- User contributions [en]

Managing Health Care Capacity

2020-04-07T07:31:22Z

80.106.187.46: /* Consequences for action */

This page collects observations, interpretations, and consequences for action about Managing Health Care Capacity during SARS-CoV2 pandemic. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What is already known=

=Italian experience=
==Observations==
* Italian clinicians look back on the first 3 months of the COVID19 epidemic in their country, and conclude that proper preparedness for the next pandemic cannot include investments in health care alone. <ref name="Nacoti2020"/>
*Different recommendations for returning to work for health care workers (7 days after the positive test instead of 14 days as in the rest of the population) due to shortage of staff raises questions

==Analysis and interpretation==
* "What we are painfully learning is that we need experts in public health and epidemics, yet this has not been the focus of decision-makers at the national, regional, and hospital levels. We lack expertise on epidemic conditions, guiding us to adopt special measures to reduce epidemiologically negative behaviors."<ref name="Nacoti2020"/>
* "This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis.3 It requires social scientists, epidemiologists, experts in logistics, psychologists, and social workers. We urgently need humanitarian agencies who recognize the importance of local engagement." <ref name="Nacoti2020"/>
* Infection committees of hospitals do not always follow the recommendations and personnel refuses to return to work earlier than 14 days or with symptoms as it is required.

==Consequences for action==
* In a pandemic, patient-centered care is inadequate and must be replaced by community-centered care. Solutions for Covid-19 are required for the entire population, not only for hospitals. Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals. <ref name="Nacoti2020">Nacoti, M., Ciocca, A., Giupponi, A., Brambillasca, P., Lussana, F., Pisano, M., ... & Longhi, L. (2020). At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. NEJM Catalyst Innovations in Care Delivery, 1(2).</ref>
* better communication on the reasons and the scientific evidence on why recommendations are different for health professionals than the rest of the population.

=References=

Translating Lessons learnt from Past Pandemics

2020-03-26T15:31:21Z

80.106.187.46: /* Analysis and interpretation */

This page collects observations, interpretations, and consequences for action about Translating Lessons Learnt of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here.

=What is already known=
* There are not yet formal 'Lessons learned' this early in the Pandemic

=Keeping Track of the Economic Burden=
==Observations==
* From previous Pandemics, we learned gradually what the burden to society has been.
* Currently, we observe reluctance of leaders to take far-reaching decisions, moving very carefully forward, guided day by day by 'how the situation evolves'.
*Apart from the direct cost from illness and mortality that mainly affects the health sector, there is the indirect cost from "aversion" behaviour (measures taken to prevent
infection). A unique situation in developed countries.
*Different approaches between countries - balance between protection of life and protection of the "economy". Critisism towards those that delay the implementation of measures of social distancing and at the same time critisism towards the implementation of measures that lead to a huge economic burden.

==Analysis and interpretation==
* Far-reaching interventions may be necessary, but difficult to take because the '''costs''' of those decisions are more visible to the leaders than the '''benefits''' that interventions may have.
* Creating evidence of economic costs to society of pandemics, especially in comparison of different interventions (or different time of interventions), will be very helpful in training leaders to be prepared for future challenges

==Consequences for action==
* Collect materials for a case study on economic costs of the pandemic

=References=

Epidemiology

2020-03-25T19:42:17Z

80.106.187.46: /* What is already known */

This page collects observations, interpretations, and consequences for action about the epidemiology of SARS-CoV2 in general. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What is already known=
* Coronavirus disease (COVID-19) is caused by SARS-COV2 and is a potentially fatal disease <ref name="Rothan2020">Rothan, Hussin A., and Siddappa N. Byrareddy. "The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak." Journal of Autoimmunity (2020): 102433.</ref> that is designated a PHEIC by WHO <Ref name="WHO-PHEIC">Emergency committee regarding the outbreak of novel coronavirus(2019-ncov) https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)</ref>.
===Symptoms===
* The predominant symptoms in laboratory-confirmed cases is fever (88%) and dry cough (68%), followed by fatigue (38%), sputum production (33%), dyspnoea (19%), sore throat (14%), headache (14%) and myalgia or arthralgia (15%). Less common symptoms are diarrhoea (4%) and vomiting (5%).<Ref name="ECDCRRA12032020">ECDC Rapid risk assessment: Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – [https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-update-Outbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf sixth update]. </ref>
* About 80% of reported cases in China had mild to moderate disease (including non-pneumonia and pneumonia cases), 13.8% had severe disease and 6.1% were critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). Current estimates suggest a median incubation period from five to six days for COVID-19, with a range from one to up to 14 days. <Ref name="ECDCRRA12032020"/>
* Italy reports consistently between 9% and 11% of the symptomatic cases to require intensive care treatment.<Ref name="Remuzzi">COVID19 and Italy: what next? Remuzzi. Lancet, March 13 2020</ref>
===Case fatality===
* Reliable estimates for case fatality for COVID-19 are still lacking and biased. Based on a large dataset from cases in China, the overall case-fatality risk (CFR) among laboratory-confirmed cases was higher in the early stages of the outbreak (17.3% for cases with symptom onset from 1-10 January) and has reduced over time to 0.7% for patients with symptom onset after 1 February. In data on diagnosed COVID-19 cases in China, Italy and South Korea, overall CFR was 2.3%, 2.8% and 0.5%, respectively, and increased with age in all settings, with the highest CFR among people over 80 years of age (14.8%, 8.2% and 3.7%, respectively).<Ref name="ECDCRRA12032020"/>

===Viral shedding===
* Over the course of the infection, the virus has been identified in respiratory tract specimens 1-2 days before the onset of symptoms and it can persist for 7-12 days in moderate cases and up to 2 weeks in severe cases. <Ref name="ECDCRRA12032020"/>
* In faeces, viral RNA has been detected from day 5 after onset and up to 4 to 5 weeks in moderate cases. <Ref name="ECDCRRA12032020"/>
* SARS-CoV2 has been detected also in whole blood, serum, saliva and urine. <Ref name="ECDCRRA12032020"/>
* Prolonged viral RNA shedding has been reported from nasopharyngeal swabs, up to 37 days among adult patients and in faeces, for more than one month after infection in paediatric patients. <Ref name="ECDCRRA12032020"/>
===Basic reproduction number (R0)===
* The current estimates of the basic reproductive number R0 are between 2 and 3 in settings from China and during the early stage of an outbreak on a cruise ship. <Ref name="ECDCRRA12032020"/>
===Asymptomatic Infections===
* Based on Chinese data, the international WHO mission report indicates that up to 75% of initially asymptomatic cases will progress to clinical disease, making the true asymptomatic infection rather rare (estimated at 1-3%). <Ref name="ECDCRRA12032020"/>
** The virus has been detected in asymptomatic persons. On a rapidly evolving cruise ship outbreak, where most of the passengers and staff were tested irrespective of symptoms, 51% of the laboratory-confirmed cases were asymptomatic at the time of confirmation. In Italy, 44% of the laboratory-confirmed cases have been asymptomatic. In Japan, 0.06% of reported cases have been asymptomatic. These proportions based on nationally notified cases likely reflect laboratory testing algorithms rather than true estimates of asymptomatic infections. <Ref name="ECDCRRA12032020"/>
** Both viral RNA and infectious virus particles were detected in throat swabs from two German citizens evacuated from Hubei province on 1 February 2020, who remained well and afebrile seven days after admission to a hospital in Frankfurt. Both a mother and a child in a family cluster remained asymptomatic (including normal chest CT images during the observation period) with qRT-PCR positive nasopharyngeal swab samples. Similar viral load in asymptomatic versus symptomatic cases was reported in a study including 18 patients. Persistent positivity of viral RNA in throat and anal swabs were reported in an asymptomatic female patient after 17 days of clinical observation and treatment. <Ref name="ECDCRRA12032020"/>
* Potential transmission from an asymptomatic person has been reported in a familial cluster of five COVID-19 patients hospitalised with fever and respiratory symptoms that had contact before their onset of symptoms with an asymptomatic family member, a young 20-year-old woman, upon her return from Wuhan. She remained asymptomatic for the whole duration of laboratory and clinical monitoring (19 days).
* Transmission in a pre-symptomatic stage of infection: In addition to case reports, the pre-symptomatic transmission has been inferred through modelling, and the proportion of pre-symptomatic transmission was estimated to be around 48% and 62%. The pre-symptomatic transmission was deemed likely based on a shorter serial interval of COVID-19 (4.0 to 4.6 days) than the mean incubation period (five days) with the authors indicating that many secondary transmissions would have already occurred at the time when symptomatic cases are detected and isolated. Major uncertainties remain in assessing the influence of pre-symptomatic transmission on the overall transmission dynamics of the pandemic.

===Vulnerable groups===
* Population groups that have been more frequently reported having severe disease and death include people above 60 years of age, males, people with underlying conditions such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer.
* The proportion of most of the reported chronic diseases and health conditions is similar to the prevalence of these conditions in the elderly age groups in China, therefore they might be surrogates of increasing age only. Higher ACE (angiotensin-converting enzyme II) gene expression may be linked to higher susceptibility to SARS-CoV-2.
* It has been shown that ACE 2 expression in lung tissues increases with age, tobacco use and with some hypertensive treatment. These observations might explain the vulnerability of older people, tobacco users/smokers and those with hypertension; they also highlight the importance of identifying smokers as a potential vulnerable group for COVID-19. <Ref name="ECDCRRA12032020"/>
* There is '''limited''' scientific evidence on the severity of illness among pregnant women with COVID-19. Pregnant women appear to experience similar clinical manifestations as non-pregnant adult patients with COVID-19 pneumonia. There is no evidence of severe adverse outcomes in neonates due to maternal COVID-19 pneumonia, and the virus has not been found in breastmilk. <Ref name="ECDCRRA12032020"/>
* Currently available information indicates that children are as likely to be infected as adults, however they experience mild clinical manifestations. About 2.4% of the total reported cases in China (as of 20 February 2020) were individuals under 19 years of age. A very small proportion of those aged under 19 years have developed severe (2.5%) or critical disease (0.2%). <Ref name="ECDCRRA12032020"/>
===Reservoir and sources===
* The three first reported cases were hospitalized on 27 December 2019 in Wuhan; one patient was a retailer on the seafood market in Wuhan, another was a frequent visitor of the same market. The third patients was not reported to be associated to the market. <Ref name="Zhu2020"> Zhu, Na, et al. "A novel coronavirus from patients with pneumonia in China, 2019." New England Journal of Medicine (2020).</ref>
* COVID19 is likely of animal origin. <ref name="Rothan2020"/> The virus has 85% similarity to a strain that was isolated from bats in East China. <Ref name="Zhu2020"/>
===Transmission Routes===
* Person-to-person transmission of COVID-19 infection is the predominant way in which this virus spreads among the human population. <ref name="Rothan2020"/>. Transmission occurs through close contact (droplets, hands) and fomites. Therefore handwashing and social distancing are effective control measures, in the absence of a vaccine.
* Extensive measures to reduce person-to-person transmission of COVID-19 have been implemented to control the current outbreak. <ref name="Rothan2020"/>
* Special attention and efforts to protect or reduce transmission should be applied in susceptible populations including children, health care providers, and elderly people.<ref name="Rothan2020"/>

=Detailed pages=
For the following specific epidemiological topics, please use the subpages to document your observations:
** [[Reservoirs]]
*** [[Sources]]
** [[Transmission routes|Transmission Routes]]
** [[Transmission Barriers]]
** [[Immune Response]]
** [[Pathogenesis]]
*** [[Risk factors for severe disease]]
** [[Contagiousness]]

For other epidemiological topics, please use this page.

=Proportion asymptomatic=
==Observations==
* A study of the COVID19 outbreak on the Pacific Princess cruise ship found proportions of asymptomatic infections up to 50% <Ref name=“Mizmuto2020”> Mizumoto, Kenji, et al. "Estimating the asymptomatic ratio of 2019 novel coronavirus onboard the princess cruises ship, 2020." medRxiv (2020). </ref>
* Based on Chinese data, the international WHO mission report indicates that up to 75% of initially asymptomatic cases will progress to clinical disease, making the true asymptomatic infection rather rare (estimated at 1-3%). <Ref name="ECDCRRA12032020"/>

==Analysis and interpretation==
* The observations by Mizumoto and the International WHO Mission seem to contradict on the issue of proportion asymptomatic infections. Though cruise ship populations are hardly representative of national populations, they can be considered reliable environments to study the natural history of infectious disease, when observing large groups of exposed susceptibles.
* Having reliable estimates of the proportion asymptomatics is relevant for modelling the disease at the population level and making predictions about group immunity and transmission coefficients.

==Consequences for action==
* Ideally, cohorts of exposed individuals need to be identified and followed up to establish the proportion asymptomatic more reliably.

=Anosmia=
==Observations==
* An increasing number of reports occur on the sudden loss of smell and taste among a proportion of the COVID19 patients. <Ref name="Business Insider">If you’ve lost your sense of smell or taste, you could be a ‘hidden carrier’ of the coronavirus. [https://www.businessinsider.nl/coronavirus-symptoms-loss-of-smell-taste-covid-19-anosmia-hyposmia-2020-3?international=true&r=US Brianna Moné. Business Insider 22 Mar 2020] </ref>
==Analysis and Interpretation==
* This observation requires a systematic clinical follow up of COVID19 patients, including pathognomonic studies
==Consequences for Action==
* If the relation COVID19 and Anosmia is confirmed, then clusters of sudden anosmia could be considered a clinical indicator of COVID19 in the population when testing is unavailable.

=References=

Microbiology

2020-03-24T11:58:18Z

80.106.187.46: /* Consequences for action */

This page collects observations, interpretations, and consequences for action about Microbiology in general of SARS-CoV2. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[Sources]], please use that page, instead of posting your content here. If you have specific microbiological topics that warrant a separate page, please create one.

=What is already known=
* Laboratory surge capacity is a critical success factor in pandemic preparedness
* ECDC has surveyed laboratory capacity in the EU (EULabCap) and reported in 2016. <Ref Name=“EULABCAP”> European Centre for Disease Prevention and Control. European Centre for Disease Prevention and Control. [https://www.ecdc.europa.eu/sites/default/files/documents/2016_EULabCap_EUreport_web_300418_final.pdf EU Laboratory Capability Monitoring System (EULabCap)] – Report on 2016 survey of EU/EEA country capabilities and capacities. Stockholm: ECDC; 2018</ref>
**
** Outbreak Assistance Laboratories in the Netherlands were found in 2009 to have sufficient capacity to process xxx samples per month of BSL3 respiratory pathogens, in addition to the routine diagnostics.<Ref name=“LvAsten”> Asten, L. van, Lubben, M. van der, Wijngaard, C. van den, Pelt, W. van, Verheij, R., Jacobi, A., Overduin, P., Meijer, A., Luijt, D., Claas, E., Hermans, M., Melchers, W., Rossen, J., Schuurman, R., Woffs, P., Boucher, C., Schirm, J., Kroes, L., Leenders, S., Galama, J., Peeters, M., Loon, A. van, Stobberingh, E., Schutten, M., Koopmans, M. Strengthening the diagnostic capacity to detect Bio Safety Level 3 organisms in unusual respiratory viral outbreaks. Journal of Clinical Virology: 2009, 45(3), 185-190</ref>

==Observation==
* Large differences exist between EU countries in numbers of Corona tests performed per capita (ref)
* Since 11 March, the Netherlands indicated that not all COVID19 suspect cases could be tested, due to limited capacity. The bottleneck are reagents, according to labs. By 7 March, 6000 tests had been performed <Ref name=“Ourworldindata”> https://ourworldindata.org/coronavirus-testing-source-data</ref>, after which no data on testing were shared.
* Between 11 and 20 march, the calculated case fatality of COVID19 in the Netherlands increased from 0.99% to 3.54% (calculated by day as number of cumulative deaths divided by number of cumulative confirmed cases). https://twitter.com/iTrainEU/status/1241048616615260166
* There are not clear criteria on who should be tested. Even inside the country sometimes different practices are followed. For example, in Greece the national public health organization has requested people that recover from the disease to be sent home after at least 5 days without symptoms and without being tested. Hospitals did not comply, and test cases once before they leave or even twice (with 10 days interval).

==Analysis and interpretation==
* The increasing case fatality suggests that an increasing amount of COVID19 goes undetected, which is supported by the statement that testing is increasingly restricted.
* As a result, the strategy can no longer comply with the WHO recommendation to test broadly, in order to identify each new case, isolate, treat and trace all contacts.
* Existing lab capacity surveys may have looked at ‘theoretical capacity’, but clearly did not take into account dependency on supply of reagents.
* Most corona diagnostics depend on automated, high-throughput devices, which use proprietary materials. If any of those materials get out of stock, machines doe not work, even when alternative (non proprietary) materials are used.
* Manual alternatives exist, but that requires specially trained lab personnel.

==Consequences for action==
* In future, laboratory capacity surveys should not only take into account if labs are qualitatively able to perform the tests, but the quantitative capacity is important as well. This should include an analysis of dependencies, such as of external supply chains and amount of competent staff to scale up manual testing, if necessary.
* maybe a central european management of available resources to keep a minimum capacity in all countries in such a huge public health emergency? proposal how this mechanism can work and under which prerequisities
* come up with a list of criteria regarding testing and priorities at each phase of the outbreak given specific scenarios on the available resources...improvision to be avoided, consistency of testing among countries
* different indicators should be used for following up the evolvement of the epidemic. Reporting only hospitalised cases / cases in ICUs and deaths could be more a more aproppriate approach after a specific point during the epidemic in order to avoid misunderstandings regarding the burden of disease in different regions of the world

=References=

Microbiology

2020-03-24T11:48:51Z

80.106.187.46: /* Observation */

Interventions

2020-03-17T09:51:00Z

80.106.187.46: /* What do we see in the European Member States? */

This page collects observations, interpretations, and consequences for action about the Interventions for SARS-CoV2 in general. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What do we see in the European Member States?=
* AU:
* BE: [https://www.belgium.be/en/news/2020/coronavirus_phase_2_maintained_transition_federal_phase_and_additional_measures Phase 2 maintained, transition to federal phase and additional measures] - as of 13 March 2020
* BU:
* CY:
* CZ:
* DE:
* DK:
* EE:
* ES:
* FI:
* FR: Containment. Full Lockdown for 2 weeks. Police enforcement of state of emergency
* GR: Mitigation approach. Schools and universities, all department stores, restaurants, theaters, museums, cinemas, beauty salons, are closed, all events are cancelled, advise working at home, stay at home when symptomatic or hen having a close contact with a confirmed case. Also there was a decision yestarday 16/03/2020 churches to be aooly measures (and all celebrations / rituals as we are going towards the Easter period to be cancelled or performed following basic rules such as every person to have at least 2 meters distance from the other). There was also a law issued recently that says that whoever is advised to stay at home (case or contact) and is caught not to be following the instructions will face legal consequences (up to 2 years of prison)! The same applies for professionals that disobey the rules. Already there are some arrests of people that opened their restaurants and other services to serve clients. Doctors have been advised not to examine patients with fever at their private offices as much as they can.
Take away services, super-markets and pharmacies are open as well as other services that have to do with transportation of goods. An online number is available for employees to call and get information on their rights on sick leave and reimbursement. At supermarkets since they were overcrowded the first days of the measures there was the decision to have a queue and based on the size of the space to let a specific number of persons enter. Inside the supermarkets there are sanitizers available and people should keep A distance of more that 2 meters from each other. super-markets will remain open on the weekends to avoid overcrowding.
These are in summary some of the measures on 17/03/2020 that Greece has 353 reported cases and 4 deaths.
* HU:
* IT:
* LT:
* LV:
* MT:
* NL: Mitigation approach. "Controlled spread", protecting vulnerables, a strong reduction of transmission by closing schools, restaurants, theaters, all events, advise working at home, stay at home when symptomatic.
* PO:
* PT:
* RO:
* SE:
* SK:

=Topic 1=

==Observations==

==Analysis and interpretation==

==Consequences for action==

=References=

Interventions

2020-03-17T09:47:23Z

80.106.187.46: /* What do we see in the European Member States? */

This page collects observations, interpretations, and consequences for action about the Interventions for SARS-CoV2 in general. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What do we see in the European Member States?=
* AU:
* BE: [https://www.belgium.be/en/news/2020/coronavirus_phase_2_maintained_transition_federal_phase_and_additional_measures Phase 2 maintained, transition to federal phase and additional measures] - as of 13 March 2020
* BU:
* CY:
* CZ:
* DE:
* DK:
* EE:
* ES:
* FI:
* FR: Containment. Full Lockdown for 2 weeks. Police enforcement of state of emergency
* GR: Mitigation approach. Schools and universities, all department stores, restaurants, theaters, museums, cinemas, beauty salons, are closed, all events are cancelled, advise working at home, stay at home when symptomatic or hen having a close contact with a confirmed case. Also there was a decision yestarday 16/03/2020 churches to be aooly measures (and all celebrations / rituals as we are going towards the Easter period to be cancelled or performed following basic rules such as every person to have at least 2 meters distance from the other). There was also a law issued recently that says that whoever is advised to stay at home (case or contact) and is caught not to be following the instructions will face legal consequences (up to 2 years of prison)! The same applies for professionals that disobey the rules. Already there are some arrests of people that opened their restaurants and other services to serve clients. Doctors have been advised not to examine patients with fever at their private offices as much as they can.
Take away services, super-markets and pharmacies are open as well as other services that have to do with transportation of goods. An online number is available for employees to call and get information on their rights on sick leave and reimbursement. At supermarkets since they were overcrowded the first days of the measures there was the decision to have a queue and based on the size of the space to let a specific number of persons enter. Inside the supermarkets there are sanitizers available and people should keep A distance of more that 2 meters from each other.
These are in summary some of the measures on 17/03/2020 that Greece has 353 reported cases and 4 deaths.
* HU:
* IT:
* LT:
* LV:
* MT:
* NL: Mitigation approach. "Controlled spread", protecting vulnerables, a strong reduction of transmission by closing schools, restaurants, theaters, all events, advise working at home, stay at home when symptomatic.
* PO:
* PT:
* RO:
* SE:
* SK:

=Topic 1=

==Observations==

==Analysis and interpretation==

==Consequences for action==

=References=

Interventions

2020-03-17T09:42:34Z

80.106.187.46: /* What do we see in the European Member States? */

This page collects observations, interpretations, and consequences for action about the Interventions for SARS-CoV2 in general. Please observe the structure of the page, when you add your content. Please use references where possible. Remember to find the relevant page. For example, if your observation is about [[transmission routes]], please use that page, instead of posting your content here.

=What do we see in the European Member States?=
* AU:
* BE: [https://www.belgium.be/en/news/2020/coronavirus_phase_2_maintained_transition_federal_phase_and_additional_measures Phase 2 maintained, transition to federal phase and additional measures] - as of 13 March 2020
* BU:
* CY:
* CZ:
* DE:
* DK:
* EE:
* ES:
* FI:
* FR: Containment. Full Lockdown for 2 weeks. Police enforcement of state of emergency
* GR: Mitigation approach. Schools and universities, all department stores, restaurants, theaters, museums, cinemas, beauty salons, are closed, all events are cancelled, advise working at home, stay at home when symptomatic or hen having a close contact with a confirmed case. Also there was a decision yestarday 16/03/2020 churches to be aooly measures (and all celebrations / rituals as we are going towards the Easter period to be cancelled or performed following basic rules such as every person to have at least 2 meters distance from the other). There was also a law issued recently that says that whoever is advised to stay at home (case or contact) and is caught not to be following the instructions will face legal consequences (up to 2 years of prison)! The same applies for professionals that disobey the rules. Already there are some arrests of people that opened their restaurants and other services to serve clients. Doctors have been advised not to examine patients with fever at their private offices as much as they can.
Take away services, super-markets and pharmacies are open as well as other services that have to do with transportation of goods. An online number is available for employees to call and get information on their rights on sick leave and reimbursement. At supermarkets since they were overcrowded the first days of the measures there was the decision to have a queue and based on the size of the space to let a specific number of persons enter. Inside the supermarkets there are sanitizers available and people should keep A distance of more that 2 meters from each other.
* HU:
* IT:
* LT:
* LV:
* MT:
* NL: Mitigation approach. "Controlled spread", protecting vulnerables, a strong reduction of transmission by closing schools, restaurants, theaters, all events, advise working at home, stay at home when symptomatic.
* PO:
* PT:
* RO:
* SE:
* SK:

=Topic 1=

==Observations==

==Analysis and interpretation==

==Consequences for action==

=References=