily reflect the views, decisions or policies of the institutions with which the authors are affiliated.\n\n**Conflict of interest:** None declared.\n\n**Authors’ contributions:** EB and BC developed the surveillance system and reporting protocol. GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript. GS performed the analysis. GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript. JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript. 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China CDC Weekly. 2020;2(8):113-22.\n  \\[[PMC free article](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC8392929\/)\\] \\[[PubMed](https:\/\/pubmed.ncbi.nlm.nih.gov\/34594836\/)\\] \\[[Google Scholar](https:\/\/scholar.google.com\/scholar_lookup?journal=China%20CDC%20Weekly.&title=The%20Novel%20Coronavirus%20Pneumonia%20Emergency%20Response%20Epidemiology%20T.%20The%20Epidemiological%20Characteristics%20of%20an%20Outbreak%20of%202019%20Novel%20Coronavirus%20Diseases%20\\(COVID-19\\)%20%E2%80%94%20China,%202020.&volume=2&issue=8&publication_year=2020&pages=113-22&pmid=34594836&)\\]\n\n***\nArticles from Eurosurveillance are provided here courtesy of **European Centre for Disease Prevention and Control**\n\n![Close](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/usa-icons\/close.svg)\n\n## ACTIONS\n- [![View on publisher site icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/launch.svg) View on publisher site](https:\/\/doi.org\/10.2807\/1560-7917.ES.2020.25.9.2000178)\n- [![Download PDF icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/file_download.svg) PDF (164.4 KB)](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/pdf\/eurosurv-25-9-1.pdf)\n- ![Cite icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/format_quote.svg) Cite\n- ![Collections icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/action-bookmark-full.svg) ![Collections icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/action-bookmark-empty.svg) Collections\n- ![Permalink icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/share.svg) Permalink\n  ## PERMALINK\n  ![Copy icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/content_copy.svg) Copy\n\n## RESOURCES\n### Similar articles\n### Cited by other articles\n### Links to NCBI Databases\n\n## Cite\n![Close icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/close.svg)\n\n- ![Copy icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/content_copy.svg) Copy\n- [![Download icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/file_download.svg) Download .nbib .nbib](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/ \"Download a file for external citation management software\")\n- Format:\n## Add to Collections\n\nFollow NCBI\n\n[NCBI on X (formerly known as Twitter)](https:\/\/twitter.com\/ncbi)\n\n[NCBI on Facebook](https:\/\/www.facebook.com\/ncbi.nlm)\n\n[NCBI on LinkedIn](https:\/\/www.linkedin.com\/company\/ncbinlm)\n\n[NCBI on GitHub](https:\/\/github.com\/ncbi)\n\n[NCBI RSS feed](https:\/\/ncbiinsights.ncbi.nlm.nih.gov\/)\n\nConnect with NLM\n\n[NLM on X (formerly known as Twitter)](https:\/\/twitter.com\/nlm_nih)\n\n[NLM on Facebook](https:\/\/www.facebook.com\/nationallibraryofmedicine)\n\n[NLM on YouTube](https:\/\/www.youtube.com\/user\/NLMNIH)\n\n[National Library of Medicine   8600 Rockville Pike  Bethesda, MD 20894](https:\/\/www.google.com\/maps\/place\/8600+Rockville+Pike,+Bethesda,+MD+20894\/%4038.9959508,%0A%20%20%20%20%20%20%20%20%20%20%20%20-77.101021,17z\/data%3D!3m1!4b1!4m5!3m4!1s0x89b7c95e25765ddb%3A0x19156f88b27635b8!8m2!3d38.9959508!%0A%20%20%20%20%20%20%20%20%20%20%20%204d-77.0988323)\n\n- [Web Policies](https:\/\/www.nlm.nih.gov\/web_policies.html)\n- [FOIA](https:\/\/www.nih.gov\/institutes-nih\/nih-office-director\/office-communications-public-liaison\/freedom-information-act-office)\n- [HHS Vulnerability Disclosure](https:\/\/www.hhs.gov\/vulnerability-disclosure-policy\/index.html)\n\n- [Help](https:\/\/support.nlm.nih.gov\/)\n- [Accessibility](https:\/\/www.nlm.nih.gov\/accessibility.html)\n- [Careers](https:\/\/www.nlm.nih.gov\/careers\/careers.html)\n\n- [NLM](https:\/\/www.nlm.nih.gov\/)\n- [NIH](https:\/\/www.nih.gov\/)\n- [HHS](https:\/\/www.hhs.gov\/)\n- [USA.gov](https:\/\/www.usa.gov\/)\n\nBack to Top\n\n![back to top icon](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/pd-medc-pmc-cloudpmc-viewer\/production\/8a2a0396\/var\/data\/static\/img\/arrow_upward.svg)","attrs_readable_markdown":"## Abstract\nIn the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China. Median case age was 42 years; 25 were male. Late detection of the clusters’ index cases delayed isolation of further local cases. As at 5 March, there were 4,250 cases.\n\n**Keywords:**  COVID-19, Novel coronavirus, SARS-COV-2, SARS, coronavirus disease 2019\n***\nA cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 \\[[1](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r1)\\]. On 12 January 2020, Chinese authorities shared the sequence of a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from some clustered cases \\[[2](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r2)\\]. Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19). As at 21 February 2020, the virus had spread rapidly mostly within China but also to 28 other countries, including in the World Health Organization (WHO) European Region \\[[3](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r3)\\-[5](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r5)\\]. Here we describe the epidemiology of the first cases of COVID-19 in this region, excluding cases reported in the United Kingdom (UK), as at 21 February 2020. The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission.\n\n## Surveillance in the WHO European Region\nOn 27 January 2020, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe asked countries to complete a WHO standard COVID-19 case report form for all confirmed and probable cases according to WHO criteria \\[[6](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r6)\\-[8](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r8)\\]. The overall aim of surveillance at this time was to support the global strategy of containment of COVID-19 with rapid identification and follow-up of cases linked to affected countries in order to minimise onward transmission. The surveillance objectives were to: describe the key epidemiological and clinical characteristics of COVID-19 cases detected in Europe; inform country preparedness; and improve further case detection and management. Data collected included demographics, history of recent travel to affected areas, close contact with a probable or confirmed COVID-19 case, underlying conditions, signs and symptoms of disease at onset, type of specimens from which the virus was detected, and clinical outcome. The WHO case definition was adopted for surveillance: a confirmed case was a person with laboratory confirmation of SARS-CoV-2 infection (ECDC recommended two separate SARS-CoV-2 RT-PCR tests), irrespective of clinical signs and symptoms, whereas a probable case was a suspect case for whom testing for SARS-CoV-2 was inconclusive or positive using a pan-coronavirus assay \\[[8](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r8)\\]. By 31 January 2020, 47 laboratories in 31 countries, including 38 laboratories in 24 European Union and European Economic Area (EU\/EEA) countries, had diagnostic capability for SARS-CoV-2 available (close to 60% of countries in the WHO European Region), with cross-border shipment arrangements in place for many of those lacking domestic testing capacity. The remaining six EU\/EEA countries were expected to have diagnostic testing available by mid-February \\[[9](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r9)\\].\n\n## Epidemiology of first cases in the European Region\nAs at 09:00 on 21 February 2020, 47 confirmed cases of COVID-19 were reported in the WHO European Region and one of these cases had died \\[[4](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r4)\\]. Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis.\n\nThe first three cases detected were reported in France on 24 January 2020 and had onset of symptoms on 17, 19 and 23 January respectively \\[[10](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r10)\\]. The first death was reported on 15 February in France. As at 21 February, nine countries had reported cases ([Figure](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#f1)): Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 – not included further).\n\n### Figure.\nEpidemic curve of reported COVID-19 cases by date of symptom onset, or date of notification, WHO European Region, as at 21 February 2020 (n = 38)a,b\n\nCOVID-19: coronavirus disease 2019; WHO: World Health Organization.\n\na Four cases were reported by Germany with unknown date of onset and unknown symptomatology. Belgium and France reported one asymptomatic case each. These cases are displayed according to their date of notification.\n\nb The figure does not include nine cases reported in the United Kingdom.\n\n[![Figure](https:\/\/cdn.ncbi.nlm.nih.gov\/pmc\/blobs\/4718\/7068164\/4cc44a9b6f2f\/2000178-f1.jpg)](https:\/\/www.ncbi.nlm.nih.gov\/core\/lw\/2.0\/html\/tileshop_pmc\/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=7068164_2000178-f1.jpg)\n\nThe place of infection (assessed at national level based on an incubation period presumed to be up to 14 days \\[[11](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r11)\\], travel history and contact with probable or confirmed cases as per the case definition) was reported for 35 cases (missing for three cases), of whom 14 were infected in China (Hubei province: 10 cases; Shandong province: one case; province not reported for three cases). The remaining 21 cases were infected in Europe. Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France \\[[12](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r12),[13](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r13)\\]. Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain. Cases linked to the Haute Savoie cluster were also detected in the UK, including the index case of this cluster, who was infected in Singapore before travelling to France \\[[14](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r14)\\]. The index cases for the cluster in Bavaria was reported to be infected in China \\[[15](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r15)\\].\n\nThe median age of the 38 cases was 42 years (range: 2–81 years) and 25 were male ([Table](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#t1)). The proportion of male cases was higher among cases acquired in Europe (14 males of 21 cases) compared with those acquired in China (8 males of 14 cases) although the difference was not statistically significant (chi-squared test: p = 0.6). There was no difference in median age by sex (males: 45 years; females: 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe: 47 years; acquired in China: 38 years, p = 0.2).\n\n### Table. Characteristics of confirmed COVID-19 cases, WHO European Region, as at 21 February 2020 (n = 38)a.\n| Characteristics | Number of cases overall | Number of cases infected in Europe | Number of cases infected in China | p valueb |\n|---|---|---|---|---|\n| Age range in years |   |   |   |   |\n| 0–17 | 4 | 3 | 0 | 0\\.08 |\n| 18–49 | 24 | 13 | 9 |   |\n| 50–64 | 7 | 5 | 2 |   |\n| ≥ 65 | 3 | 0 | 3 |   |\n| Sex |   |   |   |   |\n| Male | 25 | 14 | 8 | 0\\.6 |\n| Female | 13 | 7 | 6 |   |\n| Hospitalised |   |   |   |   |\n| Yes | 35 | 21 | 14 | ND |\n| No | 2 | ND | ND |   |\n| Unknown | 1 | ND | ND |   |\n| Symptomsc (31 cases with available information) |   |   |   |   |\n| Asymptomatic | 2 | ND | ND | ND |\n| Fever | 20 | ND | ND |   |\n| Cough | 14 | ND | ND |   |\n| Weakness | 8 | ND | ND |   |\n| Headaches | 6 | ND | ND |   |\n| Sore throat | 2 | ND | ND |   |\n| Rhinorrhoea | 2 | ND | ND |   |\n| Shortness of breath | 2 | ND | ND |   |\n| Mean days from onset to hospitalisation (29 cases) | 3\\.7 | 4\\.6 | 2\\.5 | ND |\n| Mean days from onset to first positive laboratory test (16 cases) | 5\\.1 | 6\\.5 | 5\\.2 | ND |\n\nCOVID-19: coronavirus disease 2019; ND: not determined or known; WHO: World Health Organization.\n\na The Table does not include nine cases reported in the United Kingdom.\n\nb Chi-squared test for difference in distributions between cases infected in Europe and those infected in China.\n\nc A single case could have more than one symptom. Only symptoms reported by two or more cases shown.\n\nAll but two cases were hospitalised (35 of 37 where information on hospitalisation was reported), although it is likely that most were hospitalised to isolate the person rather than because of severe disease. The time from onset of symptoms to hospitalisation (and isolation) ranged between 0 and 10 days with a mean of 3.7 days (reported for 29 cases). The mean number of days to hospitalisation was 2.5 days for cases imported from China, but 4.6 days for those infected in Europe. This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six took only a mean of 2 days to be hospitalised.\n\nSymptoms at the point of diagnosis were reported for 31 cases. Two cases were asymptomatic and remained so until tested negative. The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively. Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness. Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1). Fever was reported as the sole symptom for nine cases. In 16 of 29 symptomatic cases, the symptoms at diagnosis were consistent with the case definition for acute respiratory infection \\[[16](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r16)\\], although it is possible that cases presented additional symptoms after diagnosis and these were not reported.\n\nData on pre-existing conditions were reported for seven cases; five had no pre-existing conditions while one was reported to be obese and one had pre-existing cardiac disease. No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases.\n\nAll hospitalised cases had a benign clinical evolution except four, two reported in Italy and two reported in France, all of whom developed viral pneumonia. All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died. The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days. The duration of hospitalisation was reported for 16 cases with a median of 13 days (range: 8–23 days). As at 21 February 2020, four cases were still hospitalised.\n\n## Laboratory diagnosis\nAll cases were confirmed according to specific assays targeting at least two separate genes (envelope (E) gene as a screening test and RNA-dependent RNA polymerase (RdRp) gene or nucleoprotein (N) gene for confirmation) \\[[8](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r8),[17](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r17)\\]. The specimen types tested were reported for 27 cases: 15 had positive nasopharyngeal swabs, nine had positive throat swabs, three cases had positive sputum, two had a positive nasal swab, one case had a positive nasopharyngeal aspirate and one a positive endotracheal aspirate.\n\n## Discussion\nAs at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia. However the situation is rapidly developing, with a large outbreak recently identified in northern Italy, with transmission in several municipalities and at least two deaths \\[[18](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r18)\\]. As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region \\[[19](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r19)\\].\n\nIn our analysis of early cases, we observed transmission in two broad contexts: sporadic cases among travellers from China (14 cases) and cases who acquired infection due to subsequent local transmission in Europe (21 cases). Our analysis shows that the time from symptom onset to hospitalisation\/case isolation was about 3 days longer for locally acquired cases than for imported cases. People returning from affected areas are likely to have a low threshold to seek care and be tested when symptomatic, however delays in identifying the index cases of the two clusters in France and Germany meant that locally acquired cases took longer to be detected and isolated. Once the exposure is determined and contacts identified and quarantined (171 contacts in France and 200 in Germany for the clusters in Haute-Savoie and Bavaria, respectively), further cases are likely to be rapidly detected and isolated when they develop symptoms \\[[15](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r15),[20](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r20)\\]. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six were hospitalised after a mean of 2 days. Locally acquired cases require significant resources for contact tracing and quarantine, and countries should be prepared to allocate considerable public health resources during the containment phase, should local clusters emerge in their population. In addition, prompt sharing of information on cases and contacts through international notification systems such as the International Health Regulations (IHR) mechanism and the European Commission’s European Early Warning and Response System is essential to contain international spread of infection.\n\nAll of the imported cases had a history of travel to China. This was consistent with the epidemiological situation in Asia, and supported the recommendation for testing of suspected cases with travel history to China and potentially other areas of presumed ongoing community transmission. The situation has evolved rapidly since then, however, and the number of countries reporting COVID-19 transmission increased rapidly, notably with a large outbreak in northern Italy with 3,089 cases reported as at 5 March \\[[18](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r18),[19](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r19)\\]. Testing of suspected cases based on geographical risk of importation needs to be complemented with additional approaches to ensure early detection of local circulation of COVID-19, including through testing of severe acute respiratory infections in hospitals irrespectively of travel history as recommended in the WHO case definition updated on 27 February 2020 \\[[21](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r21)\\].\n\nThe clinical presentation observed in the cases in Europe is that of an acute respiratory infection. However, of the 31 cases with information on symptoms, 20 cases presented with fever and nine cases presented only with fever and no other symptoms. These findings, which are consistent with other published case series, have prompted ECDC to include fever among several clinical signs or symptoms indicative for the suspected case definition.\n\nThree cases were aged 65 years or over. All required admission to intensive care and were tourists (imported cases). These findings could reflect the average older age of the tourist population compared with the local contacts exposed to infection in Europe and do not allow us to draw any conclusion on the proportion of severe cases that we could expect in the general population of Europe. Despite this, the finding of older individuals being at higher risk of a severe clinical course is consistent with the evidence from Chinese case series published so far although the majority of infections in China have been mild \\[[22](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r22),[23](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r23)\\].\n\nThis preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region. Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution.\n\nWith increasing numbers of cases in Europe, data from surveillance and investigations in the region can build on the evidence from countries in Asia experiencing more widespread transmission particularly on disease spectrum and the proportion of infections with severe outcome \\[[22](https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC7068164\/#r22)\\]. Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population. Serological studies are vital to understand the proportion of cases who are asymptomatic. Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death. Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose. In addition, a number of countries in Europe are adapting and, in some cases, already using existing sentinel primary care based surveillance systems for influenza to detect community transmission of SARS-CoV-2. This approach will be used globally to help identify evidence of widespread community transmission and, should the virus spread and containment no longer be deemed feasible, to monitor intensity of disease transmission, trends and its geographical spread.\n\nAdditional research is needed to complement surveillance data to build knowledge on the infectious period, modes of transmission, basic and effective reproduction numbers, and effectiveness of prevention and case management options also in settings outside of China. Such special studies are being conducted globally, including a cohort study on citizens repatriated from China to Europe, with the aim to extrapolate disease incidence and risk factors for infection in areas with community transmission. Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level.\n\n## Acknowledgements\nWe are grateful for the essential work of a large number of public health experts, clinical microbiologists, practitioners and clinicians who have been involved in the investigations at national and regional level including all the professionals of the Canarian Health Service and the Balearic Islands Health Service. We acknowledge the work of ECDC data manager, particularly Zsolt Bartha, and country cooperation teams in rapidly establishing the online reporting system in TESSy by 26 January 2020. We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea. ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19. WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management.\n\nFunding statement: No specific funding.\n\nThe authors alone are responsible for the views presented in this manuscript and they do not necessarily reflect the views, decisions or policies of the institutions with which the authors are affiliated.\n\n**Conflict of interest:** None declared.\n\n**Authors’ contributions:** EB and BC developed the surveillance system and reporting protocol. GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript. GS performed the analysis. GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript. JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript. 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Meta Title	First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020 - PMC
Meta Description	In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany ...
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Boilerpipe Text	Abstract In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China. Median case age was 42 years; 25 were male. Late detection of the clusters’ index cases delayed isolation of further local cases. As at 5 March, there were 4,250 cases. Keywords: COVID-19, Novel coronavirus, SARS-COV-2, SARS, coronavirus disease 2019 A cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 [ 1 ]. On 12 January 2020, Chinese authorities shared the sequence of a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from some clustered cases [ 2 ]. Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19). As at 21 February 2020, the virus had spread rapidly mostly within China but also to 28 other countries, including in the World Health Organization (WHO) European Region [ 3 - 5 ]. Here we describe the epidemiology of the first cases of COVID-19 in this region, excluding cases reported in the United Kingdom (UK), as at 21 February 2020. The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission. Surveillance in the WHO European Region On 27 January 2020, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe asked countries to complete a WHO standard COVID-19 case report form for all confirmed and probable cases according to WHO criteria [ 6 - 8 ]. The overall aim of surveillance at this time was to support the global strategy of containment of COVID-19 with rapid identification and follow-up of cases linked to affected countries in order to minimise onward transmission. The surveillance objectives were to: describe the key epidemiological and clinical characteristics of COVID-19 cases detected in Europe; inform country preparedness; and improve further case detection and management. Data collected included demographics, history of recent travel to affected areas, close contact with a probable or confirmed COVID-19 case, underlying conditions, signs and symptoms of disease at onset, type of specimens from which the virus was detected, and clinical outcome. The WHO case definition was adopted for surveillance: a confirmed case was a person with laboratory confirmation of SARS-CoV-2 infection (ECDC recommended two separate SARS-CoV-2 RT-PCR tests), irrespective of clinical signs and symptoms, whereas a probable case was a suspect case for whom testing for SARS-CoV-2 was inconclusive or positive using a pan-coronavirus assay [ 8 ]. By 31 January 2020, 47 laboratories in 31 countries, including 38 laboratories in 24 European Union and European Economic Area (EU/EEA) countries, had diagnostic capability for SARS-CoV-2 available (close to 60% of countries in the WHO European Region), with cross-border shipment arrangements in place for many of those lacking domestic testing capacity. The remaining six EU/EEA countries were expected to have diagnostic testing available by mid-February [ 9 ]. Epidemiology of first cases in the European Region As at 09:00 on 21 February 2020, 47 confirmed cases of COVID-19 were reported in the WHO European Region and one of these cases had died [ 4 ]. Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis. The first three cases detected were reported in France on 24 January 2020 and had onset of symptoms on 17, 19 and 23 January respectively [ 10 ]. The first death was reported on 15 February in France. As at 21 February, nine countries had reported cases ( Figure ): Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 – not included further). Figure. Epidemic curve of reported COVID-19 cases by date of symptom onset, or date of notification, WHO European Region, as at 21 February 2020 (n = 38) a,b COVID-19: coronavirus disease 2019; WHO: World Health Organization. a Four cases were reported by Germany with unknown date of onset and unknown symptomatology. Belgium and France reported one asymptomatic case each. These cases are displayed according to their date of notification. b The figure does not include nine cases reported in the United Kingdom. The place of infection (assessed at national level based on an incubation period presumed to be up to 14 days [ 11 ], travel history and contact with probable or confirmed cases as per the case definition) was reported for 35 cases (missing for three cases), of whom 14 were infected in China (Hubei province: 10 cases; Shandong province: one case; province not reported for three cases). The remaining 21 cases were infected in Europe. Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France [ 12 , 13 ]. Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain. Cases linked to the Haute Savoie cluster were also detected in the UK, including the index case of this cluster, who was infected in Singapore before travelling to France [ 14 ]. The index cases for the cluster in Bavaria was reported to be infected in China [ 15 ]. The median age of the 38 cases was 42 years (range: 2–81 years) and 25 were male ( Table ). The proportion of male cases was higher among cases acquired in Europe (14 males of 21 cases) compared with those acquired in China (8 males of 14 cases) although the difference was not statistically significant (chi-squared test: p = 0.6). There was no difference in median age by sex (males: 45 years; females: 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe: 47 years; acquired in China: 38 years, p = 0.2). Table. Characteristics of confirmed COVID-19 cases, WHO European Region, as at 21 February 2020 (n = 38) a . Characteristics Number of cases overall Number of cases infected in Europe Number of cases infected in China p value b Age range in years 0–17 4 3 0 0.08 18–49 24 13 9 50–64 7 5 2 ≥ 65 3 0 3 Sex Male 25 14 8 0.6 Female 13 7 6 Hospitalised Yes 35 21 14 ND No 2 ND ND Unknown 1 ND ND Symptoms c (31 cases with available information) Asymptomatic 2 ND ND ND Fever 20 ND ND Cough 14 ND ND Weakness 8 ND ND Headaches 6 ND ND Sore throat 2 ND ND Rhinorrhoea 2 ND ND Shortness of breath 2 ND ND Mean days from onset to hospitalisation (29 cases) 3.7 4.6 2.5 ND Mean days from onset to first positive laboratory test (16 cases) 5.1 6.5 5.2 ND COVID-19: coronavirus disease 2019; ND: not determined or known; WHO: World Health Organization. a The Table does not include nine cases reported in the United Kingdom. b Chi-squared test for difference in distributions between cases infected in Europe and those infected in China. c A single case could have more than one symptom. Only symptoms reported by two or more cases shown. All but two cases were hospitalised (35 of 37 where information on hospitalisation was reported), although it is likely that most were hospitalised to isolate the person rather than because of severe disease. The time from onset of symptoms to hospitalisation (and isolation) ranged between 0 and 10 days with a mean of 3.7 days (reported for 29 cases). The mean number of days to hospitalisation was 2.5 days for cases imported from China, but 4.6 days for those infected in Europe. This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six took only a mean of 2 days to be hospitalised. Symptoms at the point of diagnosis were reported for 31 cases. Two cases were asymptomatic and remained so until tested negative. The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively. Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness. Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1). Fever was reported as the sole symptom for nine cases. In 16 of 29 symptomatic cases, the symptoms at diagnosis were consistent with the case definition for acute respiratory infection [ 16 ], although it is possible that cases presented additional symptoms after diagnosis and these were not reported. Data on pre-existing conditions were reported for seven cases; five had no pre-existing conditions while one was reported to be obese and one had pre-existing cardiac disease. No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases. All hospitalised cases had a benign clinical evolution except four, two reported in Italy and two reported in France, all of whom developed viral pneumonia. All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died. The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days. The duration of hospitalisation was reported for 16 cases with a median of 13 days (range: 8–23 days). As at 21 February 2020, four cases were still hospitalised. Laboratory diagnosis All cases were confirmed according to specific assays targeting at least two separate genes (envelope (E) gene as a screening test and RNA-dependent RNA polymerase (RdRp) gene or nucleoprotein (N) gene for confirmation) [ 8 , 17 ]. The specimen types tested were reported for 27 cases: 15 had positive nasopharyngeal swabs, nine had positive throat swabs, three cases had positive sputum, two had a positive nasal swab, one case had a positive nasopharyngeal aspirate and one a positive endotracheal aspirate. Discussion As at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia. However the situation is rapidly developing, with a large outbreak recently identified in northern Italy, with transmission in several municipalities and at least two deaths [ 18 ]. As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region [ 19 ]. In our analysis of early cases, we observed transmission in two broad contexts: sporadic cases among travellers from China (14 cases) and cases who acquired infection due to subsequent local transmission in Europe (21 cases). Our analysis shows that the time from symptom onset to hospitalisation/case isolation was about 3 days longer for locally acquired cases than for imported cases. People returning from affected areas are likely to have a low threshold to seek care and be tested when symptomatic, however delays in identifying the index cases of the two clusters in France and Germany meant that locally acquired cases took longer to be detected and isolated. Once the exposure is determined and contacts identified and quarantined (171 contacts in France and 200 in Germany for the clusters in Haute-Savoie and Bavaria, respectively), further cases are likely to be rapidly detected and isolated when they develop symptoms [ 15 , 20 ]. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six were hospitalised after a mean of 2 days. Locally acquired cases require significant resources for contact tracing and quarantine, and countries should be prepared to allocate considerable public health resources during the containment phase, should local clusters emerge in their population. In addition, prompt sharing of information on cases and contacts through international notification systems such as the International Health Regulations (IHR) mechanism and the European Commission’s European Early Warning and Response System is essential to contain international spread of infection. All of the imported cases had a history of travel to China. This was consistent with the epidemiological situation in Asia, and supported the recommendation for testing of suspected cases with travel history to China and potentially other areas of presumed ongoing community transmission. The situation has evolved rapidly since then, however, and the number of countries reporting COVID-19 transmission increased rapidly, notably with a large outbreak in northern Italy with 3,089 cases reported as at 5 March [ 18 , 19 ]. Testing of suspected cases based on geographical risk of importation needs to be complemented with additional approaches to ensure early detection of local circulation of COVID-19, including through testing of severe acute respiratory infections in hospitals irrespectively of travel history as recommended in the WHO case definition updated on 27 February 2020 [ 21 ]. The clinical presentation observed in the cases in Europe is that of an acute respiratory infection. However, of the 31 cases with information on symptoms, 20 cases presented with fever and nine cases presented only with fever and no other symptoms. These findings, which are consistent with other published case series, have prompted ECDC to include fever among several clinical signs or symptoms indicative for the suspected case definition. Three cases were aged 65 years or over. All required admission to intensive care and were tourists (imported cases). These findings could reflect the average older age of the tourist population compared with the local contacts exposed to infection in Europe and do not allow us to draw any conclusion on the proportion of severe cases that we could expect in the general population of Europe. Despite this, the finding of older individuals being at higher risk of a severe clinical course is consistent with the evidence from Chinese case series published so far although the majority of infections in China have been mild [ 22 , 23 ]. This preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region. Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution. With increasing numbers of cases in Europe, data from surveillance and investigations in the region can build on the evidence from countries in Asia experiencing more widespread transmission particularly on disease spectrum and the proportion of infections with severe outcome [ 22 ]. Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population. Serological studies are vital to understand the proportion of cases who are asymptomatic. Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death. Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose. In addition, a number of countries in Europe are adapting and, in some cases, already using existing sentinel primary care based surveillance systems for influenza to detect community transmission of SARS-CoV-2. This approach will be used globally to help identify evidence of widespread community transmission and, should the virus spread and containment no longer be deemed feasible, to monitor intensity of disease transmission, trends and its geographical spread. Additional research is needed to complement surveillance data to build knowledge on the infectious period, modes of transmission, basic and effective reproduction numbers, and effectiveness of prevention and case management options also in settings outside of China. Such special studies are being conducted globally, including a cohort study on citizens repatriated from China to Europe, with the aim to extrapolate disease incidence and risk factors for infection in areas with community transmission. Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level. Acknowledgements We are grateful for the essential work of a large number of public health experts, clinical microbiologists, practitioners and clinicians who have been involved in the investigations at national and regional level including all the professionals of the Canarian Health Service and the Balearic Islands Health Service. We acknowledge the work of ECDC data manager, particularly Zsolt Bartha, and country cooperation teams in rapidly establishing the online reporting system in TESSy by 26 January 2020. We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea. ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19. WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management. Funding statement: No specific funding. The authors alone are responsible for the views presented in this manuscript and they do not necessarily reflect the views, decisions or policies of the institutions with which the authors are affiliated. Conflict of interest: None declared. Authors’ contributions: EB and BC developed the surveillance system and reporting protocol. GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript. GS performed the analysis. GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript. JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript. MD, CC, VE, AG, AB, PS, MJSM, ANR, YVD, RoM, MBr, MBe, SBu, JS, LF, ALe, CS, AM, DLB, BC, SBS, SBe, SvdW, MV, BL, FR, EN, IC, ALa, MSC, FP, RiM, CM, MVR, NB, LS, SJ, KTW, MP were involved in national clinical, microbiological and public health investigations as well as data collection and reporting. All authors provided input to the outline, multiple versions of the manuscript and gave approval to the final draft. References 1. Wuhan City Health Committee (WCHC). Wuhan Municipal Health and Health Commission's briefing on the current pneumonia epidemic situation in our city 2019. [Accessed 14 Jan 2020]. Available from: http://wjw.wuhan.gov.cn/front/web/showDetail/2019123108989 2. European Centre for Disease Prevention and Control (ECDC). Rapid Risk Assessment: Outbreak of acute respiratory syndrome associated with a novel coronavirus, Wuhan, China; first update – 22 January 2020. Stockholm: ECDC; 2020. 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Learn more: [PMC Disclaimer](https://pmc.ncbi.nlm.nih.gov/about/disclaimer/) \\| [PMC Copyright Notice](https://pmc.ncbi.nlm.nih.gov/about/copyright/) ![Eurosurveillance logo](https://cdn.ncbi.nlm.nih.gov/pmc/banners/logo-eurosurv.gif) Euro Surveill . 2020 Mar 5;25(9):2000178. doi: [10\.2807/1560-7917.ES.2020.25.9.2000178](https://doi.org/10.2807/1560-7917.ES.2020.25.9.2000178) - [Search in PMC](https://pmc.ncbi.nlm.nih.gov/search/?term="Euro%20Surveill"[jour]) - [Search in PubMed](https://pubmed.ncbi.nlm.nih.gov/?term="Euro%20Surveill"[jour]) - [View in NLM Catalog](https://www.ncbi.nlm.nih.gov/nlmcatalog?term="Euro%20Surveill"[Title%20Abbreviation]) - [Add to search](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/?term="Euro%20Surveill"[jour]) # First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020 [Gianfranco Spiteri](https://pubmed.ncbi.nlm.nih.gov/?term="Spiteri%20G"[Author]) ### Gianfranco Spiteri 1European Centre for Disease Prevention and Control, Stockholm, Sweden Find articles by [Gianfranco Spiteri](https://pubmed.ncbi.nlm.nih.gov/?term="Spiteri%20G"[Author]) 1, [James Fielding](https://pubmed.ncbi.nlm.nih.gov/?term="Fielding%20J"[Author]) ### James Fielding 2World Health Organisation Regional Office for Europe, Copenhagen, Denmark Find articles by [James Fielding](https://pubmed.ncbi.nlm.nih.gov/?term="Fielding%20J"[Author]) 2, [Michaela Diercke](https://pubmed.ncbi.nlm.nih.gov/?term="Diercke%20M"[Author]) ### Michaela Diercke 3Robert Koch Institute, Berlin, Germany Find articles by [Michaela Diercke](https://pubmed.ncbi.nlm.nih.gov/?term="Diercke%20M"[Author]) 3, [Christine Campese](https://pubmed.ncbi.nlm.nih.gov/?term="Campese%20C"[Author]) ### Christine Campese 4Santé Publique France – Direction des maladies infectieuses, Saint-Maurice, France Find articles by [Christine Campese](https://pubmed.ncbi.nlm.nih.gov/?term="Campese%20C"[Author]) 4, [Vincent Enouf](https://pubmed.ncbi.nlm.nih.gov/?term="Enouf%20V"[Author]) ### Vincent Enouf 5Centre national de référence Virus des infections respiratoires, dont la grippe, Institut Pasteur, Paris, France Find articles by [Vincent Enouf](https://pubmed.ncbi.nlm.nih.gov/?term="Enouf%20V"[Author]) 5, [Alexandre Gaymard](https://pubmed.ncbi.nlm.nih.gov/?term="Gaymard%20A"[Author]) ### Alexandre Gaymard 6Centre national de référence Virus des infections respiratoires, dont la grippe, Hospices civils de Lyon, Lyon, France Find articles by [Alexandre Gaymard](https://pubmed.ncbi.nlm.nih.gov/?term="Gaymard%20A"[Author]) 6, [Antonino Bella](https://pubmed.ncbi.nlm.nih.gov/?term="Bella%20A"[Author]) ### Antonino Bella 7Istituto Superiore di Sanita, Rome, Italy Find articles by [Antonino Bella](https://pubmed.ncbi.nlm.nih.gov/?term="Bella%20A"[Author]) 7, [Paola Sognamiglio](https://pubmed.ncbi.nlm.nih.gov/?term="Sognamiglio%20P"[Author]) ### Paola Sognamiglio 8Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, Rome, Italy Find articles by [Paola Sognamiglio](https://pubmed.ncbi.nlm.nih.gov/?term="Sognamiglio%20P"[Author]) 8, [Maria José Sierra Moros](https://pubmed.ncbi.nlm.nih.gov/?term="Sierra%20Moros%20MJ"[Author]) ### Maria José Sierra Moros 9Coordination Centre for Health Alerts and Emergencies. Spanish Ministry of Health, Madrid, Spain Find articles by [Maria José Sierra Moros](https://pubmed.ncbi.nlm.nih.gov/?term="Sierra%20Moros%20MJ"[Author]) 9, [Antonio Nicolau Riutort](https://pubmed.ncbi.nlm.nih.gov/?term="Riutort%20AN"[Author]) ### Antonio Nicolau Riutort 10Servicio de Epidemiología, Dirección General de Salut Pública, Islas Baleares, Spain Find articles by [Antonio Nicolau Riutort](https://pubmed.ncbi.nlm.nih.gov/?term="Riutort%20AN"[Author]) 10, [Yulia V Demina](https://pubmed.ncbi.nlm.nih.gov/?term="Demina%20YV"[Author]) ### Yulia V Demina 11Federal Service for Surveillance on Consumer Rights Protection and Human Well-being (Rospotrebnadzor), Moscow, Russia Find articles by [Yulia V Demina](https://pubmed.ncbi.nlm.nih.gov/?term="Demina%20YV"[Author]) 11, [Romain Mahieu](https://pubmed.ncbi.nlm.nih.gov/?term="Mahieu%20R"[Author]) ### Romain Mahieu 12Department of Infectious Disease Prevention and Control, Common Community Commission, Brussels-Capital Region, 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Spallanzani, Rome, Italy Find articles by [Emanuele Nicastri](https://pubmed.ncbi.nlm.nih.gov/?term="Nicastri%20E"[Author]) 8, [Inmaculada Casas](https://pubmed.ncbi.nlm.nih.gov/?term="Casas%20I"[Author]) ### Inmaculada Casas 18National Centre for Microbiology, WHO-National Influenza Centre, Institute of Health Carlos III. Madrid, Spain Find articles by [Inmaculada Casas](https://pubmed.ncbi.nlm.nih.gov/?term="Casas%20I"[Author]) 18, [Amparo Larrauri](https://pubmed.ncbi.nlm.nih.gov/?term="Larrauri%20A"[Author]) ### Amparo Larrauri 19National Centre of Epidemiology, CIBERESP, Institute of Health Carlos III. Madrid, Spain Find articles by [Amparo Larrauri](https://pubmed.ncbi.nlm.nih.gov/?term="Larrauri%20A"[Author]) 19, [Magdalena Salom Castell](https://pubmed.ncbi.nlm.nih.gov/?term="Salom%20Castell%20M"[Author]) ### Magdalena Salom Castell 20Dirección General de Salut Pública, Islas Baleares, Spain Find articles by [Magdalena Salom Castell](https://pubmed.ncbi.nlm.nih.gov/?term="Salom%20Castell%20M"[Author]) 20, [Francisco Pozo](https://pubmed.ncbi.nlm.nih.gov/?term="Pozo%20F"[Author]) ### Francisco Pozo 18National Centre for Microbiology, WHO-National Influenza Centre, Institute of Health Carlos III. Madrid, Spain Find articles by [Francisco Pozo](https://pubmed.ncbi.nlm.nih.gov/?term="Pozo%20F"[Author]) 18, [Rinat A Maksyutov](https://pubmed.ncbi.nlm.nih.gov/?term="Maksyutov%20RA"[Author]) ### Rinat A Maksyutov 21State Research Center of Virology and Biotechnology “Vector”, Rospotrebnadzor, Moscow, Russia Find articles by [Rinat A Maksyutov](https://pubmed.ncbi.nlm.nih.gov/?term="Maksyutov%20RA"[Author]) 21, [Charlotte Martin](https://pubmed.ncbi.nlm.nih.gov/?term="Martin%20C"[Author]) ### Charlotte Martin 22St. Pierre Hospital, Brussels, Belgium Find articles by [Charlotte Martin](https://pubmed.ncbi.nlm.nih.gov/?term="Martin%20C"[Author]) 22, [Marc Van Ranst](https://pubmed.ncbi.nlm.nih.gov/?term="Van%20Ranst%20M"[Author]) ### Marc Van Ranst 23Laboratory of Clinical Virology, Department of Microbiology and Immunology, Rega Institute, KU Leuven - University of Leuven, Leuven, Belgium Find articles by [Marc Van Ranst](https://pubmed.ncbi.nlm.nih.gov/?term="Van%20Ranst%20M"[Author]) 23, [Nathalie Bossuyt](https://pubmed.ncbi.nlm.nih.gov/?term="Bossuyt%20N"[Author]) ### Nathalie Bossuyt 24Epidemiology of infectious diseases, Sciensano, Brussels, Belgium Find articles by [Nathalie Bossuyt](https://pubmed.ncbi.nlm.nih.gov/?term="Bossuyt%20N"[Author]) 24, [Lotta Siira](https://pubmed.ncbi.nlm.nih.gov/?term="Siira%20L"[Author]) ### Lotta Siira 25Expert Microbiology Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland Find articles by [Lotta Siira](https://pubmed.ncbi.nlm.nih.gov/?term="Siira%20L"[Author]) 25, [Jussi Sane](https://pubmed.ncbi.nlm.nih.gov/?term="Sane%20J"[Author]) ### Jussi Sane 26Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland Find articles by [Jussi Sane](https://pubmed.ncbi.nlm.nih.gov/?term="Sane%20J"[Author]) 26, [Karin 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Adlhoch 1European Centre for Disease Prevention and Control, Stockholm, Sweden Find articles by [Cornelia Adlhoch](https://pubmed.ncbi.nlm.nih.gov/?term="Adlhoch%20C"[Author]) 1, [Jukka Pukkila](https://pubmed.ncbi.nlm.nih.gov/?term="Pukkila%20J"[Author]) ### Jukka Pukkila 2World Health Organisation Regional Office for Europe, Copenhagen, Denmark Find articles by [Jukka Pukkila](https://pubmed.ncbi.nlm.nih.gov/?term="Pukkila%20J"[Author]) 2, [Richard Pebody](https://pubmed.ncbi.nlm.nih.gov/?term="Pebody%20R"[Author]) ### Richard Pebody 2World Health Organisation Regional Office for Europe, Copenhagen, Denmark Find articles by [Richard Pebody](https://pubmed.ncbi.nlm.nih.gov/?term="Pebody%20R"[Author]) 2, [Sonja Olsen](https://pubmed.ncbi.nlm.nih.gov/?term="Olsen%20S"[Author]) ### Sonja Olsen 2World Health Organisation Regional Office for Europe, Copenhagen, Denmark 29These authors have contributed equally to the manuscript Find articles by [Sonja Olsen](https://pubmed.ncbi.nlm.nih.gov/?term="Olsen%20S"[Author]) 2,29, [Bruno Christian Ciancio](https://pubmed.ncbi.nlm.nih.gov/?term="Ciancio%20BC"[Author]) ### Bruno Christian Ciancio 1European Centre for Disease Prevention and Control, Stockholm, Sweden 29These authors have contributed equally to the manuscript Find articles by [Bruno Christian Ciancio](https://pubmed.ncbi.nlm.nih.gov/?term="Ciancio%20BC"[Author]) 1,29 - Author information - Article notes - Copyright and License information 1European Centre for Disease Prevention and Control, Stockholm, Sweden 2World Health Organisation Regional Office for Europe, Copenhagen, Denmark 3Robert Koch Institute, Berlin, Germany 4Santé Publique France – Direction des maladies infectieuses, Saint-Maurice, France 5Centre national de référence Virus des infections respiratoires, dont la grippe, Institut Pasteur, Paris, France 6Centre national de référence Virus des infections respiratoires, dont la grippe, Hospices civils de Lyon, Lyon, France 7Istituto Superiore di Sanita, Rome, Italy 8Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, Rome, Italy 9Coordination Centre for Health Alerts and Emergencies. Spanish Ministry of Health, Madrid, Spain 10Servicio de Epidemiología, Dirección General de Salut Pública, Islas Baleares, Spain 11Federal Service for Surveillance on Consumer Rights Protection and Human Well-being (Rospotrebnadzor), Moscow, Russia 12Department of Infectious Disease Prevention and Control, Common Community Commission, Brussels-Capital Region, Brussels, Belgium 13Chief Physician, Infection control unit, Lapland Hospital District, Rovaniemi, Finland 14County Medical Officer, Jönköping Region, Jönköping, Sweden 15Santé publique France – Direction des régions, Cellule régionale Nouvelle Aquitaine, Bordeaux, France 16Santé publique France – Direction des régions, Cellule régionale Ile-de-France, Paris, France 17Santé publique France – Direction des régions, Cellule régionale Auvergne-Rhône-Alpes, Lyon, France 18National Centre for Microbiology, WHO-National Influenza Centre, Institute of Health Carlos III. Madrid, Spain 19National Centre of Epidemiology, CIBERESP, Institute of Health Carlos III. Madrid, Spain 20Dirección General de Salut Pública, Islas Baleares, Spain 21State Research Center of Virology and Biotechnology “Vector”, Rospotrebnadzor, Moscow, Russia 22St. Pierre Hospital, Brussels, Belgium 23Laboratory of Clinical Virology, Department of Microbiology and Immunology, Rega Institute, KU Leuven - University of Leuven, Leuven, Belgium 24Epidemiology of infectious diseases, Sciensano, Brussels, Belgium 25Expert Microbiology Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland 26Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland 27Public Health Agency of Sweden, Solna, Sweden 28Jönköping Region, Jönköping, Sweden 29These authors have contributed equally to the manuscript Correspondence: Gianfranco Spiteri (Gianfranco.spiteri@ecdc.europa.eu) Received 2020 Feb 24; Accepted 2020 Mar 5. This article is copyright of the authors or their affiliated institutions, 2020. This is an open-access article distributed under the terms of the Creative Commons Attribution (CC BY 4.0) Licence. You may share and adapt the material, but must give appropriate credit to the source, provide a link to the licence, and indicate if changes were made. [PMC Copyright notice](https://pmc.ncbi.nlm.nih.gov/about/copyright/) PMCID: PMC7068164 PMID: [32156327](https://pubmed.ncbi.nlm.nih.gov/32156327/) ## Abstract In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China. Median case age was 42 years; 25 were male. Late detection of the clusters’ index cases delayed isolation of further local cases. As at 5 March, there were 4,250 cases. Keywords: COVID-19, Novel coronavirus, SARS-COV-2, SARS, coronavirus disease 2019 * A cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 \[[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r1)\]. On 12 January 2020, Chinese authorities shared the sequence of a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from some clustered cases \[[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r2)\]. Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19). As at 21 February 2020, the virus had spread rapidly mostly within China but also to 28 other countries, including in the World Health Organization (WHO) European Region \[[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r3)\-[5](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r5)\]. Here we describe the epidemiology of the first cases of COVID-19 in this region, excluding cases reported in the United Kingdom (UK), as at 21 February 2020. The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission. ## Surveillance in the WHO European Region On 27 January 2020, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe asked countries to complete a WHO standard COVID-19 case report form for all confirmed and probable cases according to WHO criteria \[[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r6)\-[8](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r8)\]. The overall aim of surveillance at this time was to support the global strategy of containment of COVID-19 with rapid identification and follow-up of cases linked to affected countries in order to minimise onward transmission. The surveillance objectives were to: describe the key epidemiological and clinical characteristics of COVID-19 cases detected in Europe; inform country preparedness; and improve further case detection and management. Data collected included demographics, history of recent travel to affected areas, close contact with a probable or confirmed COVID-19 case, underlying conditions, signs and symptoms of disease at onset, type of specimens from which the virus was detected, and clinical outcome. The WHO case definition was adopted for surveillance: a confirmed case was a person with laboratory confirmation of SARS-CoV-2 infection (ECDC recommended two separate SARS-CoV-2 RT-PCR tests), irrespective of clinical signs and symptoms, whereas a probable case was a suspect case for whom testing for SARS-CoV-2 was inconclusive or positive using a pan-coronavirus assay \[[8](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r8)\]. By 31 January 2020, 47 laboratories in 31 countries, including 38 laboratories in 24 European Union and European Economic Area (EU/EEA) countries, had diagnostic capability for SARS-CoV-2 available (close to 60% of countries in the WHO European Region), with cross-border shipment arrangements in place for many of those lacking domestic testing capacity. The remaining six EU/EEA countries were expected to have diagnostic testing available by mid-February \[[9](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r9)\]. ## Epidemiology of first cases in the European Region As at 09:00 on 21 February 2020, 47 confirmed cases of COVID-19 were reported in the WHO European Region and one of these cases had died \[[4](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r4)\]. Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis. The first three cases detected were reported in France on 24 January 2020 and had onset of symptoms on 17, 19 and 23 January respectively \[[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r10)\]. The first death was reported on 15 February in France. As at 21 February, nine countries had reported cases ([Figure](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#f1)): Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 – not included further). ### Figure. Epidemic curve of reported COVID-19 cases by date of symptom onset, or date of notification, WHO European Region, as at 21 February 2020 (n = 38)a,b COVID-19: coronavirus disease 2019; WHO: World Health Organization. a Four cases were reported by Germany with unknown date of onset and unknown symptomatology. Belgium and France reported one asymptomatic case each. These cases are displayed according to their date of notification. b The figure does not include nine cases reported in the United Kingdom. [![Figure](https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4718/7068164/4cc44a9b6f2f/2000178-f1.jpg)](https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=7068164_2000178-f1.jpg) [Open in a new tab](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/figure/f1/) The place of infection (assessed at national level based on an incubation period presumed to be up to 14 days \[[11](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r11)\], travel history and contact with probable or confirmed cases as per the case definition) was reported for 35 cases (missing for three cases), of whom 14 were infected in China (Hubei province: 10 cases; Shandong province: one case; province not reported for three cases). The remaining 21 cases were infected in Europe. Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France \[[12](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r12),[13](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r13)\]. Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain. Cases linked to the Haute Savoie cluster were also detected in the UK, including the index case of this cluster, who was infected in Singapore before travelling to France \[[14](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r14)\]. The index cases for the cluster in Bavaria was reported to be infected in China \[[15](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r15)\]. The median age of the 38 cases was 42 years (range: 2–81 years) and 25 were male ([Table](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#t1)). The proportion of male cases was higher among cases acquired in Europe (14 males of 21 cases) compared with those acquired in China (8 males of 14 cases) although the difference was not statistically significant (chi-squared test: p = 0.6). There was no difference in median age by sex (males: 45 years; females: 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe: 47 years; acquired in China: 38 years, p = 0.2). ### Table. Characteristics of confirmed COVID-19 cases, WHO European Region, as at 21 February 2020 (n = 38)a. \| Characteristics \| Number of cases overall \| Number of cases infected in Europe \| Number of cases infected in China \| p valueb \| \|---\|---\|---\|---\|---\| \| Age range in years \| \| \| \| \| \| 0–17 \| 4 \| 3 \| 0 \| 0\.08 \| \| 18–49 \| 24 \| 13 \| 9 \| \| \| 50–64 \| 7 \| 5 \| 2 \| \| \| ≥ 65 \| 3 \| 0 \| 3 \| \| \| Sex \| \| \| \| \| \| Male \| 25 \| 14 \| 8 \| 0\.6 \| \| Female \| 13 \| 7 \| 6 \| \| \| Hospitalised \| \| \| \| \| \| Yes \| 35 \| 21 \| 14 \| ND \| \| No \| 2 \| ND \| ND \| \| \| Unknown \| 1 \| ND \| ND \| \| \| Symptomsc (31 cases with available information) \| \| \| \| \| \| Asymptomatic \| 2 \| ND \| ND \| ND \| \| Fever \| 20 \| ND \| ND \| \| \| Cough \| 14 \| ND \| ND \| \| \| Weakness \| 8 \| ND \| ND \| \| \| Headaches \| 6 \| ND \| ND \| \| \| Sore throat \| 2 \| ND \| ND \| \| \| Rhinorrhoea \| 2 \| ND \| ND \| \| \| Shortness of breath \| 2 \| ND \| ND \| \| \| Mean days from onset to hospitalisation (29 cases) \| 3\.7 \| 4\.6 \| 2\.5 \| ND \| \| Mean days from onset to first positive laboratory test (16 cases) \| 5\.1 \| 6\.5 \| 5\.2 \| ND \| [Open in a new tab](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/table/t1/) COVID-19: coronavirus disease 2019; ND: not determined or known; WHO: World Health Organization. a The Table does not include nine cases reported in the United Kingdom. b Chi-squared test for difference in distributions between cases infected in Europe and those infected in China. c A single case could have more than one symptom. Only symptoms reported by two or more cases shown. All but two cases were hospitalised (35 of 37 where information on hospitalisation was reported), although it is likely that most were hospitalised to isolate the person rather than because of severe disease. The time from onset of symptoms to hospitalisation (and isolation) ranged between 0 and 10 days with a mean of 3.7 days (reported for 29 cases). The mean number of days to hospitalisation was 2.5 days for cases imported from China, but 4.6 days for those infected in Europe. This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six took only a mean of 2 days to be hospitalised. Symptoms at the point of diagnosis were reported for 31 cases. Two cases were asymptomatic and remained so until tested negative. The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively. Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness. Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1). Fever was reported as the sole symptom for nine cases. In 16 of 29 symptomatic cases, the symptoms at diagnosis were consistent with the case definition for acute respiratory infection \[[16](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r16)\], although it is possible that cases presented additional symptoms after diagnosis and these were not reported. Data on pre-existing conditions were reported for seven cases; five had no pre-existing conditions while one was reported to be obese and one had pre-existing cardiac disease. No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases. All hospitalised cases had a benign clinical evolution except four, two reported in Italy and two reported in France, all of whom developed viral pneumonia. All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died. The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days. The duration of hospitalisation was reported for 16 cases with a median of 13 days (range: 8–23 days). As at 21 February 2020, four cases were still hospitalised. ## Laboratory diagnosis All cases were confirmed according to specific assays targeting at least two separate genes (envelope (E) gene as a screening test and RNA-dependent RNA polymerase (RdRp) gene or nucleoprotein (N) gene for confirmation) \[[8](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r8),[17](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r17)\]. The specimen types tested were reported for 27 cases: 15 had positive nasopharyngeal swabs, nine had positive throat swabs, three cases had positive sputum, two had a positive nasal swab, one case had a positive nasopharyngeal aspirate and one a positive endotracheal aspirate. ## Discussion As at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia. However the situation is rapidly developing, with a large outbreak recently identified in northern Italy, with transmission in several municipalities and at least two deaths \[[18](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r18)\]. As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region \[[19](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r19)\]. In our analysis of early cases, we observed transmission in two broad contexts: sporadic cases among travellers from China (14 cases) and cases who acquired infection due to subsequent local transmission in Europe (21 cases). Our analysis shows that the time from symptom onset to hospitalisation/case isolation was about 3 days longer for locally acquired cases than for imported cases. People returning from affected areas are likely to have a low threshold to seek care and be tested when symptomatic, however delays in identifying the index cases of the two clusters in France and Germany meant that locally acquired cases took longer to be detected and isolated. Once the exposure is determined and contacts identified and quarantined (171 contacts in France and 200 in Germany for the clusters in Haute-Savoie and Bavaria, respectively), further cases are likely to be rapidly detected and isolated when they develop symptoms \[[15](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r15),[20](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r20)\]. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six were hospitalised after a mean of 2 days. Locally acquired cases require significant resources for contact tracing and quarantine, and countries should be prepared to allocate considerable public health resources during the containment phase, should local clusters emerge in their population. In addition, prompt sharing of information on cases and contacts through international notification systems such as the International Health Regulations (IHR) mechanism and the European Commission’s European Early Warning and Response System is essential to contain international spread of infection. All of the imported cases had a history of travel to China. This was consistent with the epidemiological situation in Asia, and supported the recommendation for testing of suspected cases with travel history to China and potentially other areas of presumed ongoing community transmission. The situation has evolved rapidly since then, however, and the number of countries reporting COVID-19 transmission increased rapidly, notably with a large outbreak in northern Italy with 3,089 cases reported as at 5 March \[[18](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r18),[19](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r19)\]. Testing of suspected cases based on geographical risk of importation needs to be complemented with additional approaches to ensure early detection of local circulation of COVID-19, including through testing of severe acute respiratory infections in hospitals irrespectively of travel history as recommended in the WHO case definition updated on 27 February 2020 \[[21](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r21)\]. The clinical presentation observed in the cases in Europe is that of an acute respiratory infection. However, of the 31 cases with information on symptoms, 20 cases presented with fever and nine cases presented only with fever and no other symptoms. These findings, which are consistent with other published case series, have prompted ECDC to include fever among several clinical signs or symptoms indicative for the suspected case definition. Three cases were aged 65 years or over. All required admission to intensive care and were tourists (imported cases). These findings could reflect the average older age of the tourist population compared with the local contacts exposed to infection in Europe and do not allow us to draw any conclusion on the proportion of severe cases that we could expect in the general population of Europe. Despite this, the finding of older individuals being at higher risk of a severe clinical course is consistent with the evidence from Chinese case series published so far although the majority of infections in China have been mild \[[22](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r22),[23](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r23)\]. This preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region. Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution. With increasing numbers of cases in Europe, data from surveillance and investigations in the region can build on the evidence from countries in Asia experiencing more widespread transmission particularly on disease spectrum and the proportion of infections with severe outcome \[[22](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r22)\]. Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population. Serological studies are vital to understand the proportion of cases who are asymptomatic. Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death. Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose. In addition, a number of countries in Europe are adapting and, in some cases, already using existing sentinel primary care based surveillance systems for influenza to detect community transmission of SARS-CoV-2. This approach will be used globally to help identify evidence of widespread community transmission and, should the virus spread and containment no longer be deemed feasible, to monitor intensity of disease transmission, trends and its geographical spread. Additional research is needed to complement surveillance data to build knowledge on the infectious period, modes of transmission, basic and effective reproduction numbers, and effectiveness of prevention and case management options also in settings outside of China. Such special studies are being conducted globally, including a cohort study on citizens repatriated from China to Europe, with the aim to extrapolate disease incidence and risk factors for infection in areas with community transmission. Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level. ## Acknowledgements We are grateful for the essential work of a large number of public health experts, clinical microbiologists, practitioners and clinicians who have been involved in the investigations at national and regional level including all the professionals of the Canarian Health Service and the Balearic Islands Health Service. We acknowledge the work of ECDC data manager, particularly Zsolt Bartha, and country cooperation teams in rapidly establishing the online reporting system in TESSy by 26 January 2020. We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea. ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19. WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management. Funding statement: No specific funding. The authors alone are responsible for the views presented in this manuscript and they do not necessarily reflect the views, decisions or policies of the institutions with which the authors are affiliated. Conflict of interest: None declared. Authors’ contributions: EB and BC developed the surveillance system and reporting protocol. GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript. GS performed the analysis. GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript. JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript. 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China CDC Weekly. 2020;2(8):113-22. \[[PMC free article](https://pmc.ncbi.nlm.nih.gov/articles/PMC8392929/)\] \[[PubMed](https://pubmed.ncbi.nlm.nih.gov/34594836/)\] \[[Google Scholar](https://scholar.google.com/scholar_lookup?journal=China%20CDC%20Weekly.&title=The%20Novel%20Coronavirus%20Pneumonia%20Emergency%20Response%20Epidemiology%20T.%20The%20Epidemiological%20Characteristics%20of%20an%20Outbreak%20of%202019%20Novel%20Coronavirus%20Diseases%20\(COVID-19\)%20%E2%80%94%20China,%202020.&volume=2&issue=8&publication_year=2020&pages=113-22&pmid=34594836&)\] * Articles from Eurosurveillance are provided here courtesy of European Centre for Disease Prevention and Control ![Close](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/usa-icons/close.svg) ## ACTIONS - [![View on publisher site icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/launch.svg) View on publisher site](https://doi.org/10.2807/1560-7917.ES.2020.25.9.2000178) - [![Download PDF icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/file_download.svg) PDF (164.4 KB)](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/pdf/eurosurv-25-9-1.pdf) - ![Cite icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/format_quote.svg) Cite - ![Collections icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/action-bookmark-full.svg) ![Collections icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/action-bookmark-empty.svg) Collections - ![Permalink icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/share.svg) Permalink ## PERMALINK ![Copy icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/content_copy.svg) Copy ## RESOURCES ### Similar articles ### Cited by other articles ### Links to NCBI Databases ## Cite ![Close icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/close.svg) - ![Copy icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/content_copy.svg) Copy - [![Download icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/file_download.svg) Download .nbib .nbib](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/ "Download a file for external citation management software") - Format: ## Add to Collections Follow NCBI [NCBI on X (formerly known as Twitter)](https://twitter.com/ncbi) [NCBI on Facebook](https://www.facebook.com/ncbi.nlm) [NCBI on LinkedIn](https://www.linkedin.com/company/ncbinlm) [NCBI on GitHub](https://github.com/ncbi) [NCBI RSS feed](https://ncbiinsights.ncbi.nlm.nih.gov/) Connect with NLM [NLM on X (formerly known as Twitter)](https://twitter.com/nlm_nih) [NLM on Facebook](https://www.facebook.com/nationallibraryofmedicine) [NLM on YouTube](https://www.youtube.com/user/NLMNIH) [National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894](https://www.google.com/maps/place/8600+Rockville+Pike,+Bethesda,+MD+20894/%4038.9959508,%0A%20%20%20%20%20%20%20%20%20%20%20%20-77.101021,17z/data%3D!3m1!4b1!4m5!3m4!1s0x89b7c95e25765ddb%3A0x19156f88b27635b8!8m2!3d38.9959508!%0A%20%20%20%20%20%20%20%20%20%20%20%204d-77.0988323) - [Web Policies](https://www.nlm.nih.gov/web_policies.html) - [FOIA](https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/freedom-information-act-office) - [HHS Vulnerability Disclosure](https://www.hhs.gov/vulnerability-disclosure-policy/index.html) - [Help](https://support.nlm.nih.gov/) - [Accessibility](https://www.nlm.nih.gov/accessibility.html) - [Careers](https://www.nlm.nih.gov/careers/careers.html) - [NLM](https://www.nlm.nih.gov/) - [NIH](https://www.nih.gov/) - [HHS](https://www.hhs.gov/) - [USA.gov](https://www.usa.gov/) Back to Top ![back to top icon](https://cdn.ncbi.nlm.nih.gov/pmc/pd-medc-pmc-cloudpmc-viewer/production/8a2a0396/var/data/static/img/arrow_upward.svg)
Readable Markdown	## Abstract In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China. Median case age was 42 years; 25 were male. Late detection of the clusters’ index cases delayed isolation of further local cases. As at 5 March, there were 4,250 cases. Keywords: COVID-19, Novel coronavirus, SARS-COV-2, SARS, coronavirus disease 2019 * A cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 \[[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r1)\]. On 12 January 2020, Chinese authorities shared the sequence of a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from some clustered cases \[[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r2)\]. Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19). As at 21 February 2020, the virus had spread rapidly mostly within China but also to 28 other countries, including in the World Health Organization (WHO) European Region \[[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r3)\-[5](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r5)\]. Here we describe the epidemiology of the first cases of COVID-19 in this region, excluding cases reported in the United Kingdom (UK), as at 21 February 2020. The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission. ## Surveillance in the WHO European Region On 27 January 2020, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe asked countries to complete a WHO standard COVID-19 case report form for all confirmed and probable cases according to WHO criteria \[[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r6)\-[8](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r8)\]. The overall aim of surveillance at this time was to support the global strategy of containment of COVID-19 with rapid identification and follow-up of cases linked to affected countries in order to minimise onward transmission. The surveillance objectives were to: describe the key epidemiological and clinical characteristics of COVID-19 cases detected in Europe; inform country preparedness; and improve further case detection and management. Data collected included demographics, history of recent travel to affected areas, close contact with a probable or confirmed COVID-19 case, underlying conditions, signs and symptoms of disease at onset, type of specimens from which the virus was detected, and clinical outcome. The WHO case definition was adopted for surveillance: a confirmed case was a person with laboratory confirmation of SARS-CoV-2 infection (ECDC recommended two separate SARS-CoV-2 RT-PCR tests), irrespective of clinical signs and symptoms, whereas a probable case was a suspect case for whom testing for SARS-CoV-2 was inconclusive or positive using a pan-coronavirus assay \[[8](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r8)\]. By 31 January 2020, 47 laboratories in 31 countries, including 38 laboratories in 24 European Union and European Economic Area (EU/EEA) countries, had diagnostic capability for SARS-CoV-2 available (close to 60% of countries in the WHO European Region), with cross-border shipment arrangements in place for many of those lacking domestic testing capacity. The remaining six EU/EEA countries were expected to have diagnostic testing available by mid-February \[[9](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r9)\]. ## Epidemiology of first cases in the European Region As at 09:00 on 21 February 2020, 47 confirmed cases of COVID-19 were reported in the WHO European Region and one of these cases had died \[[4](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r4)\]. Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis. The first three cases detected were reported in France on 24 January 2020 and had onset of symptoms on 17, 19 and 23 January respectively \[[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r10)\]. The first death was reported on 15 February in France. As at 21 February, nine countries had reported cases ([Figure](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#f1)): Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 – not included further). ### Figure. Epidemic curve of reported COVID-19 cases by date of symptom onset, or date of notification, WHO European Region, as at 21 February 2020 (n = 38)a,b COVID-19: coronavirus disease 2019; WHO: World Health Organization. a Four cases were reported by Germany with unknown date of onset and unknown symptomatology. Belgium and France reported one asymptomatic case each. These cases are displayed according to their date of notification. b The figure does not include nine cases reported in the United Kingdom. [![Figure](https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4718/7068164/4cc44a9b6f2f/2000178-f1.jpg)](https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=7068164_2000178-f1.jpg) The place of infection (assessed at national level based on an incubation period presumed to be up to 14 days \[[11](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r11)\], travel history and contact with probable or confirmed cases as per the case definition) was reported for 35 cases (missing for three cases), of whom 14 were infected in China (Hubei province: 10 cases; Shandong province: one case; province not reported for three cases). The remaining 21 cases were infected in Europe. Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France \[[12](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r12),[13](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r13)\]. Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain. Cases linked to the Haute Savoie cluster were also detected in the UK, including the index case of this cluster, who was infected in Singapore before travelling to France \[[14](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r14)\]. The index cases for the cluster in Bavaria was reported to be infected in China \[[15](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r15)\]. The median age of the 38 cases was 42 years (range: 2–81 years) and 25 were male ([Table](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#t1)). The proportion of male cases was higher among cases acquired in Europe (14 males of 21 cases) compared with those acquired in China (8 males of 14 cases) although the difference was not statistically significant (chi-squared test: p = 0.6). There was no difference in median age by sex (males: 45 years; females: 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe: 47 years; acquired in China: 38 years, p = 0.2). ### Table. Characteristics of confirmed COVID-19 cases, WHO European Region, as at 21 February 2020 (n = 38)a. \| Characteristics \| Number of cases overall \| Number of cases infected in Europe \| Number of cases infected in China \| p valueb \| \|---\|---\|---\|---\|---\| \| Age range in years \| \| \| \| \| \| 0–17 \| 4 \| 3 \| 0 \| 0\.08 \| \| 18–49 \| 24 \| 13 \| 9 \| \| \| 50–64 \| 7 \| 5 \| 2 \| \| \| ≥ 65 \| 3 \| 0 \| 3 \| \| \| Sex \| \| \| \| \| \| Male \| 25 \| 14 \| 8 \| 0\.6 \| \| Female \| 13 \| 7 \| 6 \| \| \| Hospitalised \| \| \| \| \| \| Yes \| 35 \| 21 \| 14 \| ND \| \| No \| 2 \| ND \| ND \| \| \| Unknown \| 1 \| ND \| ND \| \| \| Symptomsc (31 cases with available information) \| \| \| \| \| \| Asymptomatic \| 2 \| ND \| ND \| ND \| \| Fever \| 20 \| ND \| ND \| \| \| Cough \| 14 \| ND \| ND \| \| \| Weakness \| 8 \| ND \| ND \| \| \| Headaches \| 6 \| ND \| ND \| \| \| Sore throat \| 2 \| ND \| ND \| \| \| Rhinorrhoea \| 2 \| ND \| ND \| \| \| Shortness of breath \| 2 \| ND \| ND \| \| \| Mean days from onset to hospitalisation (29 cases) \| 3\.7 \| 4\.6 \| 2\.5 \| ND \| \| Mean days from onset to first positive laboratory test (16 cases) \| 5\.1 \| 6\.5 \| 5\.2 \| ND \| COVID-19: coronavirus disease 2019; ND: not determined or known; WHO: World Health Organization. a The Table does not include nine cases reported in the United Kingdom. b Chi-squared test for difference in distributions between cases infected in Europe and those infected in China. c A single case could have more than one symptom. Only symptoms reported by two or more cases shown. All but two cases were hospitalised (35 of 37 where information on hospitalisation was reported), although it is likely that most were hospitalised to isolate the person rather than because of severe disease. The time from onset of symptoms to hospitalisation (and isolation) ranged between 0 and 10 days with a mean of 3.7 days (reported for 29 cases). The mean number of days to hospitalisation was 2.5 days for cases imported from China, but 4.6 days for those infected in Europe. This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six took only a mean of 2 days to be hospitalised. Symptoms at the point of diagnosis were reported for 31 cases. Two cases were asymptomatic and remained so until tested negative. The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively. Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness. Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1). Fever was reported as the sole symptom for nine cases. In 16 of 29 symptomatic cases, the symptoms at diagnosis were consistent with the case definition for acute respiratory infection \[[16](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r16)\], although it is possible that cases presented additional symptoms after diagnosis and these were not reported. Data on pre-existing conditions were reported for seven cases; five had no pre-existing conditions while one was reported to be obese and one had pre-existing cardiac disease. No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases. All hospitalised cases had a benign clinical evolution except four, two reported in Italy and two reported in France, all of whom developed viral pneumonia. All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died. The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days. The duration of hospitalisation was reported for 16 cases with a median of 13 days (range: 8–23 days). As at 21 February 2020, four cases were still hospitalised. ## Laboratory diagnosis All cases were confirmed according to specific assays targeting at least two separate genes (envelope (E) gene as a screening test and RNA-dependent RNA polymerase (RdRp) gene or nucleoprotein (N) gene for confirmation) \[[8](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r8),[17](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r17)\]. The specimen types tested were reported for 27 cases: 15 had positive nasopharyngeal swabs, nine had positive throat swabs, three cases had positive sputum, two had a positive nasal swab, one case had a positive nasopharyngeal aspirate and one a positive endotracheal aspirate. ## Discussion As at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia. However the situation is rapidly developing, with a large outbreak recently identified in northern Italy, with transmission in several municipalities and at least two deaths \[[18](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r18)\]. As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region \[[19](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r19)\]. In our analysis of early cases, we observed transmission in two broad contexts: sporadic cases among travellers from China (14 cases) and cases who acquired infection due to subsequent local transmission in Europe (21 cases). Our analysis shows that the time from symptom onset to hospitalisation/case isolation was about 3 days longer for locally acquired cases than for imported cases. People returning from affected areas are likely to have a low threshold to seek care and be tested when symptomatic, however delays in identifying the index cases of the two clusters in France and Germany meant that locally acquired cases took longer to be detected and isolated. Once the exposure is determined and contacts identified and quarantined (171 contacts in France and 200 in Germany for the clusters in Haute-Savoie and Bavaria, respectively), further cases are likely to be rapidly detected and isolated when they develop symptoms \[[15](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r15),[20](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r20)\]. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six were hospitalised after a mean of 2 days. Locally acquired cases require significant resources for contact tracing and quarantine, and countries should be prepared to allocate considerable public health resources during the containment phase, should local clusters emerge in their population. In addition, prompt sharing of information on cases and contacts through international notification systems such as the International Health Regulations (IHR) mechanism and the European Commission’s European Early Warning and Response System is essential to contain international spread of infection. All of the imported cases had a history of travel to China. This was consistent with the epidemiological situation in Asia, and supported the recommendation for testing of suspected cases with travel history to China and potentially other areas of presumed ongoing community transmission. The situation has evolved rapidly since then, however, and the number of countries reporting COVID-19 transmission increased rapidly, notably with a large outbreak in northern Italy with 3,089 cases reported as at 5 March \[[18](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r18),[19](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r19)\]. Testing of suspected cases based on geographical risk of importation needs to be complemented with additional approaches to ensure early detection of local circulation of COVID-19, including through testing of severe acute respiratory infections in hospitals irrespectively of travel history as recommended in the WHO case definition updated on 27 February 2020 \[[21](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r21)\]. The clinical presentation observed in the cases in Europe is that of an acute respiratory infection. However, of the 31 cases with information on symptoms, 20 cases presented with fever and nine cases presented only with fever and no other symptoms. These findings, which are consistent with other published case series, have prompted ECDC to include fever among several clinical signs or symptoms indicative for the suspected case definition. Three cases were aged 65 years or over. All required admission to intensive care and were tourists (imported cases). These findings could reflect the average older age of the tourist population compared with the local contacts exposed to infection in Europe and do not allow us to draw any conclusion on the proportion of severe cases that we could expect in the general population of Europe. Despite this, the finding of older individuals being at higher risk of a severe clinical course is consistent with the evidence from Chinese case series published so far although the majority of infections in China have been mild \[[22](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r22),[23](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r23)\]. This preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region. Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution. With increasing numbers of cases in Europe, data from surveillance and investigations in the region can build on the evidence from countries in Asia experiencing more widespread transmission particularly on disease spectrum and the proportion of infections with severe outcome \[[22](https://pmc.ncbi.nlm.nih.gov/articles/PMC7068164/#r22)\]. Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population. Serological studies are vital to understand the proportion of cases who are asymptomatic. Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death. Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose. In addition, a number of countries in Europe are adapting and, in some cases, already using existing sentinel primary care based surveillance systems for influenza to detect community transmission of SARS-CoV-2. This approach will be used globally to help identify evidence of widespread community transmission and, should the virus spread and containment no longer be deemed feasible, to monitor intensity of disease transmission, trends and its geographical spread. Additional research is needed to complement surveillance data to build knowledge on the infectious period, modes of transmission, basic and effective reproduction numbers, and effectiveness of prevention and case management options also in settings outside of China. Such special studies are being conducted globally, including a cohort study on citizens repatriated from China to Europe, with the aim to extrapolate disease incidence and risk factors for infection in areas with community transmission. Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level. ## Acknowledgements We are grateful for the essential work of a large number of public health experts, clinical microbiologists, practitioners and clinicians who have been involved in the investigations at national and regional level including all the professionals of the Canarian Health Service and the Balearic Islands Health Service. We acknowledge the work of ECDC data manager, particularly Zsolt Bartha, and country cooperation teams in rapidly establishing the online reporting system in TESSy by 26 January 2020. We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea. ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19. WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management. Funding statement: No specific funding. The authors alone are responsible for the views presented in this manuscript and they do not necessarily reflect the views, decisions or policies of the institutions with which the authors are affiliated. Conflict of interest: None declared. Authors’ contributions:** EB and BC developed the surveillance system and reporting protocol. GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript. GS performed the analysis. GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript. JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript. 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