Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from How primary healthcare in swiftly changed its strategy in response to the COVID-19 pandemic

Emil Larus Sigurdsson ‍ ‍ ,1,2 Anna Bryndis Blondal,2,3 Jon Steinar Jonsson,1,2 Margret Olafia Tomasdottir,1,2 Hannes Hrafnkelsson,1 Kristjan Linnet ‍ ‍ ,2 Johann Agust Sigurdsson4

To cite: Sigurdsson EL, ABSTRACT Strengths and limitations of this study Blondal AB, Jonsson JS, et al. Objective To describe how the primary healthcare (PHC) How primary healthcare in in Iceland changed its strategy to handle the COVID-19 ►► The data are based on medical records of all con- Iceland swiftly changed its pandemic. strategy in response to the tacts to the primary healthcare centres. Design Descriptive observational study. COVID-19 pandemic. BMJ Open ►► The primary healthcare in the research area serve Setting Reykjavik, the capital of Iceland. 2020;10:e043151. doi:10.1136/ the whole capital area which counts two-­thirds of Population The Reykjavik area has a total of 233 000 bmjopen-2020-043151 the population of Iceland. inhabitants. ►► The contact register information is very reliable and ►► Prepublication history for Main outcome measures The number and the mode comprehensive. this paper is available online. of consultations carried out. Drug prescriptions and To view these files, please visit ►► Due to the short study period, that is, 2 months, we changes in the 10 most common diagnoses made in the journal online (http://​dx.​doi.​ were not able to depict the long-term­ changes in PHC. Laboratory tests including COVID-19 tests. Average org/10.​ ​1136/bmjopen-​ ​2020-​ healthcare services. numbers in March and April 2020 compared with the same 043151). ►► The consequences of postponing regular healthcare months in 2018 and 2019. service are not presented. Received 28 July 2020 Results Pragmatic strategies and new tasks were Revised 21 November 2020 rapidly applied to the clinical work to meet the foreseen Accepted 23 November 2020 healthcare needs caused by the pandemic. The number of daytime consultations increased by 35% or from 780 (PHC) is the cornerstone of healthcare and to 1051/1000 inhabitants (p<0.001) during the study the first point of contact.4 In epidemics and

period. Telephone and web-­based consultations increased a pandemic, as the first line of defence, the http://bmjopen.bmj.com/ by 127% (p<0.001). The same tendency was observed role of PHC in the healthcare system is more in out-­of-­hours services. The number of consultations important than ever. Whereas the hospitals © Author(s) (or their in maternity and well-­child care decreased only by 4% have to concentrate on the disease, people-­ employer(s)) 2020. Re-­use (p=0.003). Changes were seen in the 10 most common permitted under CC BY-­NC. No diagnoses. Most noteworthy, apart from a high number centred PHC has to focus on the patients as commercial re-­use. See rights of COVID-19 suspected disease, was that immunisation, well as the health of the whole community and permissions. Published by at a population health level. In such situa- BMJ. depression, hypothyroidism and lumbago were not among the top 10 diagnoses during the epidemic period. The tions, triage and gatekeeping play a central 1Department of Family Medicine, number of drug prescriptions increased by 10.3% (from on September 24, 2021 by guest. Protected copyright. Faculty of Medicine, University role. First, the task is to protect the health- of Iceland School of Health 494 to 545 per 1000 inhabitants, p<0.001). The number of care professionals in the first line of defence Sciences, Reykjavik, Iceland prescriptions from telephone and web-­based consultations from becoming infected. Other important 2Development Centre for rose by 55.6%. No changes were observed in antibiotics responsibilities include informing the popu- Primary , prescriptions. lation, identifying and protecting individuals Primary of the Conclusions As the first point of contact in the COVID-19 and groups of vulnerable people from getting Capital Area, Reykjavik, Iceland pandemic, the PHC in Iceland managed to change its 3 infected, and last but not least, protecting Faculty of Pharmaceutical strategy swiftly while preserving traditional maternity and Sciences, University of Iceland, well-­child care, indicating a very solid PHC with substantial the tertiary care level, the hospitals so they Reykjavik, Iceland would not become overwhelmed or out of 4 flexibility in its organisation. Faculty of Medicine, function because of infected staff and too Department of Public Health and Nursing/General Practice many COVID-19 cases. Some guidelines have Research Unit, Norwegian INTRODUCTION been published to assist general practitioners 5 6 University of Science and The COVID-19 pandemic caused by (GPs) on how to act on COVID-19. Technology (NTNU), Trondheim, SARS-­COV-2 has challenged the structure, Soon after the information about the Norway organisation and flexibility of healthcare spreading of COVID-19 from Wuhan in China Correspondence to systems worldwide and has in a certain way in late 2019, Iceland, like other countries, 1–3 Dr Emil Larus Sigurdsson; led to rebooting of the general practice. In started to prepare for an epidemic (box 1). emilsig@​ ​hi.is​ the global health policy, primary healthcare Before COVID-19 was diagnosed in Iceland

Sigurdsson EL, et al. BMJ Open 2020;10:e043151. doi:10.1136/bmjopen-2020-043151 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from

During this pandemic, the PHC in Iceland has had the Box 1 Preparation and implementation of tasks in role as the first point of contact for people with symptoms primary care during COVID-19 of the respiratory tract including COVID-19 -like symp- Preparation (January 2020) toms. Directions or indications for tests were published ►► Educating staff about COVID-19 disease and the use of personal and promoted by the Directorate of Health. Most of protective equipment (PPE). the tests for COVID-19 in clinical situations were taken ►► Providing and ordering appropriate materials and supplies. in primary healthcare centres (PHCCs). Patients with ►► Educating staff about alternative management plans at work. confirmed COVID-19 infection were taken care of by Testing and treatment a special unit at Landspitali—The National University Hospital of Iceland. People in quarantine were cared ►► Patients with symptoms compatible with those of COVID-19 were offered nasopharyngeal and throat testing with specimens collected for by the PHC. The organisation of PHC in Iceland was by doctors and nurses wearing PPE. rapidly and substantively changed in order to meet the ►► All primary healthcare centres (PHCCs) had daily testing outside demands posed by the pandemic. their premises, with samples collected while patients were sitting in Thus, when the first case of COVID-19 was diagnosed their cars. At the weekends, the COVID-19 sample collections were in Iceland on 28 February 2020, the PHC sector was centralised at a single place. confronted with an entirely new and unprecedented ►► A specially equipped car was used for home visits to those who disease and the PHC preparations and actions taken were too ill to get tested at a drive-­through centre. were accelerated (box 1). To face those challenges, our ► COVID-19-­positive patients received follow-­up care by an outpa- ► PHCCs had to adapt swiftly on a much larger scale than tient clinic staffed by Landspitali—The National University Hospital of Iceland. ever before, and completely alter their tasks to defeat the enormous and acute encounter ahead. The spread The shift in workload management of COVID-19 in Iceland has already been described.9 To Patient flow systems date, information on the role of PHC in the COVID-19 ►► Patients were advised to call in advance before arriving at the pandemic is lacking and only a few reports have been PHCCs. published on that matter.10 ► Telephone consultations were offered instead of appointments. ► The aim of this paper is to describe the changes in PHC ►► The maternity and well-child­ care consultations were carried out as scheduled. in Iceland during the COVID-19 pandemic, especially in ►► Those with symptoms of respiratory tract infections were given the mode of service and in certain measures of outcomes. appointments at the healthcare centre, which did not overlap with maternity and well-child­ care consultations. ►► New PHCC bookings were scheduled through telephone screening METHODS by a nurse or a doctor. Setting

PHC preparedness The Icelandic healthcare system, like other Nordic http://bmjopen.bmj.com/ ►► The PHC personnel were divided into two groups: those working at welfare systems, is based on solidarity and equitable distri- the PHCC and the others at home carrying out phone consultations bution of services. It is mainly financed through public on the web. funds, even though the patient pays some minor fees at ►► The PHCCs were separated into two areas, one for patients with 11 respiratory tract infections and the other one for patients without the time of service. The general tasks of the PHCCs are them. Patients with respiratory symptoms were scheduled for the defined by laws and regulations, and their administration end of the day. is under the auspices of the health authorities. Thus, the ►► PHC personnel prioritised work related to COVID-19. Non-­urgent management decisions are made locally in accordance

appointments were rescheduled, and all group activities cancelled. with government policy. The healthcare offered by the on September 24, 2021 by guest. Protected copyright. ►► The access of patients was increased through telephone consul- PHCCs is based on a holistic approach thereby including tations and web chat. For example, school nurses were released general practice, maternity care, well-child­ care, school from their routine duties so they could conduct telephone COVID-19 healthcare, minor surgery and emergency care. consultations. The of Iceland had approximately 233 000 inhabitants at the beginning of 2020, or almost two-­ thirds of the total 364 000 inhabitants.12 The PHC in the Directorate of Health had published a Pandemic Reykjavik, the capital area, has 19 PHCCs. The PHCCs are National Response Plan.7 The plan was updated during staffed by GPs, midwives, nurses, psychologists and other the pandemic and adapted to these special circum- personnel. The Capital Region has PHC out-of-­ ­hours stances.8 After the first case was diagnosed, Iceland’s service, and a walk-in­ clinic which also provides home Director of Health, Iceland’s Chief Epidemiologist and visits for those too sick to attend the clinic. Additionally, the National Commissioner of the ’s PHC operates a web chat for all residents. Department of Civil Protection and Emergency Manage- The access to PHCCs is through prebooked face-to-­ ­face ment held daily public meetings with updates on the state consultations, phone consultations, web-­based consulta- of the pandemic and government reactions. Already on 6 tions and home visits. Furthermore, a walk-­in service at March, the team declared the highest alert level, an emer- the PHCCs is available during daytime for more acute gency phase, as a result of the outbreak. needs.

2 Sigurdsson EL, et al. BMJ Open 2020;10:e043151. doi:10.1136/bmjopen-2020-043151 Open access BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from

It was clear from the beginning of the pandemic that was considered at p values less than 0.05, using an exact through advertisements in the media and on-­site posters test based on the Poisson distribution for rates. Results in PHCCs, triage was needed. A week later, all patients are presented per 1000 inhabitants. R statistical software with a prebooked appointment were offered a phone was used for analysis. consultation instead of an inperson visit. At the beginning of March, patients with symptoms Patient and public involvement compatible with those of COVID-19 were offered a test. No patient involved. All PHCCs had daily testing outside their healthcare premises, with samples collected through the windows of the patients’ cars. Doctors and nurses wearing all the RESULTS necessary personal protective equipment, collected naso- Implementation of tasks and shift in workload manage- pharyngeal and throat samples from patients. During ment are shown in box 1. From the beginning, the PHC the weekends, COVID-19 virus testing was centralised in prioritised work related to COVID-19, and matters that one place. Moreover, during the day and out of hours, could wait were set aside. School nurses were called in to a specially equipped car was used for home visits to do phone consultations related to COVID-19. New PHC those too sick to get tested at a drive-­through centre. appointments were booked through telephone screening In these visits, samples were collected and people were by a nurse or a doctor and great emphasis was put on assessed for the need of hospital admission. COVID-19-­ providing maternity and well-­child care. positive patients received follow-up­ care by an outpatient The healthcare centres were also divided into two areas, clinic operated by Landspitali—The National University either for patients with or without symptoms of respira- Hospital of Iceland. tory tract infection. As of the middle of March, the PHCCs and the after-­ Data source hours service designated special rooms in their premises Data were extracted from the medical records data- for patients with possible infections and all staff wore base of the PHC in Iceland. The PHC has a common masks and gloves for general consultations. From the very medical records database that is accessible by the PHCCs. beginning it was emphasised that people should call ahead The number of contacts to PHC, types of contact, most to the PHCC in order to get permission to present there. common diagnoses according to ICD-10 (International This message was driven home with increased intensity as Classification of Diseases, Tenth Revision) version of the the pandemic approached its culmination. Furthermore, classification system for diagnoses and medical prescrip- when receptionists at the PHCC contacted clients who tions were observed for March and April in the years 2018, had appointments in order to offer a telephone consulta- 2019 and 2020. The number of blood and urine tests tion, they were asked either to call in advance or refrain

was gathered from the laboratory at Landspitali—The from turning up if any common cold symptoms should http://bmjopen.bmj.com/ National University Hospital of Iceland. Furthermore, the arise in the meantime. number of COVID-19 tests performed in March and April 2020 was obtained from the Directorate of Health. Consultation rates and modalities On average during the two periods, March/April 2018 Data analyses and 2019, the number of daytime consultations were The data analyses are descriptive and analytical, centring 780/1000 inhabitants. In the same period in 2020 the on changes in the services provided during these periods. consultations were 1051/1000 inhabitants which is a 35% All p values are two-­sided and the statistical significance (p<0.001) increase from the average number per 2018 and on September 24, 2021 by guest. Protected copyright.

Table 1 Number and mode of consultation in primary healthcare centres and out-of-­ ­hours service during March and April 2018/2019 versus 2020 PHC OHS Total 2018/2019 2020 2018/2019 2020 2018/2019 2020 N N % P value N N % P value N N % P value Telephone 335 567 +69 * 125 320 +156 * 460 887 +93 * consultations Office visits 357 209 −41 * 69 37 −46 * 426 246−42* Web-­based 88 275 +213 * 88 275 +213 * consultation Home visits 4 7 +75 * 4 7 +75 *

N=number per 1000 inhabitants. *All changes are statistically significant, p<0.001. OHS, out-­of-­hours service; PHC, primary healthcare.

Sigurdsson EL, et al. BMJ Open 2020;10:e043151. doi:10.1136/bmjopen-2020-043151 3 Open access BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from

but in the same period in 2020 they were 93/1000 inhab- itants (p<0.0001).

Tests for COVID-19 During the 2-­month period, a total of 10 162 samples was collected at the PHCCs and examined in the Department of Clinical Microbiology, Landspitali—The National University Hospital of Iceland. That is 43 samples per 1000 inhabitants. Of those tests 1089 (11%) turned out positive.

Laboratory tests The number of laboratory tests in prenatal care increased by 10% (p<0.001) between the years 2018/2019 and 2020. The number of laboratory tests in general was 335/1000 Figure 1 The number of different daytime consultation inhabitants in the years 2018/2019 but in 2020 it was modes for each week in March and April 2020. 244/1000 inhabitants, a 27% decrease (p<0.001). The most common blood tests in both periods were blood

2019 (table 1). Telephone consultations increased by 69% count, thyroid stimulating hormone, vitamin B12. The (p<0.001), web-based­ consultations by 213% (p<0.001) most common test in 2020 was test for COVID-19 from and office visits decreased by 41% (p<0.001) (table 1). throat and nasopharynx swabs. Total number of consultations in maternity and well-child­ care (telephone, office and home visits) decreased from Most common diagnoses 67.5/1000 inhabitants 2018/2019 to 65/1000 inhabitants During the pandemic, the 10 most common diagnoses 2020 or only by 4% (p=0.001). School healthcare service were substantially different from the most common diag- was stopped but maternity and well-child­ care services noses in the same months the 2 years before. Common remained stable (figure 1). diagnoses like immunisation, depression, hypothyroidism and lumbago are not among the most common diagnoses Out-of-hours consultations in the pandemic period (figure 2). Telephone consultations increased from 125/1000 inhab- itants in 2018/2019 to 320/1000 inhabitants in 2020, an Changes in the mode of patient contact leading to increase by 156% (p<0.001). Home visits increased also prescriptions and their number from 4/1000 inhabitants to 7/1000 inhabitants, a 75% All prescriptions increase. However, the number of office visits decreased In March/April 2018–2019, there was an average of 494 http://bmjopen.bmj.com/ from 69/1000 inhabitants to 37/1000 inhabitants, a 46% prescriptions issued by GPs per 1000 inhabitants and a decrease (p<0.001) (table 1). total of 545 prescriptions per 1000 inhabitants in March/ April 2020 (p<0.001), an increase of 10.3%. The number Web chat of prescriptions from telephone and web-based­ consul- In 2018 a web-­chat room was established in PHC where tations rose by 55.6% from 293 per 1000 inhabitants people could seek advice and guidance. In March/April in 2018/2019 to 456 in 2020 (p<0.001). At the same 2018 and 2019 there were 2 contacts/1000 inhabitants time, prescriptions issued by GPs during office visits, on September 24, 2021 by guest. Protected copyright.

Figure 2 The 10 most common diagnoses (ICD-10) made in 2020 (left) and 2018/2019 (right). Numbers are per 1000 inhabitants.

4 Sigurdsson EL, et al. BMJ Open 2020;10:e043151. doi:10.1136/bmjopen-2020-043151 Open access BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from

DISCUSSION Our study illustrates the importance of well-established­ PHC as the place of first contact during the COVID-19 pandemic 2020. By prompt detection and effective triage of potentially infected patients the PHC managed to establish levels of care. Furthermore, our study shows the capacity and flexibility of the comprehensive service of primary care in the capital area of Reykjavík, Iceland. The size of the PHCCs, the number of professionals as well as teamwork allowed dividing up areas and services according to risk estimates, keeping the maternity care and well-child­ care almost at the same level as before. However, the increase in the frequency of feared health complaints (ICD-10 Z71.1) and lack of face-­to-face­ contacts during this period, indicates a longer-lasting­ follow-­up as a consequence of this pandemic. Our data show a substantial increase in number of contacts with our patients during this pandemic, and an Figure 3 The number of prescriptions/1000 inhabitants in abrupt change in mode of appointments compared with primary healthcare. Changes in the mode of patient contact the same period 2018 and 2019. Those changes were in during COVID-19. harmony with recommendations from health authorities. The role of out-of-­ hours­ consultations in PHC is always plummeted as the standard care during COVID-19 by of immense importance and in this pandemic it played an 56.2% from 201/1000 to 88/1000 inhabitants in 2020 even more significant role as part of the front-line­ health- (p<0.001) (figure 3). care responses. Interestingly, there was an enormous rise in web-­based Antibiotic prescriptions consultations during the pandemic indicating that our The average number of antibiotic prescriptions was 45 traditional ways of assisting our patients, by either face-­to-­ per 1000 inhabitants in March/April 2018–2019, and face or telephone conversations, have to be revised.13–15 a total of 44 per 1000 inhabitants in March/April 2020 Of special interest is the fact that in spite of the increase (p=0.1). However, results also display an increase in tele- in web-­based and telephone consultations instead of phone and web-­based consultation prescriptions in 2020 face-­to face contacts, the number of antibiotic prescrip- (136.4%) compared with more traditional direct office tions remained constant compared with the years http://bmjopen.bmj.com/ visit contacts, from 11/1000 inhabitants to 26/1000 before. This indicates that COVID-19-like­ symptoms and inhabitants in 2020 (p<0.001). Meanwhile, prescriptions fear of superinfections had little impact on antibiotic issued after office visits were reduced from the average prescriptions.16 in 2018 and 2019 to 2020 by almost half (47.1%) from Regarding the changes in the 10 most common diag- 34/1000 inhabitants to 18/1000 inhabitants (p<0.001) noses it is of particular interest to observe the high number (figure 4). of individuals diagnosed with feared health complications in 2020. This undoubtedly indicated an area of worries in

the community. on September 24, 2021 by guest. Protected copyright. Our results show, as was expected that the list of the 10 most common diagnoses in the pandemic included diag- noses related to COVID-19, but still common diagnoses as hypertension, anxiety, insomnia and pain are among the 10 most common diagnoses. However, diagnoses such as depression, hypothyroidism and lumbago were not among 10 most common diagnoses during the epidemic. The decrease in the use of laboratory tests might indi- cate a change in ordinary patient care. Nevertheless, the number of drug prescriptions did not decrease and in fact increased slightly, suggesting that the prescription of continuous medication was not disrupted. Studies or reports on how general practice faced COVID-19 are scarce so comparison of our study with others is very 10 Figure 4 The number of antibiotic prescriptions/1000 limited. inhabitants in primary healthcare. Changes in the mode of One of the main concerns of the health authori- patient contact during COVID-19. ties in Iceland as well as elsewhere, was whether the

Sigurdsson EL, et al. BMJ Open 2020;10:e043151. doi:10.1136/bmjopen-2020-043151 5 Open access BMJ Open: first published as 10.1136/bmjopen-2020-043151 on 7 December 2020. Downloaded from hospitals, especially the intensive care units, would be Conclusions and implications overwhelmed. The number of respirators was the crit- We conclude that PHC in Iceland managed to accomplish ical obstacle. Therefore, the plan was, among other its role as a first-line­ gatekeeper and was able to change its things, to delay the spread of the virus, thereby sharp- strategy swiftly in an effort to deal with COVID-19. At the ening the gatekeeping role of the PHC and spreading same time the traditional maternity and well-­child care the workload. was preserved. The use of PHC for non-COVID-­ ­related Numerous studies have been published on secondary issues decreased, indicating a substantial flexibility in the care and hospitals' approach to the care of patients with organisation. Whether and how new technology, such COVID-19 during the pandemic, but studies in primary as web-based­ and video consultations, will be taken into care are still scarce. At present most of the literature consideration as a future option for PHC is a topic for published on the effect on primary care are reports from further research and quality development. opinion leaders, describing the actions to be taken and confirming the importance of primary care as the first Acknowledgements The authors thank the chief medical doctor at the Primary 1–3 17–20 Health Care of the Capital Area, Reykjavik, the Primary Health Care of Hofdi, contact of care. Reykjavik, the Primary Health Care of Lagmuli, Reykjavik, the Primary Health Care Furthermore, the importance of telemedicine (audio of Urdarhvarf, Reykjavik, the Primary Health Care of Salastodin, Reykjavik, and The and or video consultations) has been acknowledged.21 Out-of-­ Hours­ Clinic in Reykjavik, Iceland. Our results are in agreement with a recent compre- Contributors All authors contributed to the planning, conduct and reporting of the hensive quantitative study from USA showing changes study. ELS, JSJ, MOT, HH, KL worked on acquisition of the data. ELS, ABB and JSJ drafted the manuscript with input from MOT, HH, KL and JAS which was critically in the structure of the primary care delivery, especially reviewed by all the authors. HH performed the statistical analysis. ELS, ABB, JSJ, 22 with regard to telemedicine encounters. Although not MOT, HH, KL, JAS read and approved the final version of the manuscript. directly comparable to our results a recent study from Funding This research was supported by the Research Fund of the Icelandic Belgium, based on qualitative interviews with GPs, illus- College of Family Physicians. trates that the sudden shift in healthcare delivery has a Competing interests None declared. profound impact on the core competencies of primary Patient and public involvement Patients and/or the public were not involved in care.23 A quantitative analysis of primary care medical the design, or conduct, or reporting, or dissemination plans of this research. records in a deprived area in the UK showed that the indi- Patient consent for publication Not required. rect effect of the COVID-19 pandemic in that area was Ethics approval The study was approved by The National Bioethics Committee a decrease in common diagnoses such as diabetes, indi- and the Data Protection Authority in Iceland (VSN-20-095). cating a large number of patients having underdiagnosed Provenance and peer review Not commissioned; externally peer reviewed. 24 conditions. Our study also showed changes in the diag- Data availability statement Data are available upon reasonable request. The nosis pattern and indicated that the flexibility in our PHC data were retrieved from a medical records database in the Primary Health Care could preserve preventive measures and probably the of the Capital Area (PHCCA). The encrypted data are kept at the PHCCA and can be made available on reasonable request if permitted by the abovementioned health http://bmjopen.bmj.com/ most common diagnoses. Moreover, our study supports authorities. the experience from the coronavirus outbreak in China Open access This is an open access article distributed in accordance with the regarding the importance of PHC, especially that we will Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which 17 be ‘first in and last out’. permits others to distribute, remix, adapt, build upon this work non-commercially­ , After the first wave of the COVID-19 epidemic in and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use Iceland, national data on 8 June show that 1807 persons is non-­commercial. See: http://​creativecommons.org/​ ​licenses/by-​ ​nc/4.​ ​0/. became infected with the SARS-CoV­ -2 virus (4.9/1000) of ORCID iDs

whom 118 patients were hospitalised (or 6.5% of those on September 24, 2021 by guest. Protected copyright. infected) and of whom 30 needed intensive care. Ten Emil Larus Sigurdsson http://orcid.​ ​org/0000-​ ​0003-0796-​ ​565X Kristjan Linnet http://orcid.​ ​org/0000-​ ​0002-0189-​ ​9519 people died (0.5% of those infected).25 These figures are the lowest in the and also in compar- ison to others with similar age distribution and standard 26 of living. REFERENCES History has told us that epidemics ultimately resolve 1 Rasanathan JJK, Nolan T. A "Deep Breath In" for GPs. BMJ 2020;369:m1437. and they usually follow a certain pattern and the first 2 Kamerow D. Covid-19: Don't forget the impact on US family wave of COVID-19 epidemic in Iceland appeared to do physicians. BMJ 2020;368:m1260. 27 28 3 Fraher EP, Pittman P, Frogner BK, et al. Ensuring and sustaining a just that. pandemic workforce. N Engl J Med 2020;382:2181–3. If the COVID-19 pandemic continues for the next years 4 The Lancet. The Astana declaration: the future of primary health the PHC has gained important knowledge and experi- care? Lancet 2018;392:1369. 5 Razai MS, Doerholt K, Ladhani S, et al. Coronavirus disease 2019 ence on how to manage and optimise the care of their (covid-19): a guide for UK GPs. BMJ 2020;368:m800. patients during such a serious outbreak.29 However, due 6 Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ 2 020:m1182. to the methodological design of this study we were not 7 Landsáætlun CBRNE. Published by Iceland’s chief epidemiologist able to explore the possible long-­term effects of changing and the Icelandic Police’s department of civil protection and emergency management, 2020. the strategy in PHC which is definitely something future 8 Heimsfaraldur – Landsáætlun edition 3.1. published by Iceland’s researches must investigate. chief epidemiologist and the Icelandic Police’s department of civil

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Sigurdsson EL, et al. BMJ Open 2020;10:e043151. doi:10.1136/bmjopen-2020-043151 7