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collect aggregated data on confirmed cases at national level once the number of reported cases increases. These data can also be reported through TESSy. The number of samples tested for COVID-19 should also be collected. · Detection and assessment of community transmission: Detecting community transmission of COVID-19 is challenging as the suspect case definition is based on travel links. Severe cases may present only when significant community transmission has already occurred and sentinel surveillance covers only a small proportion of the population and might not be sensitive enough to detect ongoing low-level community transmission. Approaches to detecting community transmission could include: · Telephone helplines: data on calls to regional/national healthcare telephone helplines could be analysed to provide an indication of increases of ARI/ILI regionally and nationally. Statistical methods could be used to detect changes in trends. The helplines could also be used to sample a proportion of cases fitting the ARI/ILI case definition in order to provide indication of community transmission of COVID-19. In situations where community transmission is suspected to be occurring (e.g. SARI cases detected), the proportion of cases sampled could be increased temporarily to provide a more comprehensive assessment. · Enhanced local syndromic ILI/ARI-based surveillance: once cases are detected without links to known areas with community transmission, the local level of community transmission of COVID-19 should be assessed. This assessment should include as many general practices in the defined geographical area (for example a municipality) as possible for a limited time period (such as two weeks). The general practices should sample a proportion of ARI/ILI cases irrespective of their travel history and these samples should be tested for COVID-19. Data on such investigations should be summarised and posted on EWRS to allow Member States to assess the risk of community transmission in the area. The results from these assessments can inform Member States on whether contact tracing is still a viable response in the area. Sentinel syndromic and virological surveillance: with increasing transmission, it is likely that sentinel syndromic and virological surveillance will become increasingly more important in order to assess intensity and spread of infection. The number of outpatient sentinel sites should be increased to improve coverage of the population under syndromic surveillance. Data on the number of patients visiting with ILI/ARI symptoms will provide information on spread and intensity as well as the most affected age groups in primary care. These data should continue to be reported in TESSy according to the influenza protocol. Data on the number of COVID-19 tests performed and number of positive tests from sentinel surveillance should continue to be collected and reported in TESSy on a weekly basis within the COVID-19 reporting. If healthcare authorities recommend that patients with ARI/ILI do not visit general practitioners, there could be a significant impact on ARI/ILI surveillance systems, and sentinel surveillance might not be suitable to monitor COVID-19 intensity and spread. In these circumstances, sentinel general practices consulted through telephone could report at least the number and proportion of telephone consultations due to ARI/ILI. In addition, sites where ARI/ILI patients are directed and tested (e.g. dedicated testing centres) should be included in the surveillance, although historical data will not be available for comparison. Monitoring of healthcare telephone helplines as described above, ideally with linked systematic sampling could be an alternative or complementary approach. Depending on the resources, virological detection by RT-PCR assay could be reduced to single-gene target testing. For the specimens where the first gene test is technically not interpretable or the cycle threshold value is above 35, confirmation of positive results should be performed by a separate gene target or repeated sampling should be performed. The subset for virological characterisation including sequencing should include specimens representing different times, age groups, geographical areas of countries and different levels of clinical symptoms. If sequencing is not feasible in the short term during the epidemic, the specimens should be kept for later sequencing of a subset of viruses. Hospital SARI surveillance: all hospitalised patients with SARI should be tested for SARS-CoV-2 virus irrespective of travel history in order to detect community transmission, detect nosocomial outbreaks and to monitor intensity and impact. Testing data on SARI cases and/or ICU SARI cases should be collected, either via comprehensive surveillance or sentinel hospitals. Data collected should include at a minimum the number of COVID-19 tests performed among patients with SARI and the number of positive tests. These data should be reported in TESSy on a weekly basis. Enhanced surveillance of SARI cases can be used to identify risk groups for COVID-19, risk factors for severe illness and poor outcome. Indicators for monitoring: Countries should collect basic indicators from each region on transmissibility, seriousness and impact of the disease [89]. Transmissibility can be based on ILI/ARI rates, seriousness on
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