{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,14]],"date-time":"2025-12-14T12:05:47Z","timestamp":1765713947639,"version":"3.37.3"},"reference-count":30,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2021,2,6]],"date-time":"2021-02-06T00:00:00Z","timestamp":1612569600000},"content-version":"unspecified","delay-in-days":5,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"published-print":{"date-parts":[[2021,2]]},"abstract":"<jats:sec><jats:title>Objective<\/jats:title><jats:p>In Italy, the first diagnosis of COVID-19 was confirmed on 20 February 2020 in the Lombardy region. Given the rapid spread of the infection in the population, it was suggested that in Europe, and specifically in Italy, the virus had already been present in the last months of 2019. In this paper, we aim to evaluate the hypothesis on the early presence of the virus in Italy by analysing data on trends of access to emergency departments (EDs) of subjects with a diagnosis of pneumonia during the 2015\u20132020 period.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Time series cohort study.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting<\/jats:title><jats:p>We collected data on visits due to pneumonia between 1 October 2015 and 31 May 2020 in all EDs of the Agency for Health Protection of Milan (ATS of Milan). Trend in the winter of 2019\u20132020 was compared with those in the previous 4 years in order to identify unexpected signals potentially associated with the occurrence of the pandemic. Aggregated data were analysed using a Poisson regression model adjusted for seasonality and influenza outbreaks.<\/jats:p><\/jats:sec><jats:sec><jats:title>Primary outcome measures\u202f<\/jats:title><jats:p>Daily pneumonia-related visits in EDs.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results\u202f<\/jats:title><jats:p>In the studied period, we observed 105\u2009651 pneumonia-related ED visits. Compared with the expected, a lower occurrence was observed in January 2020, while an excess of pneumonia visits started in the province of Lodi on 21 February 2020, and almost 10 days later was observed in the remaining territory of the ATS of Milan. Overall, the peak in excess was found on 17 March 2020 (369 excess visits compared with previous years, 95%\u2009CI 353 to 383) and ended in May 2020, the administrative end of the Italian lockdown.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions\u202f<\/jats:title><jats:p>An early warning system based on routinely collected administrative data could be a feasible and low-cost strategy to monitor the actual situation of the virus spread both at local and national levels.<\/jats:p><\/jats:sec>","DOI":"10.1136\/bmjopen-2020-044388","type":"journal-article","created":{"date-parts":[[2021,2,8]],"date-time":"2021-02-08T22:41:25Z","timestamp":1612824085000},"page":"e044388","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":4,"title":["Trend of pneumonia diagnosis in emergency departments as a COVID-19 surveillance system: a time series study"],"prefix":"10.1136","volume":"11","author":[{"given":"Rossella","family":"Murtas","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1451-8292","authenticated-orcid":false,"given":"Adriano","family":"Decarli","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5681-5861","authenticated-orcid":false,"given":"Antonio Giampiero","family":"Russo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,2,8]]},"reference":[{"key":"2021020807552604000_11.2.e044388.1","article-title":"Coronavirus (SARS-CoV-2) in the environment: occurrence, persistence, analysis in aquatic systems and possible management","author":"Patel","year":"2020","journal-title":"Sci Total Environ"},{"key":"2021020807552604000_11.2.e044388.2","doi-asserted-by":"publisher","DOI":"10.1016\/j.scitotenv.2020.142939"},{"key":"2021020807552604000_11.2.e044388.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.scitotenv.2020.141711"},{"key":"2021020807552604000_11.2.e044388.4","doi-asserted-by":"crossref","first-page":"112617","DOI":"10.1016\/j.bios.2020.112617","article-title":"An integrated biosensor system with mobile health and wastewater-based epidemiology (iBMW) for COVID-19 pandemic","volume":"169","author":"Mao","year":"2020","journal-title":"Biosens Bioelectron"},{"key":"2021020807552604000_11.2.e044388.5","doi-asserted-by":"crossref","DOI":"10.1016\/j.ijheh.2020.113621","article-title":"Metropolitan wastewater analysis for COVID-19 epidemiological surveillance","volume":"230","author":"Randazzo","year":"2020","journal-title":"Int J Hyg Environ Health"},{"key":"2021020807552604000_11.2.e044388.6","doi-asserted-by":"crossref","first-page":"140719","DOI":"10.1016\/j.scitotenv.2020.140719","article-title":"Wastewater surveillance for Covid-19: an African perspective","volume":"743","author":"Street","year":"2020","journal-title":"Sci Total Environ"},{"key":"2021020807552604000_11.2.e044388.7","article-title":"The novel SARS-CoV-2 pandemic: possible environmental transmission, detection, persistence and fate during wastewater and water treatment","author":"Mohapatra","year":"2020","journal-title":"Sci Total Environ"},{"key":"2021020807552604000_11.2.e044388.8","doi-asserted-by":"crossref","unstructured":"Kogan NE , Clemente L , Liautaud P . 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