Skip to main content
NCBI home page
The European Journal of Public Health logoLink to The European Journal of Public Health
. 2024 Feb 7;34(2):402–410. doi: 10.1093/eurpub/ckad224

Primary care indicators for disease burden, monitoring and surveillance of COVID-19 in 31 European countries: Eurodata Study

Sara Ares-Blanco 1, Marina Guisado-Clavero 2, Lourdes Ramos Del Rio 3, Ileana Gefaell Larrondo 4, Louise Fitzgerald 5, Liubovė Murauskienė 6, Naldy Parodi López 7, Ábel Perjés 8, Davorina Petek 9, Ferdinando Petrazzuoli 10, Goranka Petricek 11, Martin Sattler 12, Natalija Saurek-Aleksandrovska 13, Oliver Senn 14, Bohumil Seifert 15, Alice Serafini 16, Theresa Sentker 17, Gunta Ticmane 18, Paula Tiili 19, Péter Torzsa 20, Kirsi Valtonen 21, Bert Vaes 22, Shlomo Vinker 23, Limor Adler 24, Radost Assenova 25, Maria Bakola 26, Sabine Bayen 27, Elena Brutskaya-Stempkovskaya 28, Iliana-Carmen Busneag 29, Asja Ćosić Divjak 30, Maryher Delphin Peña 31, Esperanza Díaz 32, Philippe-Richard Domeyer 33, Sabine Feldmane 34, Dragan Gjorgjievski 35, Mila Gómez-Johansson 36, Ángel Gónzalez de la Fuente 37, Miroslav Hanževački 38, Kathryn Hoffmann 39, Оксана Ільков 40, Shushman Ivanna 41, Marijana Jandrić-Kočić 42, Vasilis Trifon Karathanos 43, Erva Kirkoç Üçüncü 44, Aleksandar Kirkovski 45, Snežana Knežević 46, Büsra Çimen Korkmaz 47, Milena Kostić 48, Anna Krztoń-Królewiecka 49, Liga Kozlovska 50, Katarzyna Nessler 51, Raquel Gómez-Bravo 52, María Pilar Astier Peña 53, Heidrun Lingner 54,✉
PMCID: PMC10990533  PMID: 38326993

Abstract

Background

During the COVID-19 pandemic, the majority of patients received ambulatory treatment, highlighting the importance of primary health care (PHC). However, there is limited knowledge regarding PHC workload in Europe during this period. The utilization of COVID-19 PHC indicators could facilitate the efficient monitoring and coordination of the pandemic response. The objective of this study is to describe PHC indicators for disease surveillance and monitoring of COVID-19’s impact in Europe.

Methods

Descriptive, cross-sectional study employing data obtained through a semi-structured ad hoc questionnaire, which was collectively agreed upon by all participants. The study encompasses PHC settings in 31 European countries from March 2020 to August 2021. Key-informants from each country answered the questionnaire. Main outcome: the identification of any indicator used to describe PHC COVID-19 activity.

Results

Out of the 31 countries surveyed, data on PHC information were obtained from 14. The principal indicators were: total number of cases within PHC (Belarus, Cyprus, Italy, Romania and Spain), number of follow-up cases (Croatia, Cyprus, Finland, Spain and Turkey), GP’s COVID-19 tests referrals (Poland), proportion of COVID-19 cases among respiratory illnesses consultations (Norway and France), sick leaves issued by GPs (Romania and Spain) and examination and complementary tests (Cyprus). All COVID-19 cases were attended in PHC in Belarus and Italy.

Conclusions

The COVID-19 pandemic exposes a crucial deficiency in preparedness for infectious diseases in European health systems highlighting the inconsistent recording of indicators within PHC organizations. PHC standardized indicators and public data accessibility are urgently needed, conforming the foundation for an effective European-level health services response framework against future pandemics.

Introduction

During the initial 18 months of the pandemic, Europe documented a total of 69 279 273 confirmed COVID-19 cases as of 30 August 2021.1 In March 2020, the European Centre for Disease Prevention and Control (ECDC) recommended the rapid detection of cases and monitoring the spread of SARS-CoV-2 infection.2 To effectively combat to the pandemic, the ECDC developed a contingency plan encompassing primary health care (PHC), hospital settings and long-term facilities.3 PHC, characterized by first-contact, accessible, continuous, comprehensive and coordinated person-centred care, played a pivotal role.4 It served as the primary point of contact and was responsible for the initial examinations, follow-up, and complementary testing for COVID-19 patients in numerous European countries.5,6 The ECDC’s also involved establishing dedicated hotlines to separate COVID-19 consultations from other healthcare services, recognizing PHC’s critical role in alleviating the burden on hospitals and providing medical care for patients with other conditions. PHC bore a substantial share of the COVID-19 workload,4 with <10% of all COVID-19 cases requiring hospitalization in Europe7 and 14% in America.8 These figures improved with the availability of vaccines.9

Despite the immense strain on the entire healthcare system, the World Health Organization (WHO) concentrated solely on monitoring the pandemic by collecting daily data on case and death numbers.1 Furthermore, the ECDC incorporated indicators like the count of hospitalized cases and admissions to intensive care units (ICUs).10 In collaboration with the European Commission and other institutions, the European Observatory of Health Systems and Policies developed the COVID-19 Health System Response Monitor to track Europe’s response to the pandemic.11 Within this initiative, the Observatory qualitatively described PHC’s role in 38 of the 51 member countries. However, as of now, there are no available reports from European health institutions on the activity of COVID-19 in PHC, specifically regarding the total number of COVID-19 patients attended to in the community. These data are crucial not only for resource allocation to address COVID-19 patients in PHC but also because of its influence on the diagnosis and management of other conditions, including chronic diseases and early cancer detection.12–14

Within the European Union, there are two primary sources of information concerning the COVID-19 pandemic. Firstly, the European Surveillance System (TESSy) reports the total number of COVID-19 cases and the percentage of hospitalized patients.15 It also provides data on the percentage of cases classified as severe and those requiring ventilatory support in ICUs.16 More recently, EpiPulse was launched to integrate several previously independent surveillance systems,17 including the TESSy, the five Epidemic Intelligence Information System platforms, and the Threat Tracking Tool. This platform offers new functionalities and seamless data access through a single platform. However, it currently does not include COVID-19 data from PHC at the European level. To prepare for future waves of COVID-19 or emerging pandemics, it is imperative to understand what information has been gathered and published regarding the care of COVID-19 patients in PHC. Therefore, this study aims to describe the existing national indicators and potential indicators for disease surveillance and monitoring the disease burden of COVID-19 in PHC in Europe. Additionally, the study seeks to evaluate the availability of fundamental indicators as open data in each country.

Methods

Study design and setting

This retrospective descriptive study used a semi-structured questionnaire to collect data from 31 European countries spanning from the 12th epidemiological week (15 March 2020) to the 43th epidemiological week (31 August 2021). This research is an integral part of the Eurodata study, whose primary objective is to investigate the role of PHC during the COVID-19 pandemic in Europe.5,18

Participants

This study involved the following countries: Austria, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Cyprus, Finland, France, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Luxembourg, North Macedonia, Norway, Poland, Romania, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine and UK. All participants were required to have actively engaged in or been associated with COVID-19 response efforts in their respective countries during the pandemic. They were health professionals proficient in English and served as lead researchers in their respective countries. The majority of participants worked in general practice, except for those from Lithuania, who were involved in Public Health during the study period. Recruitment of key-informants was carried out through an open invitation within the European General Practice Research Network working group and the World Organization of Family Doctors in Europe.

Data collection

Variables to be collected:

  • Main outcome: The primary objective was to identify national or regional indicators describing disease surveillance and disease burden within PHC during the pandemic in the participating countries. COVID-19 disease surveillance indicators included: COVID-19 testing and the total number of COVID-19 cases reported in PHC. Disease burden indicators in PHC included: COVID-19 advice provided, surveillance of COVID-19 patients isolating at home, consultations with a general practitioner (GP) or other PHC professionals for COVID-19 related concerns, the total number of chest X-rays and blood test performed on COVID-19 patients, the total number of COVID-19 patients requiring follow-up through in-person or remote assessments in PHC, as well as other relevant indicators.

  • Secondary outcomes: Secondary outcomes encompassed various aspects, including the first point of contact within the health system (PHC, hospital, Accident & Emergency department, Public Health), the total number of people infected by SARS-CoV-2, hospitalizations, ICU admissions, deaths and the proportion of COVID-1 cases within PHC from as a percentage of the national total. Additionally, the study also assessed aspects, such as COVID-19 as a notifiable disease, the presence of a COVID-19 hotline, coding system within PHC and demographic information, such as gender and age distribution among individuals infected by SARS-CoV-2. Definitions of these terms can be found in Supplementary file S1.

Data collection instruments

To collect all the necessary data, a comprehensive questionnaire was developed (Supplementary file S2). The questionnaire was constructed based on the open data provided by the ECDC19 and WHO,1 supplemented by open-ended questions aimed at capturing regarding PHC-specific indicators.

Data were gathered from official sources (Supplementary file S3) and a peer-review of the national data and the international findings was conducted. At least two key-informants from each country were responsible for validation of the national data before submission to the core research team. The research team subsequently conducted a peer-review of all the submitted data, assessing potential bias and inconsistencies. In case of unclear data, key-informants were contacted to provided further details to complete the initial dataset. Any disagreements or discrepancies were thoroughly discussed and resolved among within the core research team and with the input of key-informants.5

Results

In this study, it was observed that COVID-19 was categorized as a notifiable disease in all countries included in this study. Every participant confirmed that their respective nations openly reported the cumulative count of COVID-19 cases and fatalities, which can be found in table 1 and graphically represented in figure 1. Furthermore, data stratified by gender and age range were accessible in 26 countries, and Norway went a step further by offering data on the number of migrants affected by COVID-19. Hospitalization information was accessible for 25 countries, while data on ICU admissions were also available for 25 countries. Notably, a few countries updated this information on a daily basis.

Table 1.

Description of the first-contact with the health system, the coding system in PHC and general COVID-19 indicators in 31 European countries. The data spans from 1 March 2020 (12th epidemiological week) to 31 August 2021 (43th epidemiological week)

Country Patient’s first contact with health system Coding classification in PHC Total cases Information regarding sex in total cases Information regarding age range in total cases Total hospitalized cases Number of ICU patients Total deaths
Austria GP/Hotline No codinga 684 962 Yes Yes Daily Daily 10 772
Belarus GP ICD-10 48 505 Not available Not available Not available Not available 3780
Belgium GP/A&E ICD-10/ICPC-2/Thesaurus 3BT 1 178 646 Yes Yes 77 177 13 055 25 525
Bosnia and Herzegovina GP/Hotline ICD-10 156 031 Yes Yes Daily Daily 8195
Bulgaria GP/A&E ICD-10 453 689 Not available Yes 3594 301 18 840
Croatia GP/paediatrician/PH/A&E/Hotline ICD-10 373 348 Yes Yes 31 645 Not available 8329
Czech Republic PHC ICD-10 1 666 125 Yes Yes Daily Daily 30 506
Cyprus GP ICD-10 215 208 Yes Yes 8452 954 871
Finland PHC/private sector/App ICD-10/ICPC-2 131 059 Yes Yes 4629 935 1062
France GP/Hotline CISP 6 765 708 Yes Yes 460 000 94 000 116 000
Germany GP/Hotline ICD-10 3 842 856 Yes Yes 282 785 Dailyc 92 200
Greece PHC/Hotline ICD-10 587 964 Yes Yes 87 781 8532 13 691
Hungary PHC ICD-10 812 305 No No No No 30 058
Ireland PHC, hospital ICD-10 353 789 Yes Yes 16 075 1776 4897
Israel COVID-19 telephone Hotline ICD-9 1 077 780 Yes Yes Daily 20 227b 7135
Italy GP/out of hours ICD-9 4 581 713 Yes Yes 50 399 3377 129 070
Latvia GP/A&E ICD-10 142 611 Yes Yes Not availabled Not availablee 3471
Lithuania PHC/telephone Hotline/112 ICD-10 142 244 Yes Yes Weekly Weekly 9250
Luxembourg GP/Hotline/hospital ICD-10 75 760 Yes Yes 4865 673 830
North Macedonia PHC ICD-10 177 399 Yes Yes Daily Daily 5964
Norway PHC ICPC 158 132 Yes Yes 4710 899 880
Poland PHC ICD-10 2 865 673 No No Not available Not available 75 269
Romania PHC/Hotline ICD-10 1 097 268 Yes Yes 2303 280 34 514
Serbia GP ICD-10 762 885 Not available Not available 495 831 26 390 7292
Slovenia PHC/Hotline/PH ICD-10 268 055 Yes Not available 18 517 2954 4450
Spain GP/A&E ICPC-2 4 888 230 Yes Yes 403 128 40 272 86 642
Sweden PHC/Hotline ICD-10 1 126 531 Yes Yes 21 162 7712 14 694
Switzerland GP/Hotline/A&E No codingh 774 516 No Yes Daily Daily 10 491
Turkey PHC, Hotline ICD-10 6 273 356 Yesf Yesf Not available Dailyg 56 710
Ukraine GP ICPC-2 2 286 293 Yes Yes Not available Not available 53 788
UK Phone line or online platform ICD-10 6 076 262 Yes Yes Daily Daily 117 455
Open in a new tab

Notes: A&E, Accident and Emergency Department; GP, general physician; PHC, primary health care, which includes GP, PHC nurses and other ambulatory healthcare professionals; PH, public health; ICU, intensive care unit.

a

Less than 1% of PHC centres (ICPC-2) and outpatient departments of Social Health Insurances (ICD-10) in Austria use a coding classification system.

b

This result includes severe cases (defined as those with a respiratory rate >30 breaths per minute, oxygen saturation at or below 93% and a PaO2/FiO2 < 300) whether they are candidates for ICU admissions or not.

c

Data regarding ICU admission in Germany were recorded and available daily until July 2021, after which cases were counted as total ICU cases.

d

Data on hospitalized patients are accessible from 1 January 2021.

e

These data include both moderate and severe diseases and it is not limited to ICU cases.

f

Sex and range age information is available from March 2020 to October 2020.

g

The information is from severe cases that could potentially require ICU admission, with data available up to 3 July 2021.

h

In Switzerland, systematic coding is not mandatory in ambulatory care, and electronic health record coverage is not 100%.

Figure 1.

Figure 1

Open in a new tab

A TreeMap illustrates COVID-19 cases and the proportion of hospitalized cases, ICU cases and fatalities among the total cases. The data represented are sourced from those countries that shared quantitative information in table 1.

The use of international diseases classification systems by PHC providers was consistent across all countries, except for Austria, where it was primarily voluntary and limited to the internal use within the unit, and Switzerland, where systematic coding was not obligatory (table 1). Among the classification systems employed, ICD-10 was the most widely used, followed by ICD-9 and ICPC-2. Thirteen out of 31 countries gathered primary disease surveillance data that were publicly accessible. However, the majority of countries did not publicly collect information on PHC operations and workload during the pandemic (as shown in figure 2).

Figure 2.

Figure 2

Open in a new tab

Depicts participating countries with and without available COVID-19 data in PHC

Overall, participants identified a total of 40 COVID-19 indicators related to the burden on PHC. The most frequently reported indicator was the total number of cases recorded in PHC, as reported by Belarus, Cyprus, Italy, Romania and Spain. This was followed by the number of patients whose follow-up was coordinated by a PHC provider, as reported by Croatia, Cyprus, Finland, Spain and Turkey. All the PHC indicators can be found in table 2.

Table 2.

COVID-19 indicators in PHC per country from 15 March 2020 (12th epidemiological week) until 31 August 2021 (35th epidemiological week)

Country PHC indicators Result of the indicator Total cases in PHC/total national cases (%)
Belgium Total number of any contacts with GP with ICPC-2 R80 (suspected COVID-19) recorded as reason for the contact. 435 858 Not available
Total number of any contacts with GP with ICPC-2 A77 (confirmed COVID-19) recorded as reason for the contact. 111 526 Not available
Belarusa Total COVID-19 cases in PHC 48 505 100%
Croatia Total number of procedures to patients in PHC with ICD-10 U07.1 (confirmed COVID-19) recorded as reason for procedures 681 415 Not available
Total number of phone consultations to patients with ICD-10 U07.1 or patients close family member (by physician) 480 484 Not available
Total number of consultations with ICD-10 U07.1 recorded as reason for consultation (by physician) 27 853 Not available
Total number of first visits (examinations) with ICD-10 U07.1 recorded as reason for the visit (by physician) 46 777 Not available
Total number of control visits (examinations) with ICD-10 U07.1 recorded as reason for the visit (by physician) 90 698 Not available
Total number of first home visits with ICD-10 U07.1 recorded as reason for home visit (by physician) 1797 Not available
Total number of control home visits with ICD-10 U07.1 recorded as reason for home visit (by physician) 1474 Not available
Total number of home care with ICD-10 U07.1 recorded as reason for home care (by physician) 305 Not available
Total number of telephone consultations with ICD-10 U07.1 recorded as reason for consultation (by nurse) 31 939 Not available
Total number of the first home visits with ICD-10 U07.1 recorded as reason for home visit (by nurse) 62 Not available
Total number of control home visit with ICD-10 U07.1 recorded as reason for home visit (by nurse) 26 Not available
Cyprus Total COVID-19 cases in PHC 61 093 28.38%
  Total number of suspicious patients who were checked in PHC (symptoms and COVID-19 testing) 81 881 Not available
  Total number of patients who were follow-up in PHC 58 469 Not available
  Total number of patients who were examined in PHC (X-ray or/and phlebotomy) 26 855 Not available
Finland Total number of contacts to PHC with ICPC-2 R83 recorded as reason for the contact. 1 263 626 Not available
Total number of any contacts with GP with ICD-10 U07.1 recorded as reason for the contact. 100 274 Not available
  Total number of face-to-face visits to GP with ICD-10 U07.1 recorded as reason for the visit. 7927 Not available
  Total of COVID-19 patients in primary care hospital units per day (reported separately from specialized care hospitalization from 7 December 2020, range: 1–147) Mean 42, SD 28, median 33
France Total of number of home care visits of COVID-19 suspicious cases by GPb 72 395 Not available
Description of confirmed cases of COVID-19 seen in general practicec Weekly basis Not available
Positivity rates to SARS-CoV-2 (Covid-19) among all the respiratory infections by the Sentinelles networkc Weekly basis Not available
Estimated incidence of COVID-19 cases per 100 000 population with respiratory signs observed in general practice through the Sentinelles networkc Weekly basis Not available
Italya Total COVID-19 cases in PHC 4 531 314 98.89%
  Sex of total cases in PHC (males/female) 2 248 428/2 333 266 Not available
  Sex of total deaths in PHC (males/female) 72 900/56 170 Not available
Norway Percentage of cases of COVID-19 among all respiratory infection cases in PHC Weekly basis Not available
Percentage of PHC consultations with the diagnosis codes COVID-19 (confirmed), COVID-19 (suspicious) and microbiological/immunological test for all age groups Weekly basis Not available
Poland Total number of COVID-19 test referrals issued by GPs 4 163 966 Not available
Percentage of test referrals issued by GPs/total number of all tests performed 70.5% Not available
Romania Total cases in PHC 1 087 100 99.07%
Total number of sick leaves processed by GPs of patients in quarantine 53 200 Not available
Total number of sick leaves processed by GPs of COVID-19 patients in isolation 45 432 Not available
Spain Total number of sick leaves processed by GPs of patients in quarantined 2 536 717 Not available
Total number of sick leaves processed by GPs of COVID-19 patients in isolationd 1 233 081 Not available
Total cases in PHC (Castilla-León region) 359 555 Not available
  Cumulative incidence in PHC (Castilla-León region) 38 027 Not available
  COVID-19 rate per 100 000 inhabitants in PHC (Castilla-León region) 15 847.9 Not available
  Total number of active cases at PHC (Castilla-León region) Daily basis Not available
  Percentage of daily increase in COVID-19 cases in PHC (Castilla-León region) Daily basis Not available
  Incidence by age groups and sex in PHC (Castilla-León region) Available Not available
  COVID-19 rate per 100 000 inhabitants by age groups in PHC (Castilla-León region) Available Not available
  Total number of daily follow-up of COVID-19 cases in PHC (Madrid region, from 22 April 2020) 950 277 Not available
  Total number of daily follow-up of COVID-19 cases in PHC (Navarra region, from 27 March 2020) 185 302 Not available
  Total number of active cases at home in PHC (Canary Islands region and Murcia region) Daily basis Not available
Switzerland Number of suspected COVID-19 contacts 21 962f Not available
UK Seven-day GP consultation rate per 100 000 population of suspected Coronavirus cases (Wales) Daily basis Not available
Number and rate of suspected Coronavirus per 100 000 of GP consultations per week (Wales) Weekly basis Not available
Turkeye Total number of family medicine follow-up ratio: follow-up ratio of cases and contacts whose quarantine process and home follow-up continues 89.53% Not available
Open in a new tab

Notes: PHC, primary health care; ICD-10 U07.1 and ICPC-2 R83, codes that correspond to COVID-19 disease for the Finnish Institute for health and Welfare.

a

All COVID-19 cases are firstly attended in PHC to receive any medical care.

b

This information corresponds to GPs who are part of the ‘SOS médecins’ network.

c

The Sentinelles network comprises sentinel GPs and paediatricians that report the number of cases of acute respiratory infection (ARI) seen in consultation (or teleconsultation), according to the following definition: sudden onset of fever (or feeling of fever), and respiratory signs. For each reported case of ARI, descriptive data are collected, including the results of antigenic or PCR tests for COVID-19.

d

Data are available till 11 March 2021.

e

Data corresponding to October 2020.

f

PHC variables result from the Sentinala Surveillance system consisting of a GP network of 160–180 participants who transferred on a voluntary basis their number of first contacts.

The burden of suspected cases in PHC was described using suggested indicators in Belgium, Cyprus, Finland, France, Switzerland and UK. UK proposed measuring the workload of COVID-19 cases in PHC by calculating the number of suspected cases per 100 000 of all GP consultations. Norway recommended reporting the percentage of COVID-19 cases (including suspected and confirmed cases) among all PHC consultations. Croatia proposed 11 indicators to describe the type of contact between PHC personnel and COVID-19 patients. Finland suggested using the number of face-to-face appointments with GPs as an indicator of the COVID-19 burden on PHC. Additionally, Croatia reported the number of patient examinations, and Cyprus reported the number of supplementary tests conducted in PHC. Information from sick leaves issued by GPs was recorded in Romania and Spain. The PHC variables derived from the Sentinelle Surveillance system in Switzerland consisted of a network of 160–180 GPs who voluntary reported the number of initial contacts (including practice and house visits) with patients suspected of having COVID-19. The Sentinelle GP network in France collected information on the positivity rates of SARS-CoV-2 among all respiratory infections, as well as the estimated incidence of COVID-19 cases per 100 000 populations with respiratory symptoms observed.

Discussion

In this cross-sectional study involving 31 participating countries, it was found that 14 of them made their COVID-19-related PHC data accessible to the public. The indicators used to describe this burden varied considerably across countries. The most frequently recorded indicators were the total number of COVID-19 cases in PHC, followed by the number of follow-up cases in PHC. Additional indicators included the number of COVID-19 tests administered, the number of sick leaves issued by GPs and the count of consultations or complementary tests in PHC. Surprisingly, the percentage of COVID-19 cases among all GP consultations was rarely documented. Furthermore, some countries did not provide information regarding hospitalization and ICU admissions. On a more positive note, the majority of countries shared disaggregated data by age and gender, providing a more comprehensive insight into the impact of COVID-19 on diverse demographic groups.

Historically, public health surveillance primarily concentrated on enumeration of cases and fatalities. As the field evolved, it incorporated supplementary information, such as data on health service delivery, to enhance the quality response plans.20 This study aimed to analyze national data to delineate key COVID-19 indicators in PHC, encompassing total cases, demographic breakdowns, hospitalizations, ICU admissions and total fatalities. However, only 2 out of the countries included in the study collected all these indicators at the national level. While most countries adhered to common indicators for essential data, crucial agencies, such as the ECDC and the WHO, did not publicly release a standardized minimum COVID-19 surveillance datasets to be reported as open data.21,22 For instance, the ECDC does not require the collection of sex as a mandatory dataset. Additionally, the accessibility of cumulative data as an open data resource proved to be challenging during the study period. Transparent data sharing is indispensable for an integrated pandemic response and research, as fragmented data hinder policy comparison and the identification of disease and mortality patterns.23 Several reasons have been given to explain the limited data available, including insufficient investment in local public health surveillance,24 a lack of interoperable public health data25 and time-oriented metrics for sharing information with the public.26 Remedial efforts are warranted to address these issues and enhance data quality in Europe. Notably, the European Commission has proposed a Regulation on a European Health Data Space to address some of these concerns.27

The acquisition of PHC data for COVID-19 in 14 countries represents a significant advancement, enabling a better understanding of healthcare delivery during the pandemic in Europe.28 The use of coding systems in PHC played a crucial role in obtaining this information, with Austria and Switzerland being the only exception to their widespread application. Measuring the impact of the COVID-19 pandemic on PHC workloads is undeniably crucial. Such data can contribute to the prediction of trends in hospitalization and ICU admissions, providing an average lead time of 2 days.29 This would provide more time for efficient proactive planning to ensure the availability of sufficient beds in secondary care or other healthcare facilities. Beyond that, the implications for long-term care facilities, as highlighted in this project, should not be disregarded and defining the workload is beneficial for all the professionals involved.18 It is essential to establish standardized indicators to predict the impact on regular healthcare services. Furthermore, the provision of regular care is compromised when PHC practitioners are attending to and following up on COVID-19 patients as the availability of appointments may be reduced due to high demand29 and the quality of care for chronic conditions and cancer screening can suffer negative consequences.12,14 A study involving moderate and severe COVID-19 cases revealed that these patients required an average of 12 follow-up phone calls from PHC professionals during the 6 months following their infection.31 The long-term workload implications in PHC for cases of long COVID remain unknown. Specific indicators for PHC would be instrumental to understand the healthcare system workloads, motivating the allocation of resources and garnering the attention of policy makers.

The heterogeneity of PHC indicators in our study highlights the challenge of quantifying the events that occurred in PHC during the pandemic. Various methods have been proposed to measure the pandemic’s impact on PHC. While the WHO has introduced 20 indicators to monitor healthcare capacity and utilization, specifically designed to aid decision-making during the pandemic,32 there is currently a lack of indicators focused on monitoring COVID-19 activity in PHC. The only significant indicator available is the total number of COVID-19 outpatient consultations on a monthly basis, which contributes to understanding the pandemic’s impact on essential health services. It is noteworthy that the indicators provided by the Center for Disease Control and Prevention for monitoring COVID-19 community levels and making public health recommendations primarily rely on hospital-related indicators, neglecting to incorporate PHC activity indicators.33 In Australia, an initiative to develop new information systems, including primary care data, has been launched but has yet to provide public data.34

Upon analyzing the collated European PHC COVID-19 indicators, we observed various viewpoints: the total number of patients, the total number of contacts with PHC and the total number of procedures (tests, blood tests, chest X-rays and sick leaves). Each dataset provides a different perspective that aids in better understanding the high workload experienced by PHC during the pandemic. In our opinion, future disease surveillance efforts would greatly benefit from the establishment of a dashboard incorporating new indicators to monitor not only the pandemic but also the COVID-19 workload in PHC. A promising step would be the tracking of the total number of COVID-19 cases in PHC.

In this study, we observed that some countries documented the number of contacts with suspected cases. These cases are significant as they prompt individuals to seek contact with a PHC professional, as they can be mistaken for other respiratory illnesses. Consequently, this leads to a higher number of additional appointments and presents limitations as a COVID-19 surveillance technique. Merely counting suspected cases does not offer a clear insight into the interactions between COVID-19 patients and PHC personnel, as these interactions may also be due to other respiratory illnesses. Nevertheless, variations in the frequency of contacts with PHC can offer insights into the pandemic and its impact on PHC. Norway and UK have adopted an approach that includes sharing not only COVID-19 data but also the percentage of COVID-19 cases among all respiratory infections and the GP consultation rate per 100 000 population, which might serve as a more precise indicator for understanding the COVID-19 pandemic’s impact on regular PHC workloads.

The inclusion of PHC discharges as an indicator was suggested but not collected by any of the countries in the study,35 rendering of limited utility. In this study, a variety of PHC indicators were identified, encompassing the total number of patients, contacts or procedures performed in PHC. Each dataset provides a different perspective that aids in better understanding the high workload in PHC during the pandemic. Norway and UK’s approach, which includes sharing the percentage of COVID-19 cases among all respiratory infections and the GP consultation rate per 100 000 population, could serve as a more precise indicator for understanding the impact of COVID-19 on the regular PHC workloads. A comparative analysis of the total number of patients with hospitalized cases can help identifying which healthcare facilities requires reinforcement in response according to pandemic waves. Monitoring COVID-19 test referrals issued by GPs or the total number of tests performed can also serve as valuable indicators for PHC surveillance, as exemplified by Croatia. Tracking the total number of procedures in PHC, alongside data pertaining on specific procedures, can provide a comprehensive indicator of the overall workload in PHC. The Sentinelle GP network in France and Switzerland have established open data system, although it may not comprehensively represent virus circulation in the broader community, only among those who consult with their GP.36,37 The establishment of a dashboard with new indicators could facilitate the monitoring of the pandemic and the COVID-19 workload in PHC.

Strengths and limitations

This study offers a significant contribution by being the first to describe COVID-19 indicators in PHC across Europe and analyze them. Furthermore, it provides insights into the availability of general COVID-19 surveillance data in 31 European countries. Nonetheless, certain limitations must be acknowledged. These include a reliance on raw data, which may necessitate adjustments based on population segments. The use of information collected from key-informants introduces the potential for bias. It is worth noting that, during the initial stages of the pandemic, many countries lacked testing capabilities, leading to an underestimation of COVID-19 cases. Moreover, testing policies varied among countries. The study's findings should be interpreted considering these limitations.

Implications for research and/or practice

To improve disease surveillance and the monitoring of PHC services burdens, more efforts are required to ensure the availability of open data concerning disease surveillance indicators, including those related to PHC. The mandatory implementation of disease coding systems in PHC, along with systematic data collection and recording, can facilitate the utilization of data for disease surveillance. Standardized minimum indicators should be agreed upon and embraced at both national and international levels. Consensus on defining PHC indicators should be achieved through a Delphi study. Investing in robust PHC information systems is crucial to identify weaknesses in the healthcare system and proposing strategies for better coordination among PHC hospitals, and public health.

Conclusions

The COVID-19 pandemic has revealed a critical gap in our preparedness for infectious disease outbreaks: the lack of consistent surveillance and workload indicators recording in PHC systems across European countries. This study underscores the pressing need for a standardized minimum set of infectious disease indicators to be implemented in PHC across all European nations. Furthermore, the importance of making these data accessible to the public cannot be overemphasized. These measures are essential for the development of an effective European-level response plan, providing a crucial framework for managing future pandemics while ensuring continuity of regular healthcare services.

Supplementary Material

ckad224_Supplementary_Data
ckad224_supplementary_data.docx (34.1KB, docx)

Acknowledgements

We would like to express our sincere gratitude to the Deutsche Forschungsgemeinschaft (DFG) and to HL for their support, as well as for providing the resources and encouragement to complete this work. The information from Poland was extracted by Michał Rogalski from official sources. He provided the PHC data among other COVID-19 data in his public website. Dr Mossong from the Ministry of Health of Luxembourg extracted the official data from Luxembourg. We want to acknowledge their contributions in this study. Miguel Menéndez helped us to choose the TreeMap to visualize the data, we are grateful for his insight. We would also like to thank all our colleagues for their contributions, feedback and support throughout this research project. Without their valuable participation, it would not have been possible to carry it out, helping us to understand better the context and draw meaningful conclusions.

Contributor Information

Sara Ares-Blanco, Federica Montseny Health Centre, Gerencia Asistencial Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain; Medical Specialties and Public Health, School of Health Sciences, University Rey Juan Carlos, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.

Marina Guisado-Clavero, Investigation Support Multidisciplinary Unit for Primary care and Community North Area of Madrid, Gerencia Asistencial Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain.

Lourdes Ramos Del Rio, Federica Montseny Health Centre, Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain.

Ileana Gefaell Larrondo, Federica Montseny Health Centre, Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain.

Louise Fitzgerald, Member of Irish College of General Practice (MICGP), Member of Royal College of Physician (MRCSI), Dublin, Ireland.

Liubovė Murauskienė, Department of Public Health, Institute of Health Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.

Naldy Parodi López, Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden; Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Ábel Perjés, Department of Family Medicine at the University of Semmelweis, Budapest, Hungary.

Davorina Petek, Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.

Ferdinando Petrazzuoli, Department of Clinical Sciences in Malmö, Centre for Primary Health Care Research, Lund University, Malmö, Sweden.

Goranka Petricek, Department of Family Medicine “Andrija Stampar” School of Public Health, School of Medicine, University of Zagreb, Croatia; Health Centre Zagreb West, Croatia.

Martin Sattler, European Parliament, Luxembourg, Luxembourg.

Natalija Saurek-Aleksandrovska, PZU Femilihelt, Skopje, North Macedonia.

Oliver Senn, Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland.

Bohumil Seifert, Charles University, First Faculty of Medicine, Institute of General Practice, Prague, Czech Republic.

Alice Serafini, Azienda Unità Sanitaria Locale di Modena, Laboratorio EduCare, University of Modena and Reggio Emilia, Modena, Italy.

Theresa Sentker, Center for Public Health and Healthcare, Hannover Medical School, Hannover, Germany.

Gunta Ticmane, Department of Family Medicine at Riga Stradiņš University, Riga, Latvia; Member of the board of the Rural Family Doctors’ Association of Latvia, Latvia.

Paula Tiili, Communicable Diseases and Infection Control Unit, City of Vantaa, Vantaa. University of Helsinki, Helsinki, Finland.

Péter Torzsa, Department of Family Medicine at the University of Semmelweis, Budapest, Hungary.

Kirsi Valtonen, Communicable Diseases and Infection Control Unit, City of Vantaa, Vantaa, Finland.

Bert Vaes, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.

Shlomo Vinker, Department of Family Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. WONCA Europe President, Israel.

Limor Adler, Department of Family Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Radost Assenova, Department Urology and General Practice, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria.

Maria Bakola, Research Unit for General Medicine and Primary Health Care, Faculty of Medicine, School of Health Science, University of Ioannina, Ioannina, Greece.

Sabine Bayen, Department of General Practice, University of Lille, Lille, France.

Elena Brutskaya-Stempkovskaya, General Medicine Department, Belarusian State Medical University, Minsk, Belarus.

Iliana-Carmen Busneag, Kinetic Therapy and Special Motricity, “Spiru Haret” University, Bucharest, Romania.

Asja Ćosić Divjak, Health Centre Zagreb Centar, Zagreb, Croatia.

Maryher Delphin Peña, Department of Geriatric Medicine, Hôpitaux Robert Schuman, Luxembourg, Luxembourg.

Esperanza Díaz, Pandemic Center, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway; Norwegian National Institute of Public Health, Bergen, Norway.

Philippe-Richard Domeyer, School of Social Sciences, Hellenic Open University, Patra, Greece.

Sabine Feldmane, Department of Family Medicine, Rīga Stradins University, Riga, Latvia.

Dragan Gjorgjievski, Center for family medicine, Medical faculty Skopje, Skopje, North Macedonia.

Mila Gómez-Johansson, Närhälsan Sannegården Health Centre, Gothenburg, Sweden.

Ángel Gónzalez de la Fuente, UCL Global Business School for Health, London, UK.

Miroslav Hanževački, Department of Family Medicine “Andrija Stampar” School of Public Health, School of Medicine, University of Zagreb, Croatia; Health Centre Zagreb West, Croatia.

Kathryn Hoffmann, Department of General Practice and Primary Care, Med. University of Vienna, Vienna, Austria.

Оксана Ільков, Department of Family Medicine and Outpatient Care, Medical Faculty 2, Uzhhorod National University, Uzhhorod, Ukraine.

Shushman Ivanna, Department of Family Medicine and Outpatient Care, Medical Faculty 2, Uzhhorod National University, Uzhhorod, Ukraine.

Marijana Jandrić-Kočić, Health center Krupa na Uni, Krupa na Uni,Republic of Srpska, Bosnia and Herzegovina.

Vasilis Trifon Karathanos, Laboratory of Hygiene and Epidemiology, Medical Department, Faculty of Health Sciences, University of Ioannina- Greece; GHS, Larnaca, Cyprus.

Erva Kirkoç Üçüncü, Department of Family Medicine, Prof. Dr Cemil Tascioglu City Hospital, Istanbul, Turkey.

Aleksandar Kirkovski, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, North Macedonia.

Snežana Knežević, Health center Kraljevo, Kraljevo, Serbia.

Büsra Çimen Korkmaz, Van Gürpınar District Public Hospital, Van Gürpınar, Turkey.

Milena Kostić, Health Center “Dr Đorđe Kovačević”, Lazarevac, Belgrade, Serbia.

Anna Krztoń-Królewiecka, Department of Family Medicine, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland.

Liga Kozlovska, Department of Family Medicine of Riga Stradins University, Riga, Latvia; President of the Rural Family Doctors' Association of Latvia.

Katarzyna Nessler, Department of Family Medicine UJCM at Uniwersytet Jagielloński - Collegium Medicum, Kraków, Poland.

Raquel Gómez-Bravo, CHNP, Rehaklinik, Ettelbruck, Luxembourg; Research Group Self-Regulation and Health, Institute for Health and Behaviour, Department of Behavioural and Cognitive Sciences, Faculty of Humanities, Education, and Social Sciences, Luxembourg University, Luxembourg, Luxembourg.

María Pilar Astier Peña, Technical Advisor for Quality and Safety, Territorial Healthcare Quality Unit, Territorial Healthcare Direction of Camp de Tarragona, Healthcare Institut of Catalonia, Health Departament, Generalitat de Catalunya GIBA-IIS-Aragón, Catalunya, Spain; Chair of Patient Safety Working Party of semFYC (Spanish Society for Family and Community Medicine) and Quality and Safety in Family Medicine of WONCA World (Global Family Doctors), Board Member of WONCA World and SECA (Spanish Society for Healthcare Quality), Spain.

Heidrun Lingner, Center for Public Health and Healthcare, Hannover Medical School, Hannover, Germany.

Supplementary data

Supplementary data are available at EURPUB online.

Funding

The Eurodata study was supported by the European General Practice Research Network (EGPRN) Grant [2022/01]. This publication is funded by the Deutsche Forschungsgemeinschaft (DFG) as part of the ‘Open Access Publikationskosten’ program.

Conflicts of interest: None declared.

Data availability

The data underlying this article are available in Supplementary file S3.

Ethics approval

The ethical approval was obtained from the Ethics Committee of the Hospital Universitario La Paz (Madrid, Spain), ID PI-5030. This ethical approval was provided to all the participants. Additional ethical approval according to local laws was needed in Croatia (Ethical approval from the Ethics committee, School of Medicine, University of Zagreb: Ur. Broj: 380-59-10106-22-111/76; Klasa: 641-01/22-02/01).

Key points.

  • Fourteen out of 31 countries gathered PHC data on COVID-19 patients with high heterogeneity among indicators, which difficult comparison among countries.

  • Most of the indicators collected in PHC are related to the number of appointments and follow-ups.

  • There is a need of a common PHC COVID-19 set of indicators in Europe.

References

  • 1. World Health Organization (WHO). WHO Coronavirus (COVID-19) Dashboard. 2023. Available at: https://covid19.who.int (2 June 2023, date last accessed).
  • 2. European Centre for Disease Prevention and Control. Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK—sixth update. Rapid Risk Assessment. 2020.
  • 3. European Centre for Disease Prevention and Control. Guidance for health system contingency planning during widespread transmission of SARS-CoV-2 with high impact on healthcare services. Stockholm: ECDC, 2020. [Google Scholar]
  • 4. WHO. Clinical Services and Systems: Primary Care. 2023. Available at: https://www.who.int/teams/integrated-health-services/clinical-services-and-systems/primary-care (2 June 2023, date last accessed).
  • 5. Ares-Blanco S, Guisado-Clavero MR-D, et al. Clinical pathway of COVID-19 patients in primary health care in 30 European countries: Eurodata study. Eur J Gen Pract 2023;29:2182879. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Mughal DF, Mallen C, McKee M.. The impact of COVID-19 on primary care in Europe. Lancet Reg Health Eur 2021;6:100152. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Lechien JR, Chiesa-Estomba CM, Place S, et al. ; COVID-19 Task Force of YO-IFOS. Clinical and epidemiological characteristics of 1420 European patients with mild-to-moderate coronavirus disease 2019. J Intern Med 2020;288:335–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus disease 2019 case surveillance—United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:759–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Long B, Carius BM, Chavez S, et al. Clinical update on COVID-19 for the emergency clinician: presentation and evaluation. Am J Emerg Med 2022;54:46–57. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. ECDC Europe. COVID-19: Situation Updates. 2021. Available at: https://www.ecdc.europa.eu/en/covid-19 (20 December 2022, date last accessed).
  • 11. European Observatory of Health Systems and Policies. COVID-19 Health System Response Monitor. 2022. Available at: https://eurohealthobservatory.who.int/monitors/hsrm/overview (20 December 2022, date last accessed).
  • 12. Coma E, Mora N, Méndez L, et al. Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia. BMC Fam Pract 2020;21:208. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Qi C, Osborne T, Bailey R, et al. Impact of COVID-19 pandemic on incidence of long-term conditions in Wales: a population data linkage study using primary and secondary care health records. Br J Gen Pract 2023;73:e332–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. Coma E, Guiriguet C, Mora N, et al. Impact of the COVID-19 pandemic and related control measures on cancer diagnosis in Catalonia: a time-series analysis of primary care electronic health records covering about five million people. BMJ Open 2021;11:e047567. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. ECDC. The European Surveillance System (TESSy). 2017. Available at: https://www.ecdc.europa.eu/en/publications-data/european-surveillance-system-tessy (30 May 2023, date last accessed).
  • 16. ECDC. Clinical Characteristics of COVID-19. 2022. Available at: https://www.ecdc.europa.eu/en/covid-19/latest-evidence/clinical#:∼:text=Symptoms are often episodic and,%2C cough%2C and sore throat (30 May 2023, date last accessed).
  • 17. ECDC. EpiPulse—the European surveillance portal for infectious diseases. 2021.
  • 18. Guisado-Clavero M, Ares-Blanco S, Serafini A, et al. The role of primary health care in long-term care facilities during the covid-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study). Prim Heal Care Res Dev 2023;24:e60. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19. ECDC. Surveillance and Disease Data on COVID-19. 2021. Available at: https://www.ecdc.europa.eu/en/covid-19/situation-updates (25 May 2023, date last accessed).
  • 20. Declich S, Carter AO.. Public health surveillance: historical origins, methods and evaluation. Bull World Health Organ 1994;72:285–304. [PMC free article] [PubMed] [Google Scholar]
  • 21. European Centre for Disease Prevention and Control. Strategies for the surveillance of COVID-19. Technical report. 2020. 1–7.
  • 22. World Health Organization (WHO). Global Surveillance for COVID-19 disease caused by human infection with novel coronavirus (COVID-19): interim guidance. Geneva, 2020.
  • 23. Gallo V, Chiodini P, Bruzzese D, et al. Comparing the COVID-19 pandemic in space and over time in Europe, using numbers of deaths, crude rates and adjusted mortality trend ratios. Sci Rep 2021;11:16443. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Kondilis E, Papamichail D, Gallo V, Benos A.. COVID-19 data gaps and lack of transparency undermine pandemic response. J Public Health (Oxf) 2021;43:e307–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Ronquillo JG, Lester WT, Zuckerman DM.. Using informatics to guide public health policy during the COVID-19 pandemic in the USA. J Public Health (Oxf) 2020;42:660–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Ågerfalk PJ, Conboy K, Myers MD.. Information systems in the age of pandemics: COVID-19 and beyond. Eur J Inf Syst 2020;29:203–7. [Google Scholar]
  • 27. European Commission. Proposal for a regulation of the European Parliament and of the Council on the European Health Data Space. COM(2022) 197 Final. 2022. 1–122.
  • 28. Desborough J, Dykgraaf SH, Phillips C, et al. Lessons for the global primary care response to COVID-19: a rapid review of evidence from past epidemics. Fam Pract 2021:38:811–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29. Catala M, Coma E, Alonso S, et al. Risk diagrams based on primary care electronic medical records and linked real-time PCR data to monitor local COVID-19 outbreaks during the summer 2020: a prospective study including 7,671,862 people in Catalonia. Front Public Health 2021;9:693956. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30. Kyle MA, Tipirneni R, Thakore N, et al. Primary care access during the COVID-19 pandemic: a simulated patient study. J Gen Intern Med 2021;36:3766–71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31. Ares-Blanco S, Álvarez MP, Larrondo IG, et al. SARS-CoV-2 pneumonia follow-up and long COVID in primary care: a retrospective observational study in Madrid city. PLoS One 2021;16:e0257604. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32. World Health Organization. Indicators to monitor health-care capacity and utilization for decision-making on COVID-19. 2020. 1–10.
  • 33. Centers for Disease Control and Prevention (CDC). Indicators for monitoring COVID-19 community levels and making public health recommendations. 2022. [PubMed]
  • 34. Australian Institute of Health and Welfare. Primary Health Care Data Development. National Primary Health Care Data Collection. 2022. Available at: https://www.aihw.gov.au/reports-data/health-welfare-services/primary-health-care/primary-health-care-data-development (15 December 2022, date last accessed).
  • 35. Moguerza JM, Perelló Oliver S, Martín de Diego I, et al. Health sufficiency indicators for pandemic monitoring. Int J Environ Res Public Health 2021;18:538. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36. Pullano G, Di Domenico L, Sabbatini CE, et al. Underdetection of cases of COVID-19 in France threatens epidemic control. Nature 2021;590:134–9. [DOI] [PubMed] [Google Scholar]
  • 37. Boëlle P-Y, Souty C, Launay T, et al. Excess cases of influenza-like illnesses synchronous with coronavirus disease (COVID-19) epidemic, France, March 2020. Euro Surveill 2020;25:2000326. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

ckad224_Supplementary_Data
ckad224_supplementary_data.docx (34.1KB, docx)

Data Availability Statement

The data underlying this article are available in Supplementary file S3.

Articles from The European Journal of Public Health are provided here courtesy of Oxford University Press

RESOURCES