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 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], 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.