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Id Subject Object Predicate Lexical cue
T1 0-109 Sentence denotes First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020
T2 111-119 Sentence denotes Abstract
T3 120-202 Sentence denotes In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020.
T4 203-238 Sentence denotes We detail the first European cases.
T5 239-300 Sentence denotes As at 21 February, nine European countries reported 47 cases.
T6 301-405 Sentence denotes Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China.
T7 406-449 Sentence denotes Median case age was 42 years; 25 were male.
T8 450-535 Sentence denotes Late detection of the clusters’ index cases delayed isolation of further local cases.
T9 536-574 Sentence denotes As at 5 March, there were 4,250 cases.
T10 576-670 Sentence denotes A cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 [1].
T11 671-861 Sentence denotes 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].
T12 862-958 Sentence denotes Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19).
T13 959-1135 Sentence denotes 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].
T14 1136-1293 Sentence denotes 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.
T15 1294-1453 Sentence denotes The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission.
T16 1455-1494 Sentence denotes Surveillance in the WHO European Region
T17 1495-1754 Sentence denotes 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].
T18 1755-1981 Sentence denotes 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.
T19 1982-2198 Sentence denotes 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.
T20 2199-2476 Sentence denotes 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.
T21 2477-2854 Sentence denotes 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].
T22 2855-3210 Sentence denotes 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.
T23 3211-3317 Sentence denotes The remaining six EU/EEA countries were expected to have diagnostic testing available by mid-February [9].
T24 3319-3369 Sentence denotes Epidemiology of first cases in the European Region
T25 3370-3511 Sentence denotes 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].
T26 3512-3614 Sentence denotes Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis.
T27 3615-3758 Sentence denotes 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].
T28 3759-3813 Sentence denotes The first death was reported on 15 February in France.
T29 3814-3876 Sentence denotes As at 21 February, nine countries had reported cases (Figure):
T30 3877-4013 Sentence denotes Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 – not included further).
T31 4014-4170 Sentence denotes 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
T32 4171-4211 Sentence denotes COVID-19: coronavirus disease 2019; WHO:
T33 4212-4238 Sentence denotes World Health Organization.
T34 4239-4331 Sentence denotes a Four cases were reported by Germany with unknown date of onset and unknown symptomatology.
T35 4332-4387 Sentence denotes Belgium and France reported one asymptomatic case each.
T36 4388-4454 Sentence denotes These cases are displayed according to their date of notification.
T37 4455-4527 Sentence denotes b The figure does not include nine cases reported in the United Kingdom.
T38 4528-4835 Sentence denotes 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:
T39 4836-4914 Sentence denotes 10 cases; Shandong province: one case; province not reported for three cases).
T40 4915-4962 Sentence denotes The remaining 21 cases were infected in Europe.
T41 4963-5077 Sentence denotes Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France [12,13].
T42 5078-5228 Sentence denotes Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain.
T43 5229-5405 Sentence denotes 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].
T44 5406-5491 Sentence denotes The index cases for the cluster in Bavaria was reported to be infected in China [15].
T45 5492-5543 Sentence denotes The median age of the 38 cases was 42 years (range:
T46 5544-5581 Sentence denotes 2–81 years) and 25 were male (Table).
T47 5582-5822 Sentence denotes 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).
T48 5823-5875 Sentence denotes There was no difference in median age by sex (males:
T49 5876-5894 Sentence denotes 45 years; females:
T50 5895-6010 Sentence denotes 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe:
T51 6011-6039 Sentence denotes 47 years; acquired in China:
T52 6040-6059 Sentence denotes 38 years, p = 0.2).
T53 6060-6165 Sentence denotes Table Characteristics of confirmed COVID-19 cases, WHO European Region, as at 21 February 2020 (n = 38)a
T54 6166-6287 Sentence denotes Characteristics Number of cases overall Number of cases infected in Europe Number of cases infected in China p valueb
T55 6288-6306 Sentence denotes Age range in years
T56 6307-6330 Sentence denotes     0–17 4 3 0 0.08
T57 6331-6351 Sentence denotes     18–49 24 13 9
T58 6352-6370 Sentence denotes     50–64 7 5 2
T59 6371-6388 Sentence denotes     ≥ 65 3 0 3
T60 6389-6392 Sentence denotes Sex
T61 6393-6417 Sentence denotes     Male 25 14 8 0.6
T62 6418-6438 Sentence denotes     Female 13 7 6
T63 6439-6451 Sentence denotes Hospitalised
T64 6452-6475 Sentence denotes     Yes 35 21 14 ND
T65 6476-6493 Sentence denotes     No 2 ND ND
T66 6494-6516 Sentence denotes     Unknown 1 ND ND
T67 6517-6564 Sentence denotes Symptomsc (31 cases with available information)
T68 6565-6596 Sentence denotes     Asymptomatic 2 ND ND ND
T69 6597-6618 Sentence denotes     Fever 20 ND ND
T70 6619-6640 Sentence denotes     Cough 14 ND ND
T71 6641-6664 Sentence denotes     Weakness 8 ND ND
T72 6665-6689 Sentence denotes     Headaches 6 ND ND
T73 6690-6716 Sentence denotes     Sore throat 2 ND ND
T74 6717-6743 Sentence denotes     Rhinorrhoea 2 ND ND
T75 6744-6778 Sentence denotes     Shortness of breath 2 ND ND
T76 6779-6847 Sentence denotes Mean days from onset to hospitalisation(29 cases) 3.7 4.6 2.5 ND
T77 6848-6931 Sentence denotes Mean days from onset to first positive laboratory test(16 cases) 5.1 6.5 5.2 ND
T78 6932-7001 Sentence denotes COVID-19: coronavirus disease 2019; ND: not determined or known; WHO:
T79 7002-7028 Sentence denotes World Health Organization.
T80 7029-7100 Sentence denotes a The Table does not include nine cases reported in the United Kingdom.
T81 7101-7213 Sentence denotes b Chi-squared test for difference in distributions between cases infected in Europe and those infected in China.
T82 7214-7263 Sentence denotes c A single case could have more than one symptom.
T83 7264-7314 Sentence denotes Only symptoms reported by two or more cases shown.
T84 7315-7523 Sentence denotes 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.
T85 7524-7668 Sentence denotes 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).
T86 7669-7798 Sentence denotes 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.
T87 7799-7907 Sentence denotes This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany.
T88 7908-8096 Sentence denotes 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.
T89 8097-8159 Sentence denotes Symptoms at the point of diagnosis were reported for 31 cases.
T90 8160-8226 Sentence denotes Two cases were asymptomatic and remained so until tested negative.
T91 8227-8346 Sentence denotes The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively.
T92 8347-8433 Sentence denotes Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness.
T93 8434-8594 Sentence denotes Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1).
T94 8595-8649 Sentence denotes Fever was reported as the sole symptom for nine cases.
T95 8650-8895 Sentence denotes 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.
T96 8896-9071 Sentence denotes 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.
T97 9072-9154 Sentence denotes No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases.
T98 9155-9311 Sentence denotes 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.
T99 9312-9449 Sentence denotes All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died.
T100 9450-9564 Sentence denotes The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days.
T101 9565-9655 Sentence denotes The duration of hospitalisation was reported for 16 cases with a median of 13 days (range:
T102 9656-9667 Sentence denotes 8–23 days).
T103 9668-9727 Sentence denotes As at 21 February 2020, four cases were still hospitalised.
T104 9729-9749 Sentence denotes Laboratory diagnosis
T105 9750-9977 Sentence denotes 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].
T106 9978-10031 Sentence denotes The specimen types tested were reported for 27 cases:
T107 10032-10255 Sentence denotes 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.
T108 10257-10267 Sentence denotes Discussion
T109 10268-10362 Sentence denotes As at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia.
T110 10363-10542 Sentence denotes 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].
T111 10543-10666 Sentence denotes As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region [19].
T112 10667-10892 Sentence denotes 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).
T113 10893-11054 Sentence denotes 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.
T114 11055-11334 Sentence denotes 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.
T115 11335-11607 Sentence denotes 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].
T116 11608-11791 Sentence denotes 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.
T117 11792-12042 Sentence denotes 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.
T118 12043-12343 Sentence denotes 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.
T119 12344-12403 Sentence denotes All of the imported cases had a history of travel to China.
T120 12404-12632 Sentence denotes 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.
T121 12633-12863 Sentence denotes 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].
T122 12864-13231 Sentence denotes 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].
T123 13232-13332 Sentence denotes The clinical presentation observed in the cases in Europe is that of an acute respiratory infection.
T124 13333-13481 Sentence denotes 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.
T125 13482-13675 Sentence denotes 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.
T126 13676-13715 Sentence denotes Three cases were aged 65 years or over.
T127 13716-13792 Sentence denotes All required admission to intensive care and were tourists (imported cases).
T128 13793-14068 Sentence denotes 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.
T129 14069-14307 Sentence denotes 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].
T130 14308-14416 Sentence denotes This preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region.
T131 14417-14552 Sentence denotes Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution.
T132 14553-14835 Sentence denotes 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].
T133 14836-14963 Sentence denotes Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population.
T134 14964-15053 Sentence denotes Serological studies are vital to understand the proportion of cases who are asymptomatic.
T135 15054-15181 Sentence denotes Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death.
T136 15182-15318 Sentence denotes Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose.
T137 15319-15530 Sentence denotes 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.
T138 15531-15786 Sentence denotes 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.
T139 15787-16053 Sentence denotes 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.
T140 16054-16290 Sentence denotes 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.
T141 16291-16443 Sentence denotes Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level.
T142 16445-16461 Sentence denotes Acknowledgements
T143 16462-16779 Sentence denotes 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.
T144 16780-16963 Sentence denotes 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.
T145 16964-17073 Sentence denotes We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea.
T146 17074-17186 Sentence denotes ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19.
T147 17187-17330 Sentence denotes WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management.
T148 17331-17349 Sentence denotes Funding statement:
T149 17350-17370 Sentence denotes No specific funding.
T150 17371-17575 Sentence denotes 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.
T151 17577-17598 Sentence denotes Conflict of interest:
T152 17599-17613 Sentence denotes None declared.
T153 17614-17705 Sentence denotes Authors’ contributions: EB and BC developed the surveillance system and reporting protocol.
T154 17706-17794 Sentence denotes GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript.
T155 17795-17821 Sentence denotes GS performed the analysis.
T156 17822-17885 Sentence denotes GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript.
T157 17886-17974 Sentence denotes JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript.
T158 17975-18275 Sentence denotes 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.
T159 18276-18392 Sentence denotes All authors provided input to the outline, multiple versions of the manuscript and gave approval to the final draft.