COVID-19 and HIV
“Our health systems and our social bonds are being tested in unprecedented ways by the COVID-19 pandemic. IAPAC thanks HIV and infectious disease clinicians and allied healthcare professionals who are on the front-lines of the COVID-19 response. We also applaud public health officials for the life-saving decisions they are making on a day-by-day basis, including in relation to restrictive measures such as social distancing. We call on government officials to communicate and advance evidence-based messages and public policies. And, we plead with every citizen to do her/his part to bring the COVID-19 pandemic under control.”
– Dr. José M. Zuniga, President/CEO, IAPAC
COVID-19 is a disease that can affect the lungs and airways. It is caused by a novel coronavirus called SARS-CoV-2. People with COVID-19 may have a wide range of symptoms – ranging from mild to severe. Symptoms may appear 2-14 days after exposure to the virus. Symptoms of COVID-19 include, but are not limited to:
- Fever or chills
- Shortness of breath or difficulty breathing
- Muscle or body aches
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
Many of these symptoms are similar to other illnesses that are much more common, such as cold and flu, thus if you are unsure you should contact your health professional. Do not visit your doctor’s office without an appointment, or present at an emergency room unless you are facing a life-threatening situation.
Although most people with COVID-19 get better within weeks of getting sick, some people experience post-COVID conditions. Post-COVID conditions, also called long COVID, are a wide range of new, returning, or ongoing health problems people can experience more than a month after first being infected with the virus that causes COVID-19.
People at increased risk for SARS-CoV-2 infection include those with underlying medical conditions, including asthma, chronic lung disease, diabetes, and heart disease. However, COVID-19 cases in people without these conditions do occur. Older adults and people with severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness.
Hundreds of thousands of people have died from COVID-19 in the United States. The good news is that vaccines against COVID-19 are safe, effective, reduce the risk of severe illness, and FREE. COVID-19 vaccines may be administered to most people with underlying medical conditions. Everyone 12 years of age and older is now eligible to get a free COVID-19 vaccination. Currently, three vaccines are authorized and recommended in the United States to prevent COVID-19:
- Pfizer-BioNTech: people 12 years and older, 2 shots given 3 weeks apart
- Moderna: people 18 years and older, 2 shots given 4 weeks apart
Johnson & Johnson/Janssen: people 18 years and older, 1 shot
The department of Health and Human Services (HHS) announced a plan recently to begin offering COVID-19 vaccine booster shots in the fall of 2021. CDC’s independent advisory committee, the Advisory Committee on Immunization Practices (ACIP), will continue to meet and discuss data on the evolution of the pandemic and the use of COVID-19 vaccines. ACIP will make further recommendations on the use of boosters for the public after a thorough review of the evidence.
Simple measures such as washing your hands often with soap and water can help stop viruses like coronavirus from spreading.
Following is a list of public health recommendations to avoid catching or transmitting SARS-CoV-2 infection:
- Get vaccinated!
- Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
- Always wash your hands when you get home or into work.
- Use an alcohol-based hand sanitizer if soap and water are not available.
- If you are wearing a mask: You can cough or sneeze into your mask. Put on a new, clean mask as soon as possible afterwards and wash your hands.
- If you are not wearing a mask: Always cover your mouth and nose with a tissue when you cough or sneeze, or use the inside of your elbow and do not spit. Throw used tissues in the trash.
- Avoid touching your eyes, nose, or mouth if your hands are not clean.
- Avoid close contact with people who have symptoms of coronavirus.
- Only travel on public transport if you need to.
- Work from home, if you can.
- Avoid social activities, such as going to bars, restaurants, theatres, and cinemas
- Avoid events with large groups of people, observing public health official guidance
- If you are not fully vaccinated and aged 2 or older, you should wear a mask in indoor public places.
- In general, you do not need to wear a mask in outdoor settings. In areas with high numbers of COVID-19 cases, consider wearing a mask in crowded outdoor settings and for activities with close contact with others who are not fully vaccinated.
We urge you to take any other precautions advised by your local public health and government officials. This is particularly true in relation to social distancing, which calls for avoiding large gatherings and maintaining a distance of 6 feet from people. Social distancing aims to reduce the chance of contact with people who knowingly or unknowingly carry the coronavirus infection.
Quarantine if you have been in close contact (within 6 feet of someone for a cumulative total of 15 minutes or more over a 24-hour period) with someone who has COVID-19, unless you have been fully vaccinated. People who are fully vaccinated do NOT need to quarantine after contact with someone who had COVID-19 unless they have symptoms. However, fully vaccinated people should get tested 3-5 days after their exposure, even if they don’t have symptoms and wear a mask indoors in public for 14 days following exposure or until their test result is negative.
Treatment for COVID-19 should be prescribed by your healthcare provider. People have been seriously harmed and even died after taking products not approved for COVID-19, even products approved or prescribed for other uses.
Antibiotics do not work on COVID-19, as they only kill bacteria, not viruses. The Food and Drug Administration (FDA) has approved one drug, remdesivir (Veklury), to treat COVID-19.
For mild to moderate illness, your healthcare provider might recommend the following to relieve symptoms and support your body’s natural defenses:
- Taking medications like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), to reduce fever
- Drinking water or receiving intravenous fluids to stay hydrated
- Getting plenty of rest to help the body fight the virus
For moderate to severe illness, your healthcare provider may recommend hospitalization and the following treatments:
- Slowing the virus. Antiviral medications reduce the ability of the virus to multiply and spread through the body.
- Reducing an overactive immune response. In patients with severe COVID-19, the body’s immune system may overreact to the threat of the virus, worsening the disease. This can cause damage to the body’s organs and tissues. Some treatments can help reduce this overactive immune response.
- Treating complications. COVID-19 can damage the heart, blood vessels, kidneys, brain, skin, eyes, and gastrointestinal organs. It also can cause other complications. Depending on the complications, additional treatments might be used for severely ill hospitalized patients, such as blood thinners to prevent or treat blood clots and mechanical ventilation to help people breathe.
- Supporting the body’s immune function. Plasma from patients who have recovered from COVID-19—called convalescent plasma—can contain antibodies to the virus. This could help the immune system recognize and respond more effectively to the virus, but currently the NIH COVID-19 Treatment Guidelines find there is not enough evidence to recommend these treatments.
If you are sick with COVID-19, take the following steps to care for yourself and help protect other people in your home and community:
- Stay home. Most people with COVID-19 have mild illness and can recover at home without medical care. Do not leave your home, except to get medical care. Do not visit public areas.
- Take care of yourself. Get rest and stay hydrated. Take over-the-counter medicines, such as acetaminophen, to help you feel better.
- Stay in touch with your doctor. Call before you get medical care. Be sure to get care if you have trouble breathing, or have any other emergency warning signs, or if you think it is an emergency.
- Avoid public transportation, ride-sharing, or taxis.
- As much as possible, stay in a specific room away from other people and pets in your home. If possible, you should use a separate bathroom. If you need to be around other people or animals in or outside of the home, wear a mask.
- Wash your hands often with soap and water for at least 20 seconds. This is especially important after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food.
- Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people in your home.
- Clean and disinfect high-touch surfaces in your “sick room” and bathroom. Let someone else clean and disinfect surfaces in common areas, but you should clean your bedroom and bathroom, if possible.
- Tell your close contacts that they may have been exposed to COVID-19. An infected person can spread COVID-19 starting 48 hours (or 2 days) before the person has any symptoms or tests positive. By letting your close contacts know they may have been exposed to COVID-19, you are helping to protect everyone.
- Monitor your symptoms. Symptoms of COVID-19 include fever, cough, or other symptoms.
- Follow care instructions from your healthcare provider and local health department. Your local health authorities may give instructions on checking your symptoms and reporting information.
- Be aware of emergency warning signs. If you or someone you are caring for is showing any of these signs, seek emergency medical care immediately:
- Trouble breathing
- Persistent pain or pressure in the chest
- New confusion
- Inability to wake or stay awake
- Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
Viruses constantly change through mutation, and new variants of a virus are expected to occur. Sometimes new variants emerge and disappear. Other times, new variants persist. Multiple variants of COVID-19 have emerged in the United States. At this point, the original variant that caused the initial COVID-19 cases in January 2020 is no longer circulating as newer variants have increased.
The Omicron variant of the SARS-CoV-2 virus spreads more easily than the original SARS-CoV-2 virus and how easily Omicron spreads compared to Delta remains unknown. As of December 20, 2021, Omicron has been detected in multiple countries and is rapidly increasing the proportion of COVID-19 cases it is causing. CDC expects that anyone with Omicron infection can spread the virus to others, even if they are vaccinated or don’t have symptoms. More data are needed to know if Omicron infections, especially reinfections and breakthrough infections in people who are fully vaccinated, cause more severe illness or death than infection with other variants.
CDC guidance regarding the Omicron variant includes:
- Vaccines continue to be highly effective at preventing hospitalization and death, including against this variant. Vaccines remain the best public health measure to protect people from COVID-19, slow transmission, and reduce the likelihood of new variants emerging.
- Masks offer protection against all variants. CDC continues to recommend wearing a mask in public indoor settings in areas of substantial or high community transmission, regardless of vaccination status.
- Tests can tell you if you are currently infected with COVID-19. Two types of tests are used to test for current infection: nucleic acid amplification tests (NAATs) and antigen tests. NAAT and antigen tests can only tell you if you have a current infection.
- Self-tests are easy to use and produce rapid results.
- If your self-test is positive, stay home and isolate for 10 days, wear a mask if you have contact with others, and call your healthcare provider.
- If you have any questions about your result, call your healthcare provider or public health department.
COVID-19 AND HIV
Whether people with HIV are at greater risk of acquiring SARS-CoV-2 infection is currently unknown. Data on the clinical course of COVID-19 in people with HIV are emerging. In the initial case series from Europe and the United States, no significant differences in clinical outcomes were found between people with HIV who developed COVID-19 and individuals without HIV.
Following is a summary of World Health Organization (WHO) guidance regarding COVID-19 and HIV:
- People living with HIV who have not achieved viral suppression through antiretroviral therapy (ART) may have a compromised immune system that leaves them vulnerable to opportunistic infections and further disease progression.
- At present there is no evidence to suggest that there is an increased risk of infection and increased severity of illness for people living with HIV. We know that during the SARS and MERS outbreaks there were only a few case reports of mild disease among people living with HIV.
- Current clinical data suggest the main mortality risk factors are linked to older age and other comorbidities including cardiovascular disease, diabetes, chronic respiratory disease, and hypertension. Some very healthy and younger people have also developed severe disease from coronavirus infection.
- People living with HIV who know their HIV status are advised to take the same precautions as the general population (e.g., wash hands often, cough hygiene, avoid touching your face, social distancing, seek medical care if symptomatic, self-isolation if in contact with someone with COVID-19, and other actions per local and national government responses). People living with HIV who are taking antiretroviral drugs should ensure that they have at least a 30-day supply of these drugs, if not a 3- to 6-month supply and ensure that their vaccinations are up to date (influenza and pneumococcal vaccines). Polypharmacy considerations should also be taken into account, including related to adequate supplies of medications for comorbidities (e.g., hypertension, diabetes), as well as contraception and gender-affirming hormone therapy.
- It is also an important opportunity to ensure that all people living with HIV who are not yet on ART get initiated on ART to achieve viral suppression. People who feel they may have been at HIV risk are advised to seek testing to protect against HIV disease progression and complications from any other comorbidities.
There is no evidence that HIV pre-exposure prophylaxis (PrEP) prevents the acquisition of coronavirus, or that its use will help patients recover quicker. If you are having unprotected sex and you think you are vulnerable to acquiring HIV, continue to take PrEP. Regarding HIV antiretrovirals, there is no evidence these medications are effective to treat COVID-19.
World Health Organization Coronavirus Homepage (World Health Organization)
Coronavirus disease (COVID-19): HIV and antiretrovirals (World Health Organization)
Coronavirus disease (COVID-19) Pandemic Public Advice, Country and Technical Guidance, Situation Reports (World Health Organization)
What People Living with HIV Need to Know about HIV and COVID-19 (UNAIDS)
COVID-19 (Global Fund to Fight AIDS, Tuberculosis, & Malaria)
COVID-19 Prevention and Control among People who use Drugs and People in Prisons (UN Office on Drugs and Crime)
Strategic Considerations for Mitigating the Impact of COVID-19 on Key Population-Focused HIV Programs (PEPFAR, USAID)
PEPFAR Technical Guidance in Context of COVID-19 Pandemic (PEPFAR) (updated 8/18/21)
Rolling Updates on Coronavirus Disease (World Health Organization)
Coronavirus disease (COVID-19) Weekly Epidemiological Update and Weekly Operational Update (World Health Organization)
Maintaining Essential Health Services: Operational Guidance for the COVID-19 Context (World Health Organization)
Community-Based Health Care, including Outreach and Campaigns, in the Context of the COVID-19 Pandemic (World Health Organization)
Information note on HIV and COVID-19 (World Health Organization)
COVID-19 and HIV: What you need to know (International AIDS Society)
WHO Science conversation Episode #48 – HIV & COVID-19 (World Health Organization)
WHO warns that HIV infection increases risk of severe and critical COVID-19 (World Health Organization)
WHO Report: Clinical features and prognostic factors of COVID-19 in people living with HIV hospitalized with suspected or confirmed SARS-CoV-2 infection (World Health Organization)
Clinical Case Series/Systematic Reviews
Barcelona (Spain): COVID-19 in Patients with HIV: Clinical Case Series
Chicago, IL (USA): A Case Series of Five People Living with HIV Hospitalized with COVID-19 in Chicago, Illinois
Chile: Clinical characteristics and outcomes of people living with HIV hospitalized with COVID-19: a nationwide experience
Germany: COVID-19 in People Living With Human Immunodeficiency Virus: A Case Series of 33 Patients
Germany: HIV and SARS-CoV-2 co-infection: cross-sectional findings from a German ‘hotspot’
Istanbul (Turkey): HIV/SARS-CoV-2 Coinfected Patients in Istanbul, Turkey
London (UK): Hospitalized Patients with COVID-19 and HIV: A Case Series
Madrid (Spain): Description of COVID-19 in HIV-Infected Individuals: A Single-Centre, Prospective Cohort
Milan (Italy): Clinical Features and Outcomes of HIV Patients with Coronavirus Disease 2019
Multi Center: COVID‑19 Among People Living with HIV: A Systematic Review
Newark, NJ (USA): COVID-19 Pneumonia in Patients with HIV – A Case Series
New York, NY (USA): Presenting Characteristics, Comorbidities, and Outcomes among 5,700 Patients Hospitalized with COVID-19 in the New York City Area
New York, NY (USA): Outcomes among HIV-Positive Patients Hospitalized with COVID-19
New York, NY (USA): Clinical Features and Outcomes of HIV/SARS‐CoV‐2 Coinfected Patients in the Bronx, New York City
New York, NY (USA): HIV-1 Infection Does Not Change Disease Course or Inflammatory Pattern of SARS-CoV-2-Infected Patients Presenting at a Large Urban Medical Center in New York City
New York, NY (USA): COVID-19 Outcomes Among Persons Living With or Without Diagnosed HIV Infection in New York State
Rome (Italy): COVID‐19 in people living with HIV: Clinical implications of dynamics of the immune response to SARS‐CoV‐2
Uganda: HIV and SARS-CoV-2 Coinfection: A Case Report From Uganda
United Kingdom: Features of 16,749 Hospitalised UK Patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol
United Kingdom: HIV infection and COVID-19 death: a population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform
Wuhan (China): Recovery from COVID-19 in Two Patients With Coexisted HIV Infection
Wuhan (China): A Survey for COVID-19 among HIV/AIDS Patients in Two Districts of Wuhan, China
Cohort Study: HIV and SARS-CoV-2 Co-infection: A Systematic Review of the Literature and Challenges
Review Article: COVID-19 in Immunocompromised Hosts: What We Know So Far
Review Article: Human Immunodeficiency Virus (HIV) and outcomes from coronavirus disease 2019 (COVID-19) pneumonia: A Meta-Analysis and Meta-Regression
Review Article: Immune deficiency is a risk factor for severe COVID-19 in people living with HIV
Review Article: Overview of SARS-CoV-2 infection in adults living with HIV
Cape Town (South Africa): Maternal and neonatal outcomes of COVID-19 in a high-risk pregnant cohort with and without HIV
Review Article: SARS-CoV-2 infection and coronavirus disease 2019 severity in persons with HIV on antiretroviral treatment
European and UK Resources
Coronavirus (European Centre for Disease Control and Prevention)
EACS & BHIVA Statement on Risk of COVID-19 for People Living with HIV (European AIDS Clinician Society and British HIV Association)
Mental health and wellbeing in the time of coronavirus – tracking the impact (Public Health England)
Coronavirus (COVID-19) (US Centers for Disease Control and Prevention)
HIV and COVID-19 Basics (US Centers for Disease Control and Prevention)
Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions (US Department of Health and Human Services)
COVID-19 Treatment Guidelines: Special Considerations in People With HIV (National Institutes of Health)
COVID-19 (2019 novel coronavirus) resource center for physicians (American Medical Association)
IDSA Guidelines on the Treatment and Management of Patients with COVID-19 (Infectious Diseases Society of America)
COVID-19: Special Considerations for People Living with HIV (Infectious Diseases Society of America)
Guidance for COVID-19 and People with HIV (Guidelines Working Groups of the NIH Office of AIDS Research Advisory Council)
Coronavirus, COVID-19, and Considerations for People Living with HIV and LGBTQIA+ People (Fenway Institute)
Animals and COVID-19 (US Centers for Disease Control and Prevention)
Nursing Home Infection Preventionist Training Course (US Centers for Disease Control and Prevention)
Reducing Stigma (US Centers for Disease Control and Prevention)
Coping with Stress (US Centers for Disease Control and Prevention)
Help for Mental Illnesses (US National Institutes for Health)
Contact Tracing (US Centers for Disease Control and Prevention)
Ready, Set, PrEP (HIV.gov)
APA COVID-19 Information and Resources (American Psychological Association)
Small and Large Gatherings (US Centers for Disease Control and Prevention)
CDC Updates and Shortens Recommended Isolation and Quarantine Period for General Population (US Centers for Disease Control and Prevention)
CDC COVID Data Tracker (US Centers for Disease Control and Prevention)
Coronavirus (COVID-19) and People with HIV (U.S. Department of Health & Human Services)
White House National COVID-19 Preparedness Plan 2022
National COVID-19 Preparedness Plan (The White House)
COVID-19: The Biden-Harris plan to beat COVID-19
Test to Treat (Office of the Assistant Secretary for Preparedness and Response)
New ‘Test to Treat Initiative’ Makes COVID Treatments More Accessible to Those Who Need Them Most (Office of the Assistant Secretary for Preparedness and Response)
Fact Sheet: COVID-19 Test to Treat (Office of the Assistant Secretary for Preparedness and Response)
Latin America/Caribbean Resources
PAHO Coronavirus Disease (COVID-19) pandemic (Pan American Health Organization)
COVID-19 Latest Updates on the COVID-19 Crisis from Africa (Africa CDC)
WHO Regional Office for Africa (WHO Regional Office, Africa)
COVID-19 Coronavirus South African Resource Portal (Department of Health, South Africa)
COVID-19 and coronavirus in people living with HIV (NAM, AIDSMAP)
Coronavirus information for people living with HIV (POZ)
HIV and COVID-19: What Do We Know Now? (POZ)
People with HIV can produce an adequate immune response to SARS-CoV-2 (NAM, AIDSMAP)
Legal/Human Rights Resources
Human Rights and Covid-19 Pandemic (JBRA Assisted Reproduction)
Multisystem Inflammatory Syndrome in Children and Adolescents Temporally Related to COVID-19 (World Health Organization)
Paediatric Inflammatory Multisystem Syndrome and SARS-CoV-2 Infection in Children (European CDC)|
Covid-19 vaccine for 5- to 11-year-olds is safe and shows ‘robust’ antibody response, Pfizer says (CNN Health)
Viral Hepatitis Resources
COVID-19 Information for People Affected by Hepatitis B or C (Hepatitis Australia)
COVID-19 Information for People Living with Viral Hepatitis (World Hepatitis Alliance)
Paxlovid for the Treatment of COVID-19: Considerations for People with HIV and Hepatitis C (Infectious Diseases Society of America, HIVMA)
AMA Telehealth quick guide (American Medical Association)
General Provider Telehealth and Telemedicine Tool Kit (American Academy Family Physicians)
Information Note: Tuberculosis and COVID-19 (World Health Organization)
Ensuring Continuity of TB Services During the COVID-19 Pandemic (World Health Organization)
Tuberculosis and COVID-19: What to Do? (Stop TB Partnership)
Vaccines for COVID-19 (US Centers for Disease Control and Prevention)
COVID-19 Vaccine Booster Shots (US Centers for Disease Control and Prevention)
Allergic Reactions after COVID-19 Vaccination (US Centers for Disease Control and Prevention)
COVID-19 Vaccines for People who are Moderately or Severely Immunocompromised (US Centers for Disease Control and Prevention)
COVID-19 vaccines in people with HIV (AIDSMAP)
Comirnaty and Pfizer-BioNTech COVID-19 Vaccine(US Food & Drug Administration)
Spikevax and Moderna COVID-19 Vaccine(US Food & Drug Administration)
Janssen COVID-19 Vaccine (US Food & Drug Administration)
COVID-19 Vaccines and People with HIV – Frequently Asked Questions (HIVMA)
COVID-19 Vaccination Recommendations for People with HIV (HIVMA)
Recomendaciones de vacunación para la COVID-19 en personas con VIH (Español) (HIVMA)
COVID-19 Vaccines and HIV (UNAIDS)
BNT162b2 vaccine breakthrough: clinical characteristics of 152 fully vaccinated hospitalized COVID-19 patients in Israel
Effectiveness of SARS-CoV-2 mRNA Vaccines for Preventing Covid-19 Hospitalizations in the United States
Household Transmission of SARS-CoV-2 in the United States
Altered Immunocompetence: General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP) (US Centers for Disease Control and Prevention)
Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Signing the Advisory Committee on Immunization Practices’ Recommendation for an Additional Dose of an mRNA COVID-19 Vaccine in Moderately to Severely Immunocompromised People (US Centers for Disease Control and Prevention)
The Advisory Committee on Immunization Practices’ Updated Interim Recommendation for Allocation of COVID-19 Vaccine (US Centers for Disease Control and Prevention)
COVID-19 Vaccine Boosters (US Centers for Disease Control and Prevention)
Safety and efficacy of the mRNA BNT162b2 vaccine against SARS-CoV-2 in five groups of immunocompromised patients and healthy controls in a prospective open-label clinical trial
Safety and antibody response to the first dose of severe acute respiratory syndrome coronavirus 2 messenger RNA vaccine in persons with HIV
The BNT162b2 mRNA Vaccine Elicits Robust Humoral and Cellular Immune Responses in People Living With Human Immunodeficiency Virus (HIV)
Association Between Immune Dysfunction and COVID-19 Breakthrough Infection After SARS-CoV-2 Vaccination in the US
COVID-19 infections post-vaccination by HIV status in the United States
Similar risk of SARS-CoV-2 infection and similar nucleocapsid antibody levels in people with well-controlled HIV and a comparable cohort of people without HIV
Anti-spike antibodies and neutralising antibody activity in people living with HIV vaccinated with COVID-19 mRNA-1273 vaccine: a prospective single-centre cohort study
Variants of Concern
Variants of the Virus (US Centers for Disease Control and Prevention)
What You Need to Know about Variants (US Centers for Disease Control and Prevention)
Omicron Variant: What You Need to Know (US Centers for Disease Control and Prevention)
Understanding Variants (US Centers for Disease Control and Prevention)
SARS-CoV-2 Variant Classifications and Definitions (US Centers for Disease Control and Prevention)
Tracking SARS-CoV-2 variants (World Health Organization)
SARS-CoV-2 variants of concern as of 12 May 2022 (European Centre for Disease Prevention and Control)