These trials were designed to assess the efficacy of HCQ, and may not be of sufficient power to detect any but the most common adverse events. Risk of bias summary: review authors' judgements about each 'Risk of bias' item for each included trial. Other outcomes (e.g. Hoffman M, Kleine-Weber H, Schroeder S, Krger N, Herrier T, Erichsen S, et al. Participants receiving at least one dose of HCQ had an increased risk of adverse events compared to those not receiving HCQ (RR2.39, 95% CI 1.83 to3.11; 700 participants; 1 RCT;Analysis 5.3). Ourpredefinedspecific adverse event, prolongation of the QTinterval on electrocardiogram (ECG), was reported by one trial (Cavalcanti 2020). We graded the effect estimate for participants hospitalized due to COVID19 as very low certainty, again downgrading by one level for serious indirectness and by two levels for very serious imprecision. Cochrane Handbook for Systematic Reviews of Interventions version 6.0 (updated July 2019). It's important to keep taking hydroxychloroquine. will be administered for 5 days to subjects presenting with concomitant influenza A or B infection".4Horby 2020 authors presented the percentage of participants in each arm receiving dexamethasone or azithromycin. We graded the effects estimate for participants who developed prolonged QT interval on ECG as very low certainty; data for this outcome came from one trial, and the certainty of the evidence was downgraded for risk of bias, as the trial was openlabel;indirectness, as severe COVID patients were excluded; and imprecision, as the low event rate and small sample size led to a broad confidence interval. One trial (22 participants) reported this comparison(Huang 2020). The other trials recruited from March until May or June 2020:in Brazil (Cavalcanti 2020);Egypt (AbdElsalam 2020); Iran (Davoodi 2020);Spain (Mitj 2020a);Taiwan (Chen 2020c); the UK (Horby 2020);the USA and Canada (Skipper 2020; around 90% of participants were in the USA); and one trial recruited participants in 30 countries globally(Pan 2020). Other experimental antivirals beingstudiedincludethe influenza treatments umifenovir (Arbidol),Deng 2020, and favipiravir, Cai 2020, and the antiretroviral protease inhibitor combination lopinavir/ritonavir (Cao 2020). This may lead to changes in survival analysis, which is what was employed for the primary outcome of time to negative PCR for SARSCoV2. BS receivessupport fromthe MRC (project number MR/V033441/1). Pagliano P, Piazza O, De Caro F, Ascione T, Filippelli A. Cochrane, 2019, Available from www.training.cochrane.org/handbook. 37/75 had umifenovir (Arbidol); 13/75 ribavirin; 13/75 lopinavir/ritonavir; 8/75 oseltamivir; 1/75 entecavir;6/75 corticosteroids;32/75 antibacterials. No significant difference was found for time to clinical improvement (HR 1.01, 95% CI 0.59 to 1.74; 119 participants; 1 RCT; Analysis 1.8) or time to negative PCR for SARSCoV2 on respiratory samples (HR 0.85, 95% CI 0.58 to 1.23; 150 participants; 1 RCT; Analysis 1.9). Imputation of PCR results not available as negative results, with no sensitivity analysis, nor reporting of how much missing data there were for each outcome. "The patient receives the medication (intervention or comparison) in sealed envelopes that are coded. Given theuncertain effects ofantiviral drugs fortreatmentof COVID19, or the effectiveness of the newly developed vaccines, identifying existing medicines that may be of benefit is of high importance. We took measures to limit bias in the review process by following the procedures outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). The trial was terminated early, and as the primary outcome was alongitudinal timeupdating variable, this could have led to misleading results. Safety of hydroxychloroquine among outpatient clinical trial participants for COVID-19, Coronavirus epidemic and chloroquine controversy, Treatment of COVID-19 cases and chemoprophylaxis of contacts as prevention (HCQ4COV19), Safety and efficacy of hydroxychloroquine associated with azithromycin in SARS-CoV-2 virus (Coalition Covid-19 Brasil II), Treatment of moderate to severe coronavirus disease (COVID-19) in hospitalized patients, Chloroquine diphosphate for the treatment of severe acute respiratory syndrome secondary to SARS-CoV2 (CloroCOVID19), Proflaxis using hydroxychloroquine plus vitamins-zinc during COVID-19 pandemia, Efficacy and safety of hydroxychloroquine and azithromycin for the treatment of hospitalized patients with moderate to severe COVID-19, ALBERTA HOPE COVID-19 for the prevention of severe COVID19 disease, Clinical trial of combined use of hydroxychloroquine, azithromycin, and tocilizumab for the treatment of COVID-19 (TOCOVID), Hydroxychloroquine in the prevention of COVID-19 infection in healthcare workers, A study of quintuple therapy to treat COVID-19 infection, A study of hydroxychloroquine, vitamin C, vitamin D, and zinc for the prevention of COVID-19 infection (HELPCOVID-19), Hydroxychloroquine vs nitazoxanide in patients with COVID-19, Hydroxychloroquine, hydroxychloroquine, azithromycin in the treatment of SARS CoV-2 infection (WU352), Efficacy of ivermectin as add on therapy in COVID-19 patients, Military COVID-19 hydroxychloroquine pre-exposure and post-exposure prophylaxis study, Unable to access - removed from clinicaltrials.gov website, Evaluate the efficacy and safety of oral hydroxychloroquine, indomethacin and zithromax in subjects with mild symptoms of COVID-19, A real-life experience on treatment of patients with COVID 19, Hydroxychloroquine as chemoprevention for COVID-19 for high risk healthcare workers, Clinical trial to evaluate efficacy of 3 types of treatment in patients with pneumonia by COVID-19 (Covid-19HUF), IMPACT: IMPact of Antimalarials on Covid-19 Infections in RAPPORT (IMPACT), Efficacy and safety of hydroxychloroquine and azithromycin for the treatment of ambulatory patients with mild COVID-19, Double therapy with IFN-beta 1b and hydroxychloroquine, Hydroxychloroquine treatment of healthcare workers with COVID19 illness at Montefiore, High-dose hydroxychloroquine for the treatment of ambulatory patients with mild COVID-19, Assessment of efficacy and safety of HCQ and antibiotics administrated to patients COVID19(+), Use of hydroxychloroquine alone or associated for inpatients with SARS-CoV-2 virus (COVID-19), Efficacy and safety study of allogeneic HB-adMSCs for the treatment of COVID-19, International ALLIANCE study of therapies to prevent progression of COVID-19. Investigation of three clusters of COVID-19 in Singapore: implications for surveillance and response measures. Chloroquine (CQ) or hydroxychloroquine (HCQ) given by any route of administration and dose used alone or in combination with other treatments. One trial (821 participants) reported this comparison (Boulware 2020). Setting:11 public hospitals in northern, central, and southernTaiwan. For the most part their conclusions match ours regarding the finding of HCQ showing no benefit for mortalityfrom COVID19, but with less precision. Mahvas M, Tran VT, Roumier M, Chabrol A, Paule R, Guillaud C, et al. Skipper CP, Pastick KA, Engen NW, BangdiwalaAS, Abassi M, Lofgren SM, et al. Of the remaining 860 records, we excluded 603 based on the assessment of titles and abstracts. Hydroxychloroquine should only be used for COVID-19 in a hospital or during clinical trials. For Objective 1 treatment of COVID19, we included nine RCTs and assessed seven outcomes. Dates of recruitment: 22 March to 6 May with followup for all outcomes until 15 June 2020. Hydroxychloroquine in the treatment of COVID-19: a multicenter randomized controlled study, American Journal of Tropical Medicine and Hygiene. Both drugs have been used widely and for many years for the treatment and prevention of malaria (although they are now largely ineffective against falciparum malaria)and in the treatment of rheumatological conditions, such as systemic lupus erythematosus and rheumatoid arthritis (Fiehn2020; Steinhardt 2011). Not reported. Comparison 3: HCQ + azithromycin versus standardcare for treatment, Outcome 4: Participants with any adverse events, Comparison 3: HCQ + azithromycin versus standardcare for treatment, Outcome 5: Participants with serious adverse events. Serological testsare being used for detecting antibodies to SARSCoV2 for confirmation of past infection, although there are concerns regarding the evidence fortheir accuracy and valuein certain populations and clinical situations (Deeks 2020). Adaptive factorial design RCT (RECOVERY) comparing a HCQwith standard of care (SOC) in patients hospitalized with COVID19. HR is a Specialist Registrar in Clinical Pharmacology in Liverpool, and is employed as a fulltime NHS clinician, and has no conflicts of interest to declare with respect to chloroquine or hydroxychloroquine for the management of COVID19. Reported as doubleblinded: Neither the research performers nor the patients were aware of the treatment assignments.. Appropriate method: the tablets were unmarked. Data on antibiotics and other antivirals not reported. It is used alone or in combination with other anti-arthritic medications to treat rheumatoid arthritis. Fiolet2020, published in August 2020, describes results from 29 studies including 3 RCTs, but studies with no mortality were excluded. We assessed Mitj 2020aas at high risk of bias for incomplete outcome data: 60 participants wereexcluded from the intentiontotreat (ITT) analysis due to negative baseline SARSCoV2 swab,missing reverse transcription polymerase chain reaction (RTPCR) at all followup visits, or consent withdrawal, and a further 23 participants had protocol deviations including eightparticipants lost to followup. However, only the primary outcome and adverse events were reported in the final report. No eligible trials provided outcome results for this objective. We performed a sensitivity analysis using modified intentiontotreat data, where trials reported this information. Adverse events were assessed through selfreporting by participants using an online survey inBoulware 2020, and through telephone and inperson visits in Mitj 2020b. No blinding, but unlikely to have affected outcome assessment. A variety of secondary outcomes were measured, including hospitalization due to COVID19, which partly addressed our outcome of disease severity in participants developing COVID19 (Boulware 2020; Mitj 2020b). The comparator in Boulware 2020was placebo in the form ofunmarked folic acidtablets, which closely resembled HCQ tablets, to be taken on the same schedule as HCQ. Chloroquine and hydroxychloroquine equally affect tumor necrosis factor-alpha, interleukin 6, and interferon-gamma production by peripheral blood mononuclear cells. Clinical characteristics of Coronavirus Disease 2019 in China. Experts can't agree, www.nature.com/articles/d41586-020-00974-w. Liu Y, Yan L-M, Wan L, Xiang T-X, Le A, Liu J-M, et al. Blinding of participants and personnel (performance bias), Blinding of outcome assessment (detection bias). Antibody tests for identification of current and past infection with SARS-CoV-2. Accordingly,we decided notto include results fromTang 2020in the analysis for this outcome, as participants remained in hospital until they were deemed no longer infectious. Metaanalysis of six trials that reported the number of participants experiencing serious adverseevents showed no significant difference between participants receiving HCQ and those receiving standard care (RR 0.82, 95% CI 0.37to 1.79;1004 participants; 6RCTs;Analysis 1.11) (Cavalcanti 2020; Chen 2020a; Chen 2020b; Chen 2020c; Mitj 2020a; Tang 2020). Adverse events have been a particular concern with CQ and HCQ. Mitj 2020breported underlying cardiovasculardiseasein 13% of participants, respiratory disease in 4%, metabolic disease in 8%, and some nervous system disease in 15%. cardiovasculardisease: HCQ: 130 (11.6%) and standard care: 178(14.9%); respiratory disease: HCQ: 64 (5.7%) and standard care: 47 (3.9%); metabolic disease: HCQ: 99 (8.9%) and standard care: 94 (7.8%); nervous system disease: HCQ: 170(15.2%) and standard care: 170 (14.2%). Exposure was deemed to be high risk (neither eye protection nora surgical mask/respirator was worn) in 88% of participants, with 60% inBoulware 2020 wearing no personal protective equipment. For continuous data, we planned to also perform sensitivity analyses using the methods described by Ebrahim 2013 and Ebrahim 2014. Shah 2020is a systematic review of the evidence for HCQ in preventing COVID19, which was published in March 2020. We performed all metaanalyses usingrandomeffects models. Ten trials were at high risk of bias for selective reporting (AbdElsalam 2020; Cavalcanti 2020; Chen 2020a; Chen 2020b; Chen 2020c; Davoodi 2020; Huang 2020; Mitj 2020a; Mitj 2020b; Skipper 2020), all of which reported outcomes that deviated from those stated in the protocol (described inCharacteristics of included studies). Only one trial included an arm with a combination of HCQ and azithromycin (217 participants), and so few conclusions can be drawn about the efficacy or safety of this combination treatment. Regarding our secondary outcomes, the following information was reported. Additionally,Skipper 2020used the change in symptoms over 14 days from enrolment as their primary outcome. BS and HR prepared initial drafts of Background and Methods; selected studies; assessed risk of bias; extracted data; synthesized data;and prepared initial drafts of results,'Summary of findings' tables, discussion, and conclusions. 1Authors of Chen 2020a comment that among the test group the occurrence of adverse events in subjects with moderate to severe disease is not related to medication. Primary: negative conversion of SARSCoV2 by 28 days and whether patients with severe COVID19 had clinical improvement by 28 days (Negative conversion: two consecutive reports of a negative result for SARSCoV2 at least 24 hours apart without a subsequent report of a positive result by the end of the study. Is hydroxychloroquine a possible postexposure prophylaxis drug to limit the transmission to healthcare workers exposed to coronavirus disease 2019? Of these, no participants died inChen 2020a; Chen 2020c; Mitj 2020a;Tang 2020.bNot downgraded for risk of bias, as most of the evidence comes from Horby 2020and Pan 2020, which havelow risk of bias for this outcome.cNot downgraded for indirectness, but it is noted that the population in the largest trial, Horby 2020, was mostly severely/critically unwell.dThis was selected as the most relevant of three related outcomes reported by trials in this review. Comparison 3: HCQ + azithromycin versus standardcare for treatment, Outcome 3: Length of hospital stay in days. The authors of both studies also speculate that CQ and HCQ could impact on disease severity in COVID19 through modulating the excess cytokine release that appears to contribute to lifethreatening forms of the disease (Liu 2020b; Wang 2020b). Three anti-malarial drugs are prescribed for lupus symptoms. For rheumatological conditions, the mechanism of action is not fully delineated, but appears to arise from multiple effects. We graded the effects estimate for participants with serious adverse events as low certainty, meaning that HCQ may result in no difference to the risk of developing serious adverse events compared with placebo; the certainty of the evidence was downgraded by one level for serious indirectness and one level for serious imprecision. A trial of lopinavirritonavir in adults hospitalized with severe Covid-19. Two review authors (BS and HR or MC) independently screened the search results using Covidence (Covidence), and retrieved the fulltext articles of all potentially relevant trials. Centralized webbased randomization was done. Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial, Emerging prophylaxis strategies against COVID-19, Does hydroxychloroquine combat COVID-19? Dates of recruitment: first patient randomized 29March 2020; the last patient underwent randomization on 17 May2020; followup was completed on 2 June 2020. The optimal information size to be confident that this is a true reflection of risk of serious adverse events would be larger than the total number of participants in this trial. QT prolongation was not assessed due to lack of inperson assessment (which would be necessary for electrocardiography to be performed) in Boulware 2020; there was one inperson assessment in Mitj 2020b, but at the participant's home, where electrocardiography may not have been practical. HIV and nonHIV immunosuppression were reported in 1/821 and 4/821 participants, respectively (Boulware 2020). 3arm RCT comparing HCQ with HCQ plus azithromycinand a control group receiving standard care for treatment of COVID19. Regarding outcomes forObjective 1 treatment of COVID19, the review uses a different primary outcome measure for virological clearance: negative polymerase chain reaction (PCR) test at 14 days is used in place of time to negative PCR for SARSCoV2; the latter was not measured and reported consistently by trials. Low-dose hydroxychloroquinetherapy and mortality in hospitalizedpatients with COVID-19: a nationwide observational study of 8075 participants. We graded the effect estimate for negative SARSCoV2 PCR at 14 days as low certainty, that is HCQ may make no difference to the proportion of people who have a negative SARSCoV2 swab at 14 days; the certainty of the evidence was downgraded by one level for serious risk of bias, as both trials in this analysis were at high risk of bias across several domains; and one level for serious indirectness, as almost all participants had mild or moderate COVID19, all were hospitalized, and all were from one country(Chen 2020a; Tang 2020). Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Setting:outpatients at Mostafavian Fever Clinic in Sari, Iran. Despite no human data on prophylaxis early in the pandemic, the Indian Council of Medical Research (ICMR)recommended HCQ as preexposure prophylaxis for frontline healthcare workers having highrisk contact with patients with suspected or confirmed COVID19, and postexposure prophylaxis for household and healthcare worker contacts of patients with confirmed COVID19 (ICMR 2020). In participants treated with HCQ compared with standard therapy,metaanalysis suggested increased mortality with HCQ (RR 1.92, 95% CI 1.26 to 2.93), although the authors identified significant unexplained heterogeneity and problems with study quality, and concluded that better RCTs are urgently needed. CQ was part ofstandard careat the start of the trial, but then abandoned. We also thank Paul Garner (CIDG Coordinating Editor) for hiscontributions to this review. But the FDA doesn't recommend it for this use.. Shah S, Das S, Jain A, Misra DP, Negi VS. A systematic review of the prophylactic role of chloroquine and hydroxychloroquine in coronavirus disease-19 (COVID-19), International Journal of Rheumatic Diseases, A pharmacovigilance study of hydroxychloroquine cardiac safety profile: potential implication in COVID-19 mitigation. If using the SMD, we would reexpress the SMD in the units of one or more of the specific measurement instruments used in the original studies, to aid interpretation. All adverse reactions after drug withdrawal or symptomatic treatment disappeared.2Skipper 2020 authors describe these adverse events as side effects reported at day 5. Pan 2020followed participants up to discharge from hospital. AbdElsalam 2020,Chen 2020b,Chen 2020c,Davoodi 2020,andPan 2020 did not report time from symptom onset to enrolment. We are uncertain whether HCQ increases or decreases the proportion of people with clinical improvement at day 28 from enrolment. Chloroquine or hydroxychloroquine for prophylaxis of COVID-19, Hydroxychloroquine prophylaxis for COVID-19 contacts in India. If the ICC was estimated, we would perform sensitivity analyses to investigate the robustness of our analyses. " Hydroxyurea is a monohydroxyl-substituted urea (hydroxycarbamate) antimetabolite. Concerns have been raised about airborne transmission: viability of SARSCoV2 has been demonstrated for at least three hours when suspended in an aerosol (van Doremalen 2020). Comparison 2: CQ versus lopinavir/ritonavirfor treatment, Outcome 4: Clinical improvement at day 10 from enrolment. This is likely due to the increased rate of adverse effects seen with CQ compared with HCQ in other conditions. Efficacy of tocilizumab in patients hospitalized with covid-19. No blinding or placebo used. Comparison 1: HCQ versus standard care without HCQ, or placebo, for treatment, Outcome 5: Proportion admitted to hospital (if receiving ambulatory treatment). Any disagreements were resolved through discussion. Of the total drug interactions, 23 are major, 37 are moderate, and 6 are minor. An earlytrial showed no benefit on time to clinical improvement,mortality, or clearance of the virus from the respiratory tract(Wang 2020c). Abstract Background: The American Academy of Ophthalmology recommendations on screening for chloroquine (CQ) and hydroxychloroquine (HCQ) retinopathy are revised in light of new information about the prevalence of toxicity, risk factors, fundus distribution, and effectiveness of screening tools. QTinterval prolongation was not measured in thistrial. Home Analysis Hydroxyurea Hydroxychloroquine-sulfate Hydroxyurea and Hydroxychloroquine sulfate drug interactions - a phase IV clinical study of FDA data Summary: Drug interactions are reported among people who take Hydroxyurea and Hydroxychloroquine sulfate. Our second primary outcome, production of antibodies toSARSCoV2, was assessed by Mitj 2020bat 14 days. Deng L, Li C, Zeng Q, Liu X, Li X, Zhang H, et al. Primary: time to negative rRTPCR assessments from randomization up to 14 days.. We graded the effect estimate for death as highcertainty, implying that treatment with HCQ results in no difference to death from any cause in people with COVID19. It was not possible to disaggregate data for specific serious adverse events for each trial, nor was it possible to disaggregate data for serious adverse events attributed to the intervention drug for each trial. Five participants in the HCQ clusters(with a denominator of 1197, which is unexplained in its deviation from the randomized total of 1225) and 8/1300 in the standard care clusters died (Mitj 2020b). Time to negative PCR for SARSCoV2 on respiratory samples, Number of participants admitted to hospital (if receiving ambulatory treatment), Number of participants requiring mechanical ventilation, Time to clinical improvement, as defined by study authors, Duration of mechanical ventilation postenrolment in survivors of COVID19, Development of confirmed COVID19, as defined by study authors, Development of COVID19 in household contacts of the recipient of the prophylaxis, Disease severity of participants who develop COVID19, as defined by study authors, All serious adverse events attributed to study drug (i.e. Two review authors (BS and HR, MC, or TK) assessed the methodological quality of studies using the Cochrane 'Risk of bias' tool, and reported the results in a 'Risk of bias' figure(Higgins 2011). We were unable to extract length of hospital admission as a mean, but visual inspection of the KaplanMeier chart appeared to show a median time to discharge of around 11 days for the CQ arm, and around 14 days for theLPV/r arm(Huang 2020). Randomization was performed centrally by means of an electronic casereport form system (RedCap) as described in the Supplementary Appendix., The trial statistician, not involved with patient enrolment or care, generated the randomization table in R software (R Core Team, 2019) and implemented in the RedCap. For safety outcomes, we planned to include all participants receiving at least one dose of the intervention drug or placebo. HCQ may result in little or no difference in serious adverse events when compared with placebo. Hydroxychloroquine is recommended in combination with primaquine for the treatment of uncomplicated malaria caused by chloroquine-sensitive P. falciparum or P. vivax, and P. malariae, P. knowlesi, P. ovale from all regions. Two trials provided a breakdown of contact history: 238/293(81%) had healthcare exposure history and 2% were household contactsinMitj 2020a; 51% ofparticipantsinSkipper 2020were healthcare workers, whilst29% had household exposure to someone with COVID19. Mitj O, Corbacho-Monn M, Ubals M, Tebe C, Peafiel J, Tobias A, et al. QTinterval prolongation on ECG was not reported, but followup was performed remotely using an online survey, so ECG was not performed as part of the trial (Boulware 2020). People who have been exposed to SARSCoV2, as defined by study authors. No report of loss to followup, or missing data. Comparison 1: HCQ versus standard care without HCQ, or placebo, for treatment, Outcome 6: Progression to mechanical ventilation. The pharmacological cointerventions reported per arm in the treatment trials for comparison 1 (HCQ versus standard care without HCQ or placebo) are shown in Table 7. There was no difference in the risk of symptomatic confirmed COVID19 or production of antibodies to SARSCoV2 between study arms. RCT investigating treatment with HCQ vs standard care without HCQ. People who have COVID19, as defined by study authors. Antimalarials for the treatment of COVID-19: systematic review - preliminary report. Does hydroxychloroquine prevent the transmission of COVID-19? Colson P, Rolain JM, Lagier JC, Brouqui P, Raoult D. Chloroquine and hydroxychloroquine as available weapons to fight COVID-19, Hydroxychloroquine as a treatment for coronavirus disease COVID-19, www.clinicaltrialsregister.eu/ctr-search/search?query=EUCTR2020-000890-25-FR, Clinical trial randomized, unblinded and controled for evaluation of efficacy and safety of hydroxychloroquine chemoprophylaxis against SARS-CoV-2 (COVID-19) infection in healthcare professionals, www.clinicaltrialsregister.eu/ctr-search/search?query=EUCTR2020-001421-31-ES++, Chloroquine and hydroxychloroquine in Covid-19, Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. The casecontrol study involveda telephone survey of healthcare workers tested for SARSCoV2when suspected of having symptomatic COVID19: the 378 cases (172 of whom took HCQ) had a positive PCR test for SARSCoV2, whilst 373 controls (193 of whomusedHCQ) had a negative test (Chatterjee 2020). No description beyond randomised using the balance block method. Accessibility No information about method of randomization in trial report, however baseline differences seem significant for duration of symptoms prior to hospital admission, age, baseline severity, and baseline radiographic characteristics. No trial protocol is available. Reviews published early in the outbreak relied on preclinical data, expert commentary, and small, mostly nonrandomized studies. The effect of human mobility and control measures on the COVID-19 epidemic in China, Is the coronavirus airborne? Interactions Print Save Hydroxyurea Interactions There are 248 drugs known to interact with hydroxyurea, along with 5 disease interactions. During the COVID19 outbreak in Catalonia, a public health ordinance required all patients who tested positive for COVID19 in any of the designated diagnostic laboratories to be notified to the SUVEC.. 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