Ref. Ares(2021)896652 - 02/02/2021
29th July 2020
COVID-19 ̶ KCE CONTRIBUTIONS
INTERNATIONAL COMPARISON OF COVID-19
TESTING AND CONTACT TRACING STRATEGIES
KCE: VICKY JESPERS, JUSTIEN CORNELIS, CHRIS DE LAET, DOMINIQUE ROBERFROID,
SOPHIE GERKENS
FPS HEALTH, FOOD CHAIN SAFETY AND ENVIRONMENT: LIEVEN DE RAEDT
SCIENSANO: ANA HOXHA
Acknowledgements: Tinne Lernout (Belgium), Sofieke Klamer (Belgium), Ilse Peeters (Belgium),
Sara Dequeker (Belgium); Natalia Bustos Sierra (Belgium); Dan Brun Petersen (Denmark), Bolette
Søborg (Denmark), Francesco Maraglino (Italy), Patrizia Parodi (Italy), Oscar Pérez Olaso (Spain),
Berta Suarez Rodríguez (Spain), Fernanco Simón Soria (Spain), Silvia Herrera Leon (Spain), Eline
van Daalen (The Netherlands), Anne-Ruthi Knevel (The Netherlands), Jerom Geffen (The
Netherlands), Ingrid Van Hattem (The Netherlands). No validation received from France nor
Germany by July 16th.
This document is a rapid review of scientific literature retrieved from several publicly funded COVID-
19 resource collections. The literature included in these repositories is not always peer-reviewed or
externally validated. KCE synthesised the evidence in a short time frame to respond to urgent
questions and could therefore not follow its regular methodological procedures.
1
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1
TABLE OF CONTENTS
LIST OF FIGURES ........................................................................................................ 7
LIST OF TABLES .......................................................................................................... 7
LIST OF ABBREVIATIONS ........................................................................................... 8
1
PROBLEM DESCRIPTION ............................................................................... 9
2
OBJECTIVE ...................................................................................................... 9
3
METHODS ...................................................................................................... 10
4
OVERVIEW OF EPIDEMICS IN SELECTED COUNTRIES............................. 10
5
DEFINITIONS ................................................................................................. 13
5.1
POPULATION AT RISK FOR SEVERE COVID-19 ILLNESS ........................................13
5.2
COVID-19 CASE DEFINITION .......................................................................................13
5.3
TESTING .........................................................................................................................14
5.3.1
Strategy ............................................................................................................14
5.3.2
Type of test .......................................................................................................14
5.4
CONTACTING AND TRACING / CONTACT IDENTIFICATION ....................................15
6
COMPARISON ............................................................................................... 16
6.1
TESTING STRATEGY ....................................................................................................16
6.1.1
Symptomatic persons .......................................................................................16
6.1.2
Asymptomatic persons .....................................................................................16
6.1.3
Laboratory organisation ....................................................................................16
6.1.4
Communication towards the patient .................................................................17
6.2
SURVEILLANCE STRATEGY ........................................................................................23
6.3
TRACING STRATEGY....................................................................................................26
6.3.1
Organisation of contact tracing .........................................................................26
6.3.2
Monitoring of contact tracing ............................................................................27
6.3.3
The use of contact tracing APPs ......................................................................27
6.4
ISOLATION AND QUARANTINE STRATEGIES ............................................................31
6.4.1
Isolation strategies ............................................................................................37
6.4.2
Quarantine strategies .......................................................................................40
6.4.3
Monitoring of compliance ..................................................................................40
6.5
OUTBREAK DETECTION AND CONTROL STRATEGIES ...........................................40
6.5.1
Surveillance systems ........................................................................................40
6.5.2
Systematic testing in nursing homes and high risk groups ..............................41
6.5.3
Outbreak or cluster identification and investigation ..........................................41
7
DISCUSSION AND CONCLUSIONS .............................................................. 47
7.1
HAVING A NATIONAL TESTING AND TRACING PLAN ADAPTED TO THE SPREAD
OF THE EPIDEMIC.........................................................................................................47
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2
7.2
AN ATTENTION ON STOCKS AS WELL AS ON LABORATORY CAPACITY AND
RAPIDITY ........................................................................................................................48
7.3
A RAPID INFORMATION SYSTEM FOR IMPROVED SURVEILLANCE AND
OUTBREAK DETECTION ..............................................................................................48
7.4
A FOCUS ON MONITORING OF NURSING HOMES OR SPECIFIC POPULATIONS 48
7.5
AN APPLICATION TO IMPROVE CONTACT TRACING? .............................................49
7.6
MEASURES FOR RECALCITRANT PEOPLE AND AN INCREASED MONITORING ..49
7.7
STUDY LIMITATIONS ....................................................................................................49
7.8
CONCLUSION ................................................................................................................50
■
APPENDIX ...................................................................................................... 51
1
RESULTS FOR BELGIUM .............................................................................. 51
1.1
EXISTENCE OF A PLAN TO PREVENT THE SECOND WAVE ...................................51
1.2
TESTING STRATEGY ....................................................................................................53
1.2.1
Indications for PCR testing ...............................................................................53
1.2.2
PCR testing conditions: how and by whom? ....................................................56
1.2.3
Indications and conditions for serological testing .............................................58
1.2.4
Laboratory capacity ..........................................................................................59
1.2.5
Communication of test results to the patient ....................................................61
1.2.6
Recording and surveillance of test results ........................................................61
1.2.7
How is testing reimbursed ................................................................................62
1.3
ISOLATION STRATEGIES AND MONITORING OF CONFIRMED CASES ..................63
1.3.1
Suspected cases (having symptoms) ...............................................................63
1.3.2
Confirmed cases ...............................................................................................63
1.4
CONTACT TRACING STRATEGY .................................................................................64
1.4.1
Contact definition ..............................................................................................64
1.4.2
Organisational process of contact tracing ........................................................66
1.4.3
Testing of contacts ............................................................................................68
1.4.4
Contact tracing Apps ........................................................................................68
1.5
QUARANTINE STRATEGIES AND MONITORING OF CONTACTS ............................69
1.6
EARLY CASE DETECTION METHODS.........................................................................70
1.6.1
Surveillance based indicators used to detect early cases ................................70
1.6.2
Identification of clusters ....................................................................................70
1.6.3
In hospitals ........................................................................................................70
1.6.4
In nursing homes and other collective residential facilities...............................71
1.6.5
In schools ..........................................................................................................72
1.6.6
Precarious population .......................................................................................73
1.7
COORDINATION AND RESPONSIBILITY OF TESTING AND TRACING ....................73
2
RESULTS FOR DENMARK ............................................................................ 75
2.1
EXISTENCE OF A PLAN TO PREVENT THE SECOND WAVE ...................................75
2.2
TESTING STRATEGY ....................................................................................................75
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2.2.1
Indications for PCR testing ...............................................................................75
2.2.2
PCR testing conditions: how and by whom? ....................................................76
2.2.3
Indications and conditions for serological testing .............................................77
2.2.4
Laboratory capacity ..........................................................................................77
2.2.5
Communication of test results to the patient ....................................................77
2.2.6
Recording and surveillance of test results ........................................................78
2.2.7
How is testing reimbursed? ..............................................................................78
2.3
ISOLATION STRATEGIES AND MONITORING OF CONFIRMED CASES ..................79
2.3.1
Suspected cases (having symptoms) ...............................................................79
2.3.2
Confirmed cases ...............................................................................................79
2.4
CONTACT TRACING STRATEGY .................................................................................79
2.4.1
Contact definition ..............................................................................................79
2.4.2
Organisational process of contact tracing ........................................................80
2.4.3
Testing of contacts ............................................................................................80
2.4.4
Contact tracing Apps ........................................................................................81
2.5
QUARANTINE STRATEGIES AND MONITORING OF CONTACTS ............................81
2.6
EARLY CASE DETECTION METHODS.........................................................................81
2.6.1
Surveillance based indicators used to detect early cases ................................81
2.6.2
Identification of clusters ....................................................................................82
2.6.3
In hospitals ........................................................................................................82
2.6.4
In nursing homes and other collective facilities ................................................82
2.6.5
In schools ..........................................................................................................83
2.6.6
Precarious population .......................................................................................83
2.7
COORDINATION AND RESPONSIBILITY OF TESTING AND TRACING ....................84
3
RESULTS FOR FRANCE ............................................................................... 85
3.1
EXISTENCE OF A PLAN TO PREVENT THE SECOND WAVE ...................................85
3.2
TESTING STRATEGY ....................................................................................................87
3.2.1
Indications for PCR testing ...............................................................................87
3.2.2
PCR testing conditions: how and by whom? ....................................................87
3.2.3
Indications and conditions for serological testing .............................................88
3.2.4
Laboratory capacity ..........................................................................................88
3.2.5
Communication of test results to the patient ....................................................89
3.2.6
Recording and surveillance of test results ........................................................89
3.2.7
How is testing reimbursed? ..............................................................................90
3.3
ISOLATION STRATEGIES AND MONITORING OF CONFIRMED CASES ..................91
3.3.1
Suspected cases (having symptoms) ...............................................................91
3.3.2
Confirmed cases ...............................................................................................91
3.4
CONTACT TRACING STRATEGY .................................................................................92
3.4.1
Contact definition ..............................................................................................92
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3.4.2
Organisational process of contact tracing ........................................................93
3.4.3
Testing of contacts ............................................................................................94
3.4.4
Contact tracing apps .........................................................................................94
3.5
QUARANTINE STRATEGIES AND MONITORING OF CONTACTS ............................95
3.6
EARLY CASE DETECTION METHODS.........................................................................96
3.6.1
Surveillance based indicators used to detect early cases ................................96
3.6.2
Identification of clusters ....................................................................................97
3.6.3
In hospitals ........................................................................................................98
3.6.4
In nursing homes and other collective facilities ................................................98
3.6.5
In schools ..........................................................................................................99
3.6.6
Precarious populations ...................................................................................100
3.7
COORDINATION AND RESPONSIBILITY OF TESTING AND TRACING ..................100
4
RESULTS FOR GERMANY .......................................................................... 101
4.1
EXISTENCE OF A PLAN TO PREVENT THE SECOND WAVE .................................101
4.2
TESTING STRATEGY ..................................................................................................101
4.2.1
Indications for PCR testing .............................................................................101
4.2.2
PCR testing conditions: how and by whom? ..................................................102
4.2.3
Indications and conditions for serological testing ...........................................102
4.2.4
Laboratory capacity ........................................................................................103
4.2.5
Communication of test results to the patient ..................................................103
4.2.6
Recording and surveillance of test results ......................................................103
4.2.7
How is testing reimbursed? ............................................................................104
4.3
ISOLATION STRATEGIES AND MONITORING OF CONFIRMED CASES ................104
4.3.1
Suspected cases (having symptoms) .............................................................104
4.3.2
Confirmed cases .............................................................................................105
4.4
CONTACT TRACING STRATEGY ...............................................................................105
4.4.1
Contact definition ............................................................................................105
4.4.2
Organisational process of contact tracing ......................................................107
4.4.3
Testing of contacts ..........................................................................................108
4.4.4
Contact tracing Apps ......................................................................................108
4.5
QUARANTINE STRATEGIES AND MONITORING OF CONTACTS ..........................109
4.6
EARLY CASE DETECTION METHODS.......................................................................110
4.6.1
Surveillance based indicators used to detect early cases ..............................110
4.6.2
Identification of clusters ..................................................................................110
4.7.1
In hospitals ......................................................................................................111
4.7.2
In nursing homes and other collective facilities ..............................................111
4.7.3
In schools ........................................................................................................111
4.7.4
Precarious population .....................................................................................112
4.8
COORDINATION AND RESPONSIBILITY OF TESTING AND TRACING ..................112
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5
RESULTS FOR ITALY .................................................................................. 113
5.1
EXISTENCE OF A PLAN TO PREVENT THE SECOND WAVE .................................113
5.2
TESTING STRATEGY ..................................................................................................114
5.2.1
Indications for PCR testing .............................................................................114
5.2.2
PCR testing conditions: how and by whom? ..................................................115
5.2.3
Indications and conditions for serological testing ...........................................116
5.2.4
Laboratory capacity ........................................................................................116
5.2.5
Communication of test results to the patient ..................................................117
5.2.6
Recording and surveillance of test results ......................................................117
5.2.7
How is testing reimbursed? ............................................................................118
5.3
ISOLATION STRATEGIES AND MONITORING OF CONFIRMED CASES ................118
5.3.1
Suspected cases (having symptoms) .............................................................118
5.4.1
Confirmed cases .............................................................................................119
5.5
CONTACT TRACING STRATEGY ...............................................................................119
5.5.1
Contact definition ............................................................................................119
5.5.2
Organisational process of contact tracing ......................................................120
5.5.3
Testing of contacts ..........................................................................................121
5.5.4
Contact tracing Apps ......................................................................................121
5.6
QUARANTINE STRATEGIES AND MONITORING OF CONTACTS ..........................122
5.7
EARLY CASE DETECTION METHODS.......................................................................123
5.7.1
Surveillance based indicators used to detect early cases ..............................123
5.7.2
Identification of clusters ..................................................................................123
5.7.3
In hospitals ......................................................................................................123
5.7.4
In nursing homes and other collective facilities ..............................................124
5.7.5
In schools ........................................................................................................124
5.7.6
Precarious population .....................................................................................124
5.8
COORDINATION AND RESPONSIBILITY OF TESTING AND TRACING ..................125
6
RESULTS FOR SPAIN ................................................................................. 126
6.1
EXISTENCE OF A PLAN TO PREVENT THE SECOND WAVE .................................126
6.2
TESTING STRATEGY ..................................................................................................127
6.2.1
Indications for PCR testing .............................................................................127
6.2.2
PCR testing conditions: how and by whom? ..................................................127
6.2.3
Indications and conditions for serological testing ...........................................128
6.2.4
Laboratory capacity ........................................................................................130
6.2.5
Communication of test results to the patient ..................................................131
6.2.6
Recording and surveillance of test results ......................................................131
6.2.7
How is testing reimbursed? ............................................................................132
6.3
ISOLATION STRATEGIES AND MONITORING OF CONFIRMED CASES ................133
6.3.1
Suspected cases (having symptoms) .............................................................133
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6.3.2
Confirmed cases .............................................................................................133
6.4
CONTACT TRACING STRATEGY ...............................................................................135
6.4.1
Contact definition ............................................................................................135
6.4.2
Organisational process of contact tracing ......................................................136
6.4.3
Testing of contacts ..........................................................................................136
6.4.4
Contact tracing apps .......................................................................................136
6.5
QUARANTINE STRATEGIES AND MONITORING OF CONTACTS ..........................138
6.6
EARLY CASE DETECTION METHODS.......................................................................140
6.6.1
Surveillance based indicators used to detect early cases ..............................140
6.6.2
Identification of clusters ..................................................................................140
6.6.3
In hospitals ......................................................................................................142
6.6.4
In nursing homes and other collective facilities ..............................................142
6.6.5
In schools ........................................................................................................143
6.6.6
Precarious population .....................................................................................145
6.7
COORDINATION AND RESPONSIBILITY OF TESTING AND TRACING ..................146
7
RESULTS FOR THE NETHERLANDS ......................................................... 147
7.1
EXISTENCE OF A PLAN TO PREVENT THE SECOND WAVE .................................147
7.2
TESTING STRATEGY ..................................................................................................147
7.2.1
Indications for PCR testing .............................................................................147
7.2.2
PCR testing conditions: how and by whom? ..................................................148
7.2.3
Indications and conditions for serological testing ...........................................149
7.2.4
Laboratory capacity ........................................................................................149
7.2.5
Communication of test results to the patient ..................................................150
7.2.6
Recording and surveillance of test results ......................................................151
7.2.7
How is testing reimbursed? ............................................................................152
7.3
ISOLATION STRATEGIES AND MONITORING OF CONFIRMED CASES ................152
7.3.1
Suspected cases (having symptoms) .............................................................152
7.3.2
Confirmed cases .............................................................................................154
7.4
CONTACT TRACING STRATEGY ...............................................................................154
7.4.1
Contact definition ............................................................................................154
7.4.2
Organisational process of contact tracing ......................................................155
7.4.3
Testing of contacts ..........................................................................................156
7.4.4
Contact tracing Apps ......................................................................................157
7.5
QUARANTINE STRATEGIES AND MONITORING OF CONTACTS ..........................158
7.6
EARLY CASE DETECTION METHODS.......................................................................162
7.6.1
Surveillance based indicators used to detect early cases ..............................162
7.6.2
Identification of clusters ..................................................................................163
7.6.3
In hospitals ......................................................................................................163
7.6.4
In nursing homes and other collective facilities ..............................................163
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7.6.5
In schools ........................................................................................................163
7.6.6
Precarious population .....................................................................................167
7.7
COORDINATION AND RESPONSIBILITY OF TESTING AND TRACING ..................167
LIST OF FIGURES
Figure 1 – 7-day moving average of the number of COVID-19 cases per 1 million inhabitants
reported by each country in March-July 2020 ...............................................................................10
Figure 2 – 7-day moving average of the number of COVID-19 cases per 1 million inhabitants
reported by each country in June-July 2020 .................................................................................11
Figure 3 – 7-day moving average of the number of COVID-19 deaths per 1 million inhabitants
reported by each country in March-July 2020 ...............................................................................11
Figure 4 – 7-day moving average of the number of COVID-19 deaths per 1 million inhabitants
reported by each country in June-July 2020 .................................................................................12
Figure 5 – The cumulative number of tests per 100 000 persons by country* .............................12
Figure 6 – Case finding .................................................................................................................14
Figure 7 – Contact and tracing procedures steps .........................................................................15
LIST OF TABLES
Table 1 – Test capacity .................................................................................................................17
Table 2 – Communication of results to the patient ........................................................................18
Table 3 – Testing strategy by country ...........................................................................................18
Table 4 – Surveillance strategy by country ...................................................................................23
Table 5 – Tracing strategy by country ...........................................................................................27
Table 6 – Isolation cases and quarantine contacts .......................................................................31
Table 7 – WHO and ECDC guidance on isolation strategy ..........................................................37
Table 8 – Isolation strategy by country .........................................................................................39
Table 9 – Testing characteristics in collectivities by country .........................................................42
Table 10 – Outbreak and early case detection strategies by country ...........................................43
8
LIST
OF ABBREVIATION DEFINITION
ABBREVIATIONS App
Application
ELISA
Enzyme-linked immunosorbent assay
ECDC
European Centre for Disease Prevention and Control
FEDASIL
Federal agency for the reception of asylum seekers
FPS (FOD, SPF)
Federal Public Service (Federale Overheidsdienst,
Service public Fédéral)
GEES
Group of Experts on the Exit Strategy
GGD
Gemeentelijke
of
Gemeenschappelijke
Gezondheidsdienst – Municipal or public health
services of the Netherlands
GP
General practitioner
NIHDI – RIZIV – National Institute for Health and Disability Insurance -
INAMI - LIKIV
Rijksinstituut voor Ziekte- en Invaliditeitsverzekering -
Institut National d'Assurance Maladie-Invalidité -
Landesinstitut für Kranken- und Invalidenversicherung
OCMW-CPAS
Public centre for social welfare – Openbaar centrum
voor maatschappelijk welzijn – Centres public d’action
sociale
PCR
Polymerase chain reaction
RMG
Belgian Risk Management group
9
■
SCIENTIFIC REPORT
1 PROBLEM DESCRIPTION
Despite the overall declining trend in the number of new hospitalisations related to COVID-19 (June
10th 2020), there continue to be newly confirmed cases indicating that community transmission still
occurs in Belgium.
Testing and tracing are key elements that enable to identify cases, find their contacts and stop
infection transmission. They also allow to detect asymptomatic and mild symptomatic cases early.
Both interventions are strongly intertwined as a control strategy for early control and avoidance of a
resurgence of the epidemic.
Several measures (underlined) of the WHO exit procedures guideline, dated April 24th, stipulate the
importance of setting up strategies to detect early cases.
1. Disease transmission is under control.
2. Health systems are able to "detect, test, isolate and treat every case and trace every contact".
3. Hot spot risks are minimised in vulnerable places, such as nursing homes.
4. Schools, workplaces and other essential places have established preventive measures.
5. The risk of importing new cases "can be managed".
6. Communities are fully educated, engaged and empowered to live under a new normal.
For Belgium the Group of Experts on the Exit Strategy (GEES) identifies
the first line of defence against a second wave, to be the
individual testing and contact tracing. The
second line of
defence is monitoring of virus resurgence country-wide. These two lines of defence require the
persisting strong attention and action of the government(s).
This project compares the COVID-19 contact tracing and testing strategy among different countries.
The Belgian Risk Management group (RMG) was interested in learning about innovative initiatives
from abroad that may curb the epidemic. These initiatives may have been used in the first wave,
been planned for the second wave, or been implemented and ongoing.
2 OBJECTIVE
The objective of the project is to provide a structured comparison of the testing and contact tracing
strategies in a group of selected countries. It highlights policies and implementations in order to
provide a rationale and country-experience based advice to the RMG and international health
authorities. The objective of the study does
not include an evaluation of the strategies described.
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10
3 METHODS
This is an observational study that compares the testing and contact tracing strategy of Belgium,
Denmark, France, Germany, Italy, Spain and The Netherlands. The countries were pragmatically
selected due to time constraints. Information on the contact tracing and testing has been retrieved
through the official COVID-19 websites of each country, open source databases and direct
communication with people working on the COVID-19 response in the selected countries. We
searched for a description of strategies on the following topics: a plan to prevent the second wave;
a testing strategy (indications for PCR testing, PCR testing conditions; how and by whom, indications
and conditions for serological testing, laboratory capacity, communication of test results to the
patient, recording and surveillance of test results, how is testing reimbursed), isolation strategies and
monitoring of a confirmed case, contact tracing strategy, quarantine strategies and monitoring of
contacts, early case detection methods, and coordination and responsibility of testing and tracing.
The described strategies are thus the theoretical published descriptions by country. No operational
data was collected. The study was performed between June 8th and July 15th with data collection up
to July 13th.
4 OVERVIEW OF EPIDEMICS IN SELECTED COUNTRIES
Figure 1 describes the evolution of COVID-19 cases per 1 million inhabitants reported by the
countries included in the study. The graph shows that, during the peak of the epidemic in March-
April, the most country hit was Spain, followed by Belgium and Italy. Since the beginning of June the
countries show a more similar and comparable trend among them (Data source: European Centre
for Disease Prevention and Control (ECDC)).
Figure 1 – 7-day moving average of the number of COVID-19 cases per 1 million inhabitants
reported by each country in March-July 2020
Figure 2 is a zoom of figure 1 and wants to focus on the trends of the last month and a half when all
the countries are past the peak of their epidemic and are reporting lower number of cases per 1
million inhabitants. More recently the countries with the highest reporting among the studied
countries, are Spain, Belgium and France.
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11
Figure 2 – 7-day moving average of the number of COVID-19 cases per 1 million inhabitants
reported by each country in June-July 2020
Figure 3 shows the number of COVID-19 deaths per 1 million inhabitants among the studied
countries, and during the epidemic peak in April Belgium shows the highest rate.
Differently from the other counties, Belgium has included from the beginning of the epidemic the
number of possible COVID-19 deaths in the mortality count. This makes comparisons between
countries more difficult especially for the beginning of the crisis.
Figure 3 – 7-day moving average of the number of COVID-19 deaths per 1 million inhabitants
reported by each country in March-July 2020
When zooming in the last months and a half
(Figure 4) the number of COVID-19 deaths has
decreased and is more comparable among the studied countries.
12
Figure 4 – 7-day moving average of the number of COVID-19 deaths per 1 million inhabitants
reported by each country in June-July 2020
The cumulative number of COVID-19 tests performed on July 12th 2020 in each country per 100,000
citizens is highest for Denmark (20,836/100k) and lowest for France (2,588/100k) and The
Netherlands (2,404/100k). Belgium is situated in the higher range with 9,082 tests per 100,000
persons, similar to Germany (7,610/100k) and Italy (9,516/100k).
Figure 5 – The cumulative number of tests per 100 000 persons by country*
*The data are retrieved from FIND, a WHO Collaborating Centre which created an interactive map with
publicly available data at https://finddx.shinyapps.io/FIND_Cov_19_Tracker/.
The map was developed using
open-source code initially
developed by the London School of Hygiene & Tropical Medicine.
13
5 DEFINITIONS
5.1 Population at risk for severe COVID-19 illness
While the majority of cases of COVID-19 have a mild illness, epidemiological data shows that the
following
patient
factors
are
associated
with
a
more
serious
or
deadly
illness
(https://www.ecdc.europa.eu/en/current-risk-assessment-novel-coronavirus-situation):
Risk of hospitalisation increases with age from the age of 30 years
Risk of death increases from the age of 50 years although the majority of deaths are among the
oldest age group
Older males are particularly affected requiring more intensive care and respiratory support
Considerable excess mortality in multiple countries affecting both the 15−64 and 65+ years age
groups is seen in the pooled analysis of all-cause excess mortality from EuroMOMO. This is
particular as at this time of year competing drivers (influenza and high/low temperatures) are
largely absent.
Persons over 65 years of age and/or with underlying health conditions infected with COVID-19
are at increased risk of severe illness and death compared with younger individuals
Long-term care facilities, which commonly house the elderly and the frail, have been heavily
affected by COVID-19. The disease spreads rapidly on introduction, causing high morbidity in
residents, commonly with a case fatality of over 25%. The facilities were the focus of over half of
the fatal COVID-19 cases in several EU countries.
Collectivities (nursing homes, temporary homes or boarding schools for chronically ill children or with
learning issues, youth care, or adult persons with disability, psychiatric collectivities, prisons, and
lodgings for seasonal workers) have been recognised as places where grouped cases can occur and
where transmission chains are maintained, especially where social distance and hygiene measures
are difficult to be respected.
Specifically, in Belgium people living a precarious situation can include, persons not benefiting from
the National Institute for Health and Disability Insurance health insurance (NIHDI - of RIZIV - INAMI)
and may not come forward for health care and may not be tested, as for example,
persons not in order with their social security contributions,
detainees confined in penitentiary establishments (whose health coverage is provided by the
FPS Justice department),
applicants for international protection who reside in accommodation facilities (whose coverage
is provided by federal agency for the reception of asylum seekers (FEDASIL) or the public center
for social welfare (OCMW-CPAS),
and persons without a residence permit (whose coverage is provided by urgent medical
assistance).
5.2 COVID-19 case definition
The World health organization
(WHO) defines a COVID-19 case as: A person with laboratory
confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.
While the European Centre for Disease Prevention and Control
(ECDC) defines a case as: any
person meeting the laboratory criteria of detection of SARS-CoV-2 nucleic acid in a clinical specimen.
Each country has used a slightly adapted case definition, often depending on the availability of the
tests at the time. The case definition was adapted along the course of the epidemic.
14
5.3 Testing
5.3.1 Strategy
Testing aims at diagnosing patient with symptoms and at the start of the epidemic was mostly
performed in a hospital or triage setting. To stop the resurgence of the virus, testing currently aims
to case finding (figure) and can be performed in additional settings such as general practitioners
ambulatory or nursing homes by trained personnel.
Figure 6 – Case finding
Case-finding is identifying
symptomatic or asymptomatic contagious individuals called “cases”
or highly “suspected cases” with COVID-19, through polymerase chain reaction (PCR) testing on
swab samples. The suspected person will be
isolated. When a test result proves the patient as a
confirmed case,
contact tracing is started. Contacts are those people who have been in close
contact with a case in the period the case was infectious (pre-symptoms and/or while symptomatic).
All contacts identified will need to stay at home (or in another setting) in quarantine. By
isolating
cases and
quarantining contacts for 2–14 days, it separates “cases” or people with COVID-19 and
“contacts” from the rest of the population, reducing exposure of the public. These ‘intrusive’ actions,
if carried out promptly and systematically, can stop an epidemic from spreading.
Case finding can also be performed through
systematic screening procedures in already identified
risk groups, or by identifying new risk areas or groups followed by screening, and testing the contacts
of suspected or confirmed patients diagnosed by for example a general practitioner. Priority testing
can for example be set up for workers in certain critical services.
5.3.2 Type of test
There is currently no perfect ‘gold standard test’ for the diagnosis of COVID-19 to which diagnostic
tools can be compared to. Knowing the advantages and limitations of each tool is essential to use
tests and interpret results adequately.
The majority of molecular diagnostics developed for the detection of COVID-19 involve
real-time
PCR. (Sciensano fact sheet June 14th) The assays are indicated for the qualitative detection of
nucleic acid from SARS-CoV-2 on upper respiratory tract samples (e.g. naso-pharyngeal specimens,
oro-pharyngeal specimens) and lower respiratory tract samples (e.g. bronchoalveolar lavage (BAL)
specimens, endotracheal aspirates, expectorated sputum). A correct sample collection technique is
essential to ensure best test performance and avoid false-negatives. Further, the use of saliva which
is easy to collect (including self-collection by the patient) as a sample is currently been explored
internationally. For example, a PCR on saliva samples collected at home has been approved for use
in the US
(FDA news). In France
(France news) a reverse transcription‐loop‐mediated isothermal
amplification (RT-LAMP) is in development as a rapid diagnostic test.
Immunological
assays
(via
Enzyme-linked
immunosorbent
assay
(ELISA)
or
immunochromatography techniques) have been developed for the measurement of circulating
antibodies of COVID-19 patients
(Sciensano COVID-19_fact_sheet). Total seroconversion rates are
high but persistence of antibodies after COVID-19 and correlation between antibody levels and
protection against re-infection or disease is currently unknown. A large number of in-house and
commercial tests are being developed of different qualities. Prior to implementation, tests must be
registered and quality checked by the usual regulatory bodies.
15
5.4 Contacting and tracing / Contact identification
A contact and tracing procedure consists of the steps below.
Figure 7 – Contact and tracing procedures steps
It is normally conducted by local health authorities, who conduct an epidemiological interview,
normally conducted through phone, with newly diagnosed cases. During this interview detailed
information regarding the symptoms, onset and description, are asked to the patient. The patients is
also asked to identify a possible source of infection, and to provide a list of the people with whom
he/she has been in close contact. This list should contain identifying information about the person
which whom the case came in contact and a possible contact of the person, as for example the
phone numbers, email address or home address. This should allow the tracing of contacts in order
to communicate them the quarantine, testing and/or monitoring measures to put in place.
link to page 20 link to page 19
16
6 COMPARISON
6.1 Testing strategy
A summary of the testing strategies by country is in
Table 3.
6.1.1 Symptomatic persons
All the testing strategies (status June 30th – to July 9th) include the testing of
symptomatic people
inclusive mild symptoms. A prescription by a medical doctor after assessment (including telephone)
is the rule in most countries investigated (except in Denmark where anyone can be tested).
6.1.2 Asymptomatic persons
Asymptomatic persons who have been in
close contacts with a confirmed case are tested in five
out of the seven countries (not in Italy and the Netherlands). The definition of ‘close contact’ differs
slightly between the countries where testing is performed but the basis is the same: a close contact
is a person who had contact with the case from 2 days before symptom onset in the case (or 7 days
before the test in asymptomatic cases in France) up to 7 days after and in the following
circumstances: (i) household members of the case (living in the same home); (ii) persons sharing a
confined space for over 15 minutes with the case; or (iii) when there was direct physical contact with
the case likely transferring body fluids. The fact that the contact and the case were both wearing
approved surgical masks or were separated by a glass may nevertheless exclude the contact from
close contacts (e.g. in France).
Testing of asymptomatic persons in
collectivities i.e. hospitals, nursing homes, precarious
populations in housing structures is proposed or planned in the context of protecting a known
at risk
population (likely to develop severe illness when infected) or to detect early outbreaks in places
where
clusters are more likely to happen (high concentration of persons in a limited living space).
Protection of the elderly in nursing homes by weekly testing of the staff is planned in Denmark in
case of spread of infection with COVID-19 in a municipality or another geographically delimited area
(and advised in France in case of gradual resurgence). In Germany, Italy and Spain systematic or
serial testing in a collectivity is advised once a single confirmed case is detected (in Belgium for 2
cases). This case is then considered an outbreak and the outbreak strategies are applied.
In case of
hospitalisation (for any reason) systematic testing is performed in Belgium (when
laboratory capacity is available), Denmark, and Germany. The reasoning may be either to protect
the out-patient undergoing a procedure with a COVID-19 exposure or the protection of hospital staff
and admitted patients from asymptomatic cases being hospitalised.
A
personal free choice to be tested when asymptomatic is possible against payment in Germany
and free in Denmark, and for travel against payment in Belgium.
6.1.3 Laboratory organisation
Since the start of the epidemic laboratory capacity to perform PCR testing has been increased in all
countries. National networks commonly use clinical public hospital and private laboratories, but
university and veterinary research units as well as biotechnology and pharmaceutical industries have
joined the effort during the height of test shortage. France has also invested in high intensity
machines, bought in China, and created 21 dedicated high-intensity PCR diagnostic laboratories
functioning 7d/7 during the crisis. Similarly, Belgium created extra test capacity as an overflow
mechanism to the national laboratory. Countries are continuously augmenting laboratory capacities.
For example, Belgium, plans a capacity of 80 000 per day by October 2020. The daily capacity
between countries varies and is stated below
(Table 1). The quality control for testing is performed
in COVID-19 reference centres (e.g. in Belgium, Germany, Italy, Spain, and the Netherlands).
link to page 20
17
Table 1 – Test capacity
Belgium
Denmark
France
Germany
Italy
Spain
The
Netherlands
Capacity tests per day
Around 30 000
11 000
Around
170 000
80 000
32 664
6 400
135 000
Population*
11 600 000
5 800 000
67 064 000
83 800 000
60 500 000
46 800 000
17 100 000
Capacity tests per 1000 inhabitants
Around 2.6
1.9
Around 2.0
2
1.3
0.7
0.4
(per day)
Number of laboratories
90
Not found
Not found
200
238
176
64
Laboratories
●
University
X
X
X
X
X
●
Governmental
X
X
X
X
●
Veterinary
X
X
X
X
●
(Pharmaceutical) Industry
X
X
Any laboratory that is COVID-19
X
X
X
X
X
validated
*rounded to the nearest thousand
The SI-DEP centralised database platforms in France and Spain work in real-time; prescribers can directly access the result. The centralised ‘federal platform’
in Belgium links results from test centres and back to the medical doctors through ‘the eHealth platform’. Results are shared via regional networks of laboratories
and doctors in real-time. In The Netherlands results are forwarded by secure email (not clear if this is real-time). The result is also forwarded directly to the
contact tracing system in Belgium, France, Germany, Italy, and Spain to start the contact tracing programme.
6.1.4 Communication towards the patient
The results recorded into the centrally organised databases can be accessed by the prescribing doctor for all countries except the Netherlands where the
laboratories communicate preliminary results by email or phone and mail a confirmation report in a second stage. In Denmark the testing appointments are
equally centralised through the personal ID-number and linked to the result and tracking system. In Denmark testing appointments can be made by citizens and
results are accessed through the ID system. Patients in most countries will receive the result via the doctor or tracing centre
(Table 2). In France, communication
of results to the patient is firstly done either by the laboratory (by phone) and/or via the SI-DEP database. Patients are then contacted by the general practitioner
(GP) and by a contact tracing centre of the health insurance. In some settings (e.g. in school), communication is done via the regional health agencies.
18
Table 2 – Communication of results to the patient
Belgium
Denmark
France
Germany
Italy
Spain
The Netherlands
Doctor (by phone)
X
X
X
X
X
X
X
Platform for patients health data / app
X
X
X
*
Laboratory
X
Contact tracing centre
X
X
Regional health service (by phone)
X
*
X
* available in some regions
Table 3 – Testing strategy by country
Indications for PCR Testing
Lab capacities
Communication and recording
Belgium
1. Symptomatic people
15 000 PCR tests per day on average
Currently 24-48 hours between the consultation and test
2. High risk contacts of COVID+
have been performed daily since mid-
results. Efforts to shorten the duration to 24h.
And if the capacity is sufficient:
June 2020 by the National network of
Results reported to the GP (eHealthBox) and to call centres,
+/-90 clinical labs (mostly hospital labs,
3. Any person requiring hospitalisation
and reported in the COVID-19 database managed by
and some private labs).
Sciensano.
4. Each new entry in a collective facility (e.g.
nursing homes)
The GP informs the patients. The patient has also access to
University and veterinary research
test results via usual online portals that allows patients to
Management by the regional health authorities
units, as well as biotechnology and
consult various personal health data.
in case of a cluster (2 positive cases) in a
pharmaceutical industries joined the
collective facility.
The mandatory reporting of all possible cases to the health
effort during the period of tests
inspectorate of the Federated entity is done via the eForm. For
5. PCR tests in the context of international
shortage.
possible cases (with symptoms) the reporting is done at the time
travel can exceptionally be performed and
of testing, and for asymptomatic cases when the result is known
charged to
travellers if the foreign
(no time window specified).
government's requirement is stated on the
Estimated daily Capacity July 6th is
website of the Federal Government Foreign
30 000. Will increase to 80.000 in
Affairs.
October 2020.
COVID-19
reference
centre
University Hospital Leuven.
Shortages are followed up nationally by
a taskforce for testing and shortages
and through the email-address
xxxxxxxxxxxxxxx@xxxxxxxxxx.xx
19
Shortages survey June 11th (personal
communication Sciensano) response of
66 labs out of all laboratories:
Shortages in swabs: 21 / 66 labs
Shortages in transport medium: 12 / 66
labs
Shortages in extraction reagents: 14 /
66 labs. (+ 10 run lower volumes due
to extraction reagent shortages)
Shortages in amplification reagents: 7 /
66 labs ((+ 10 run lower volumes due
to extraction reagent shortages)
Denmark
1. Symptomatic people (even with mild
Whole country: 11 000 tests per day Individuals with a NemID* will be able to see their test result
symptoms)
Capital Region: 1 500 tests per day
on sundhed.dk and in the MinSundhed app. Most people
2. Close contacts of a confirmed case
to be extended to 5 000 tests per
can expect to be able to see their test results the day after
3. Asymptomatic inhabitants of nursing care
day in June
the sample is taken, but in some cases, it may take up to 72
homes (and other institutions) as well as
hours (three days).
frontline nursing home personnel in case of
lndividuals without a NemID can contact their doctor to get
Public-private cooperation: government
infection among inhabitants or colleagues.
the results (also from sundhed.dk) or by calling the contact
& pharmaceutical industry labs.
From 30/06, systematic testing of nursing
tracing centre Coronaopsporing
staff working at nursing homes and in home
The system is centralised. All appointments for testing must
care in case of spread of infection with
be booked TestCentre Denmark (on-line coronaprover.dk)
COVID-19 in a municipality or another
and Corona Tracking (Coronaopsporing) which is a division
geographically delimited area
of the Danish Patient Safety Authority contacts by phone
4. Patients expected to be hospitalised for 24
any individual tested positive to track close contacts.
hours or more, independently of the patient’s
*NemID (literally: EasyID) is a common log-in solution for
condition (referral by the hospital)
Danish Internet banks, government websites and some other
5. Out-patients who presumably will undergo
private companies. Everyone in Denmark who is over 15
one or more procedures which constitute a
years old and has a CPR-Number is eligible for a NemID that
serious risk of exposure to COVID-19
can be used with their bank as well as public institutions.
6. Anyone who wants to be tested (schedule a
test online at coronaprover.dk, or as part of
government monitoring)
France
1. Symptomatic people (a prescription is
All research and veterinarians labs are
A maximum time limit of 24 hours between the consultation
required)
now requested to support public
and test results is required.
2. High
risk contacts
of COVID+
(no
laboratories.
All results are directly reported by laboratories into one
prescription is required)
Three types of structures are used:
database in real time (in the SI-DEP database).
1. Hospital laboratories (capacity:
20
3. Preventive testing campaigns are planned in
35 000 tests/day), for people
case of identified clusters (managed by
presenting
in
emergency
regional health authorities and GPs), in
departments
or
hospitalised
collectivities,
and
for
the
precarious
patients.
populations (depending of the spread of the
2. Dedicated
high-level
PCR
epidemic, see 7.5 for details)
diagnostic laboratories: 21 sites with
Systematic testing is not recommended in
high intensity machines publicly
companies, public services, or for all patients
financed and created during the
admitted to hospital.
crisis, open (7/7), (40 000 tests/day)
3. Private city laboratories (60 000
tests/day, may increase further).
Germany
1. All people with respiratory symptoms OR
Around 200 laboratories available
Laboratory results are available in around 24h
loss of smell/taste
Total capacity of almost 170 000 Medical doctors and laboratories need to report COVID-19
2. Category I of contacts of confirmed cases
tests per day
and SARS-CoV-2 cases to the local public health authority
with symptoms or not
within 24h.
3. People with clinical or radiological evidence
of viral pneumonia related to hospital or
nursing home
4. Systematic screening of all new people
being admitted to a hospital
5. Serial testing can be performed on the staff
and the residents of a nursing home if there
is a confirmed case
6. All those who want to be tested and are
willing to pay for the test
Italy
1. A person with an acute respiratory infection
There is a National Reference Monitoring is carried out through two daily data flows:
AND without another aetiology to explain
Laboratory
o
data sent by the regions and coordinated by the
the cause AND history of travel in
238 laboratories designated at
Ministry of Health and the National Institute of Health
countries/areas in which local transmission
regional
level
for
performing
o
has been reported in the previous 14 days
Integrated COVID-19 surveillance system, where the
COVID-19 RT-PCR
before symptoms onset
regions send the data to the National Institute of
Total capacity of almost 80 K tests
2. A person with any acute respiratory infection
Health
per day
AND had contact with a probable or
confirmed COVID-19 case in the 14 days
The regional distribution is different
before symptoms onset.
for each region
3. A person with a severe acute respiratory
infection
(SARI)
AND
need
for
hospitalisation
AND
without
another
aetiology
21
4. Asymptomatic close contacts at the end of
quarantine are tested whenever possible.
5. In the case of outbreaks involving hospitals,
long-term care, RSA or other residential
structures for the elderly, the test must be
offered to the residents and to all the health
workers involved.
Spain
1. Symptomatic people
176 public laboratories perform A maximum time limit of 24 hours between the consultation
2. Asymptomatic people considered as close
PCR tests
and test results is required.
contacts (according to Regional Health
In the week June 26 - July 2:
All results are directly reported by laboratories into one
Authorities).
200 986 PCRs were performed.
database in real time.
3. Single case in social health centres will be
Communication by the general practitioner to the patient.
considered an outbreak: PCR will be carried
The Autonomous Regions have to notify the state level (by
out on close contacts or, depending on the
using the national COVID-19 confirmed case notification
circumstances, on all residents and workers
survey) through the SiViEs surveillance tool managed by the
of the centre, in the manner established by
National Epidemiology Centre each day before 12:00 all
each Autonomous Region.
information accumulated and updated up to 24:00 the
previous day will be incorporated. This surveillance has
been in place since 12 May.
The
1. All people with symptoms of infection can be
Initially 2 reference labs (Erasmus Currently 24-48 hours between the consultation and test results.
Netherlands
tested
MC & RIVM-IDS), and 13 regional
1. Results of diagnostics from Erasmus MC and RIVM-IDS:
2. No PCR testing in asymptomatic people
labs.
To the hospitals:
(close contacts)
Other medical microbiological labs, As soon as possible through telephone and via secure email
bioveterinary
labs,
and
HPV-
screening labs can be validated.
(‘caremail’ or ‘zorgmail’) if available.
Currently 49 extra labs validated.
Request form to include a direct 24/7 telephone number of
The criteria indicate that they should
the physician-microbiologist to receive the test result.
be able to assess at least 100 tests
To the GGD:
a day.
As soon as possible via secure email (zorgmail), until
The coordination of the organisation
midnight.
and logistics of extra testing is done
Positive as well as negative results.
by the project group of the GGD’s
and they are supported by the
Later, a definitive report will be sent through secured email
National Government.
or by mail.
The GGD (Gemeentelijke of Gemeenschappelijke
Gezondheidsdienst – Municipal or public health services of
the Netherlands) will NOT be called by phone.
For questions on the results, the GGD can contact a
virologist of the reference centres by telephone.
22
2. Results of diagnostics from GGD to the patient:
In case of a positive test:
Patient is told by the GGD to stay home
GGD gives information on what the person and housemates
should do
GGD investigates contacts and calls them
Mandatory reporting of confirmed (tested) cases to the Public
Health Services.
Transfer of daily information from the electronic patient file
(checkbox) to the National Institute of Public Health and the
Environment is done.
link to page 25
23
6.2 Surveillance strategy
Each country has a surveillance system in place with a centralised database covering the national
territory (see summary
Table 4). Medical personnel in general practices, hospitals, nursing homes,
laboratories, contact tracing team and call centres, and regional public health authorities, all have to
report COVID-19 cases to the local / regional or national public health authority within a set time
frame, mostly 24h.
Table 4 – Surveillance strategy by country
Surveillance
Belgium
From two cases in a collective facility: management by federated entities
Registration of:
○ Confirmed cases by date, age, sex and province
○ Cumulative number of confirmed cases by municipality
○ Confirmed cases by date and municipality
○ Hospitalisations by date and province
○ Mortality by date, age, sex, and province
○ Total number of tests performed by date
Four indicators are used to monitor the evolution of the epidemic: confirmed cases,
new hospitalisations of laboratory-confirmed COVID-19 cases, intensive care unit
occupancy, and deaths (now presented with the 7-day moving average).
Seroprevalence on blood donation samples (n=1500) organised by the Red Cross
and Sciensano
Measure and follow-up of prevalence, seroprevalence and seroconversion in
healthcare workers (n=785) in Belgian hospitals (Sciensano and the Institute of
Tropical Medicine) between March and September 2020
Denmark
Systems used for surveillance of COVID-19 include:
national-level tracking of number of:
○ tests,
○ hospital admissions,
○ patients needing ventilator assistance for breathing,
○ deaths
a website with voluntary self-reporting of symptoms where citizens report influenza-
like symptoms
(https://influmeter.dk)
a panel testing surveillance system is initiated by the Statens Serum Institut (SSI)
based on a sample of GPs and a sample of their patients who are tested on a weekly
basis.
Blood banks testing for antibodies
Testing of random samples of the total population (PCR and antibodies)
From May 7, monitoring of the development of COVID-19 infections in the population
based on the testing of random samples of the total population.
Continuous testing of health care personnel and personnel in nursing homes etc. with no
symptoms is being initiated. Prevention of infection by regular staff testing - Denmark July
13th:
In case of spread of infection with COVID-19 in a municipality or another geographically
delimited area, regular testing of health and care professionals in that area should be
conducted. This is for the purpose of preventing the spread of infection
A cross-cutting group ‘signal group’ under the leadership of the Statens Serum Institut
and with Representatives from the National Board of Health and the National Board of
Patient Safety continuously assess the incidence of local spread of infection, with the aim
of being able to initiate quickly preventive measures if there is evidence in the surveillance
of the spread of infection via chains of infection or outbreaks. If the group assesses that
in an area there is a spread of infection, there cannot be immediately explained by a local
outbreak at a particular institution or the like, the Danish Agency for Patient Safety should
enter into a dialogue with the municipality and their infection hygienic unit for the purpose
of initiating regular testing of health and care personnel in the area in question. Healthcare
24
professionals should be tested every 7 days for 2 months or until the spread of infection
in the area where the chains of infection are not covered.
France
A surveillance is done by regional health agencies to identify potential chains of
transmission and clusters, in collaboration with the National Public Health Institute
and the Ministry of Health.
Critical clusters: how to identify a critical cluster is not yet defined but the proposal is
to base the identification on a set of indicators:
○ The absolute number of cases
○ The density of incidence in the district (e.g. from 50 cases/100 000
inhabitants/week).
○ The context in which this cluster occurs: company, school, nursing home for
older people, precarious population
Monitoring of:
○ Mortality of COVID-19 hospitalised patients (per day and in total);
○ Mortality of COVID-19 patients in homes for the elderly and nursing homes (per
day and in total);
○ Overall and excess mortality;
○ The number of new hospitalised patients for COVID-19 and the total number of
people hospitalised for COVID-19;
○ The number of new patients admitted to intensive care unit for COVID-19 and
the total number of persons admitted to ICU for COVID-19;
○ The number of tests performed;
○ The number of confirmed cases (PCR-positive);
○ The time lapse between the steps of the testing-tracing-isolating strategy;
○ The effective reproduction number (R) and the doubling time of the epidemic;
The scenario 3 (low level diffuse epidemic) of the strategic plan can be based on
indicators such as an R >1.
Germany
Laboratories need to electronically report positive and negative results of SARS-CoV-2
testing to the national Robert Koch Institute.
Additionally to the laboratory test, data on demographics (age and gender), clinical
symptoms and hospitalisations, is also collected.
Italy
The surveillance strategy of Italy to monitor the second Phase of the COVID-19 epidemic
includes the following indicators:
Process indicators on monitoring capacity
1.1
Number of symptomatic cases per month in which the symptom onset date is
reported / total of symptomatic cases reported to the surveillance system in the same
period.
1.2
Number of cases reported per month with a history of hospitalsation (in
departments other than ICU) indicating the date of hospitalisation / total of cases with
history of hospitalisation (in departments other than ICU) notified to the surveillance
system in the same period.
1.3
Number of cases reported per month with history of transfer / hospitalisation in
the intensive care unit (ICU) which indicates the date of transfer or hospitalisation in ICU
/ total of cases with history of transfer / hospitalisation in intensive care notified to the
surveillance system during the same period.
1.4
Number of cases reported per month in which the municipality of residence or
residence is reported / total of cases reported to the surveillance system in the same
period.
1.5
Number of checklists administered weekly to residential social-health facilities
(optional).
1.6
Number of residential social-health structures responding to the checklist weekly
with at least one problem encountered (optional).
Process indicators on diagnostic capacity
2.1
Percentage of positive swabs excluding as far as possible all screening activities
and "re-testing" of the same subjects, overall and by macro-setting, per month.
2.2
Time between start date of symptoms and date of diagnosis.
2.3
Time between symptom start date and isolation date (optional).
25
2.4
Number, type of professional profiles and person-time dedicated in each
territorial service to contact-tracing.
2.5
Number, type of professional profiles and person- time dedicated in each
territorial service to the activities of collection/ sending to the reference laboratories, and
monitoring of close contacts and cases placed in quarantine and isolation respectively.
2.6
Number of confirmed cases of infection in the region for which a regular
epidemiological investigation was carried out with tracing of close contacts / total of new
confirmed cases of infection.
Research and management of contacts
3.1
Number of cases reported in the last 14 days.
3.2
Rt calculated on the basis of the integrated surveillance (two indicators are used,
based on the beginning of symptoms and the date of hospitalisation).
3.3
Number of cases reported to the sentinel surveillance COVID-net per week
(optional).
3.4
Number of cases by diagnosis date and symptoms onset date reported to
COVID-19 integrated surveillance per day.
3.5
Number of new clusters (2 or more epidemiologically linked cases or an
unexpected increase in the number of cases in a defined time and place)
3.6
Number of new confirmed cases by Region not associated with known
transmission chains.
3.7
Number of accesses to the emergency unit with ICD-9 classification compatible
with syndromic panels attributable to COVID-19 (optional).
3.8
Occupancy rate of total ICU beds for COVID-19 patients.
3.9
Bed occupancy rate for COVID-19 patients by province
Spain
SiViEs surveillance tool managed by the National Epidemiology Centre:
Individual record of every notified case
Number of suspected cases in primary care and attended in hospitals (do not include
persons indicated as having PCR for screening purposes). This information shall be
reported in aggregate to the CCAES at established intervals.
Percentage of suspected cases of COVID-19 in primary and hospital care where a
PCR has been performed (not including PCRs resulting from screening tests in
hospitals). This information shall be reported to the CCEAS on a weekly basis. It shall
be reported on Wednesdays before 12 noon with the data from the previous week,
from Monday to Sunday.
Number of close contacts confirmed as cases. This information shall be reported in
aggregate on a weekly basis to the CCAES from the contact tracking systems that
are established. Contacts confirmed as case that week/follow up contacts that week
x 100) It will be notified on Wednesdays before 12 noon with the data of the previous
week, from Monday to Sunday.
Number of professionals from the epidemiological surveillance services (public health
technicians, epidemiologists, public health nurses, other technical staff) dedicated to
the response in relation to the number of daily cases detected and the reference
population. Indicating the initial personnel and the new reinforcement personnel
incorporated. This information will be notified on a weekly basis to the CCAES. It shall
be reported on Wednesdays before 12 noon with the data of the previous week, from
Monday to Sunday.
Notification of clusters/outbreaks (with a data collection form)
The
Mandatory reporting of confirmed (tested) cases to the Public Health Services.
Netherlands
Transfer of daily information from the electronic patient file (checkbox) to the National
Institute of Public Health and the Environment is done.
The reported surveillance indicators for cases vary slightly between countries with reporting of cases
by age, sex, municipality, number of admitted cases to hospital, number needing intensive care, and
deaths and mortality. Surveillance on a regional level is active in France (e.g. evaluation of the
number of cases/100 000 inhabitants/week per region and district and identification of the number of
outbreaks, defined as the occurrence of at least 3 confirmed or suspicious cases, within a period of
7 days, and belonging to the same community). In Belgium, regions take action after they are
informed i.e. two cases in a collectivity.
link to page 29
26
Several other methods to survey or to describe and study (some are research initiatives) the general
population by PCR or serological tests are:
1. Serial PCR testing on a set of patients: in Denmark a sample of GPs test a set number of their
patients on a weekly basis
2. PCR testing and antibody testing on a random sample of the population: Denmark
3. PCR test campaigns in case of outbreak or for some target population: France
4. Sporadic mass testing campaign in long-term care facilities: Belgium
5. Seroprevalence on blood donation samples: Belgium
6. Seroprevalence per gender, age and region estimated from anonymised random samples from
clinical laboratories including for health workers to analyse the level of herd immunity: France
7. Measurement and follow-up of prevalence, seroprevalence and seroconversion in healthcare
workers: Belgian hospitals
6.3 Tracing strategy
The tracing strategy by country is summarised in
Table 5.
6.3.1 Organisation of contact tracing
All countries have a system in place for tracing and contacting the contacts of cases. The
organisation happens at the regional level. The approach differs from country to country:
1. Call centres or call teams have been created to telephone the cases and identify close contacts:
Belgium (Federated entities), Denmark (division of the Danish Patient Safety Authority), France
(trained teams at the health insurance - Ameli), Germany (local health authority), Italy (prevention
departments of the local health authority), Spain (Autonomous regions), and the Netherlands
(local health authority - GGD).
2. A face to face interview of cases, or of family members and caregivers of cases to identify
contacts (Italy when hospitalised, by GPs in Denmark and France)
3. Contacts of cases call the tracing centre themselves:
a. In France whenever a case refuses to give the names of contacts, the case can personally
ask the contact to directly call the centre.
b. Additionally (in France), people using the STOPCOVID-App and who have been in contact
with a confirmed case receive App quarantine instructions and are recommended to
contact the contact-tracing platform. Improved dissemination of the App is in progress by
transparent communication.
c. In Denmark a contact can anonymously log into the App SmitteStop”. The App wil tell the
person if he was in contact for more than 15 minutes at a distance of 1 meter; the App will
prompt the person to get tested.
4. Local field tracing teams for outbreaks: In Germany each call team (one team for each 20 000
persons) is supported by a mobile team (medical students). The creation of mobile teams in case
of outbreak is also in process in France. In Belgium, a field supervisor can visit the
patient/contact’s residence if a contact by telephone was not possible.
5. Specific measure for health workers or population at risk: In France, if the case worked in a
hospital or in a medico-social institution, the determination of measures and evaluation of the
contact should be referred to the occupational physician and the operational hygiene team of the
health care institution. In other workplaces, the occupational physician as well as a reference
COVID-19 person is also implied, especially for workers at risk.
6. The Ministry of health is informed of contacts domiciled abroad (Italy).
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6.3.2 Monitoring of contact tracing
Italy monitors the time between the steps of testing-tracing-isolation (between time of positive test
and contact identification) and France plans to have similar indicators. Italy as from June 25th
makes a distinction between "cases identified by the diagnostic suspect" (swab positive cases
emerging from clinical activity) and "cases identified by screening activities" (investigations and
tests, planned at national or regional level, which diagnose positive swab cases).
Similarly, in Spain health care workers have to report the number of close contacts confirmed as
cases on a weekly basis.
6.3.3 The use of contact tracing APPs
On June 16th, the German federal government launched the
Corona-Warn-App developed by the
SAP corporation and Deutsche Telekom (cost of around €20 mil ion) and overseen by cyber security
experts from German research institutes. The App sends a push message to users if they have been
exposed to a person diagnosed with COVID-19 (at least 15 minutes within the last 14 days). The
App installation is voluntary via google or Apple. Specification for the smartphone needed are at least
Android 6 or iOS (13.5). Not all laboratories and public health offices are equipped with the necessary
digital infrastructure to send test results to the system. Hence, people who have been tested by such
laboratories and found to be infected must contact a telephone hotline.
The app
StopCovid developed in France and the
IMMUNI application in Italy, both used on a
voluntary basis, have the same features as the German App. The application will use pseudonymised
data, Bluetooth technology, without the use of geolocation, and will not lead to the creation of a
registry of contact persons.
The Danish Health Authority asks, on a voluntary basis, those who have tested positive to inform
persons with whom they have been in close contact with, so they too can be tested. This can be
done automatically and anonymously with the
App “SmitteStop”. If an App user tests positive, they
can log into the App using their NemID, upon which a notification will be prompted to users who have
been in contact with infected users for more than 15 minutes at a distance of 1 meter.
The Spanish have a voluntary self-assessed symptoms based App called
Asistencia-Covid19. A
COVID-19 tracing App is in trial in the Canary Islands.
At the beginning of July, users in the Netherlands will be able to test a
corona-notification-App in
the region of Twente.
For Belgium, an App is being developed aiming to be ready by September. It will have the same
characteristics as the German App.
Table 5 – Tracing strategy by country
Tracing
Belgium
1. GPs are the first point of contact for all suspicious patients.
2. Positive patients (or before test results if asked by the GP) are contacted by call centres
managed by the federated entities.
3. Close contacts are contacted by the call centres; contacts receive a texted code to take
to their GP.
4. Apps is work in progress: should be voluntary, bluetooth technology, anonymised data,
and without geolocalisation.
5. Contact definition:
From 2 days before the first symptoms (or 2 days before the test for asymptomatic people);
People living in the same place;
Face-to-face contacts < 1.5 m for at least 15 min (cumulative), without use of a plexiglas;
Direct physical contact;
Direct contact with excretions or body fluids;
People performing care acts without protective equipment (and not always within a distance
of 1.5m);
People having shared a confined space for at least 15 min (where a distance of 1.5 m was
not always respected and/or where objects were shared; except if plexiglas was used);
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For schools: the whole class for children < 6 years old; only neighbours for children ≥ 6
years. (Decision in concert with competent authorities, see below);
People who have travelled with a COVID-19 patient > 15 minutes (with specific rule for
aircrafts).
Denmark
1. The Danish Health Authority asks everyone (on a voluntary basis) who has been tested
positive for coronavirus to contact themselves the persons that they have been in close
contact with, so they too can be tested. This can be done also automatically and
anonymously with the app “SmitteStop”. They can log into the app using their NemID*,
upon which a notification will be prompted to users who have been in contact with
infected users for more than 15 minutes at a distance of 1 meter.
2. From May 30th, corona-infected citizens must declare with whom they have had contact.
Resistance to do so will result in a fine.
3. From June 10th, the Danish Patient Safety Authority contacts all infected persons with an
offer to assist in tracing and contacting close contacts (nudge strategy).
4. An employee from Corona Tracking (Coronaopsporing) which is a division of the Danish
Patient Safety Authority contacts by phone any individual tested positive to track close
contacts and refer them for testing (centralised strategy)
For individuals with symptoms: close contacts from 48 hours before symptoms started to
48 hours after cessation of symptoms must be traced
For individuals without symptoms: close contacts met 48 hours before the test to 7 days
after the test must be traced
5. GPs can also refer close contacts for testing. The doctor creates two referrals for testing
at a hospital testing clinic. The testing takes place at an interval of two days after
exposition to infection. The individual subsequently returns to coronaprover.dk and
books the appointments.
6. Close contacts are defined as:
People you live with
People you have had direct physical contact with (e.g. hug)
People who have had unprotected and direct contact with infectious secretions from you
(for example, if you have accidentally coughed or sneezed at them, or if they have touched
your used handkerchief, etc.)
People you have had close "face-to-face" contact with within 1 meter for more than 15
minutes (for example, during a conversation)
Healthcare professionals and others who have participated in your care and have not used
the recommended protective equipment.
*NemID (literally: EasyID) is a common log-in solution for Danish Internet banks, government
websites and some other private companies. ... Everyone in Denmark who is over 15 years
old and has a CPR-Number is eligible for a NemID that can be used with their bank as well as
public institutions.
France
1. GPs in the front line (identification and information of contacts within the household).
2. Trained teams of the health insurance (identification and information of contacts outside
the household).
3. Registry of positive patients (results in real time provided by the laboratories) and
registry of contacts (managed by the health insurance).
4. Use of Apps (StopCovid): voluntary basis, Bluetooth technology, pseudonymised data,
and no geolocalisation
5. Information of the population is considered as an important successful factor.
6. Contact definition:
From 2 days before the first symptoms (or 7 days before the test for asymptomatic people);
People living in the same place;
Face-to-face < 1m (no time limit);
Direct physical contact;
Direct contact with several episodes of coughing or sneezing in a confined space;
People having given or received hygienic or care acts;
People having shared a confined space for at least 15 min;
Student and teacher in the same school class (no age specification). Decision in concert
with competent authorities (see 7.5).
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Germany
1. Performed by local and state public health authorities
2. One contact tracing team, of five members each, for every 20,000 inhabitants is
recommended
3. The teams are helped by mobile teams composed by medical students
4. The contact tracing activity is mainly through phone calls
5. Use of an Apps (CoronaWarn): voluntary basis, Bluetooth technology, anonymised data,
and no geolocalisation
6. There are three types of contacts based on the risk of infection with for each specific
recommendations for the reporting and monitoring.
Italy
1. Performed by field teams of the local public health authorities
2. Interview with the index case through a phone call or by hospital staff from family
members or caregivers.
3. Identification and list of close contacts with the information needed for the tracing
4. Use of an Apps (Immuni): voluntary basis, Bluetooth technology, anonymised data, and
no geolocalisation
5. Contact definition:
contact is any person exposed to a probable or confirmed COVID-19 case in a span of 48
hours before, up to 14 days after, the onset of symptoms or until the time of diagnosis and
isolation of the case. If the case has no symptoms, 48 h before sample collection.
A Close contact (high risk exposure) is:
a person living in the same house as a COVID-19 case;
a person who has had direct physical contact with a COVID-19 case (eg handshake);
a person who has had unprotected direct contact with the secretions of a COVID-19 case
(for example, touching used handkerchiefs with bare hands);
a person who has had direct contact (face to face) with a COVID-19 case, at a distance of
less than 2 meters and at least 15 minutes;
a person who has been in a closed environment (for example classroom, meeting room,
hospital waiting room) with a COVID-19 case in the absence of suitable PPE;
a healthcare professional or other person who provides direct assistance to a COVID-19
case or laboratory staff involved in handling samples of a COVID-19 case without using
the recommended PPE or by using unsuitable PPE;
a person who has travelled sitting in a train, plane or any other form of transportation within
two places in any direction compared to a COVID-19 case; travel companions and staff
assigned to the plane / train section where the index case was sitting are also close
contacts.
Spain
1. When a PCR is positive, the lab will inform the physician (to inform the patient) and a sort
of ‘call centre’ of the Autonomous Region will start the process of contact tracing.
2. PCR testing in every close contact.
3. Contact definition:
A close contact (within 2 days before the onset of symptoms of the case until the time when
the case is isolated and in asymptomatic cases confirmed by PCR, contacts should be
sought from 2 days before the date of diagnosis) is defined as follows:
Any person who has provided care to a case: health or social-health personnel who have
not used the appropriate protective measures, family members or persons who have other
similar physical contact.
Any person who has been in the same place as a case, at a distance of less than 2 metres
(e.g. housemates, visitors) and for more than 15 minutes.
Close contact in an aircraft, train or other long-distance transport (and where possible
access to passenger identification) is considered when within two seats of a case and the
crew or equivalent personnel who have had contact with that case (see flight schematic).
All persons within the 5x5 seatings including path way.
4. Spain plans to launch a COVID-19 tracing app through a pilot project in the Canary Islands
on June 24th 2020. If successful, it will be applicable nationally with the aim of being
interoperable between countries. In the event this app becomes available nationally,
would complement the Asistencia-Covid19 app, launched a few months ago to support
those users who present symptoms of the virus.
30
The
1. Source and contact tracing will be initiated in case of positive PCR test by the GGD’s
Netherlan
(within 24h).
ds
2. Source tracing:
The patient is asked where/how (s)he might got infected
GGDs should pay attention to local, regional or national clusters of confirmed cases. They
should conduct more investigation and take if necessary supplementary measures.
3. Contact tracing:
GGD initiates contact tracing after receiving notification of a confirmed case
Rapid notification by treating physician and lab are essential including patients’ contact
details. Only PCR testing in housemates, (close) contacts, if they present symptoms (no
PCR testing in asymptomatic persons)
Each contact tracing procedure is custom work and is concentrated on the 3 categories of
contacts.
4. Contacts definition:
Housemates (Category 1): Living in the same environment during long-time < 1.5m
distance of the patient.
Other close contacts (Category 2):
○ (i) > 15 minutes <1.5m distance with the patient during the infectious period. (Health
care professionals using prescribed protection materials are not considered close
contact)
○ (ii) In circumstances < 15 minutes with high risk of infection e.g. coughing at face,
direct physical contact, kissing, etc.
Other contacts (Category 3): > 15 minutes >1.5m distance of the patient during the
infectious period e.g. office, class, meetings, etc. The contact tracing of these contacts
might in a later stage supplemented with anonymous track-and-trace apps, specifically for
contacts who cannot be approached by the index patient.
The infectious period starts 2 days before the clinical signs and ends when the patient is
24h free of clinical signs and minimum 7 days (14 days in case of immunocompromised
patients) after the start of the symptoms.
In asymptomatic infections, look back at contacts 2 days before the test.
5. There are specific policies available (quarantine / isolation measures) in the following
contacts:
Child care & primary education
Health care practitioners working outside the hospital
Airplane policy
Foreign travellers
6. Contract tracing app: Pilot test (privacy, user friendliness, safety, etc.) at the beginning
of July of the corona-notification-app in the region of Twente. The app will be used
supplementary to the regular source and contact tracing of the GGD. The app
remembers e.g. train contacts, street contacts etc. It works through Bluetooth
technology. It is aimed that the cabinet can decide mid-July on the use of the app.
link to page 33
31
6.4 Isolation and quarantine strategies
Isolation strategies concern confirmed cases (in France, also suspected cases with a negative result) while quarantine strategies concern contacts of
confirmed cases or travellers. An overview by country is presented i
n Table 6.
Table 6 – Isolation cases and quarantine contacts
Isolation and quarantine
Belgium
Confirmed case at least 7 days following test results. Contact with GP on day 7, if asymptomatic isolation stopped.
Quarantine of their contacts for 2 weeks, with a reduction to 10 days if tested 2 times negative and asymptomatic.
Isolation structures are proposed for homeless people.
Specific measures for health care workers:
○ Positive test and worker is asymptomatic: home isolation for 7 days after the date of sampling: in case of workforce shortage authorised to work
with protective equipment in a COVID-19 unit or in a cohort team (providing home care to COVID-19 patients).
○ Close contact with a negative test: work is exceptionally allowed if this is necessary to ensure continuity of services but only if strict hand hygiene
is observed, an active monitoring of body temperature and symptoms, and the social distance of 1.5 m from colleagues is maintained.
Denmark
Case with symptoms: continue self-isolation until 48 hours after the symptoms are gone (if only a loss of taste and smell remains, the individual is
considered symptom-free)
Case no symptoms: self-isolation until 7 days after taking the test. If symptoms appear during the 7 days, self-isolation home for up to 48 hours after
you are symptom-free (except the loss of taste and smell)
France
Isolation of confirmed cases until complete recovery (at least 2 days symptom free).
Quarantine of their contacts: 2 weeks, with a softening (i.e. allowed to go out for essential needs after test result) if tested negative and asymptomatic
(NB. If asymptomatic, the test must be performed at day 7 after the last contact => if asymptomatic and negative, the quarantine can be softened from
day 8).
If confirmed cases stay within the households: isolation of the whole household, except to respond to basic needs if asymptomatic (limited frequency
and following of barrier measures).
Isolation structures are proposed (in respect of the individual choice).
Population at risk: Promotion of voluntary isolation, with accompanying measures to adapt daily life (with the GP as principal actor, i.e. assessing the
risk and informing people). The occupational physician is also implied for active workers at risk.
Germany
All SARS-CoV-2 confirmed cases need to self-isolate themselves for at least 14 days from onset of symptoms (or hospital discharge) and if free of
symptoms for at least 48h.
Quarantine of their contacts Category I
If a close contact was previously reported as a COVID-19 case, no quarantine is required, self-monitoring should be carried out.
Italy
All confirmed cases need to be isolated until the end of the symptoms and after two sequential negative tests 24 hours apart from each other.
32
All close contacts and those who are discharged from the hospital clinically cured but still COVID-19 positive, must be placed in quarantine at home for
14 days and must be monitored daily. They need to:
○ ban mobility from their home
○ ban social contacts
○ remain reachable for surveillance
○ measure their body temperature twice a day
○ in case of symptoms, contact the general practitioner and self-isolate themselves
Persons arriving in Italy from third countries are quarantined (all countries except:
○ a) Member States of the European Union;
○ b) States parties to the Schengen Agreement;
○ c) United Kingdom of Great Britain and Northern Ireland;
○ d) Andorra, Monaco;
○ e) Republic of San Marino and Vatican City State)
Asymptomatic close contacts at the end of quarantine are tested whenever possible.
The public health operator of the territorially competent Prevention Department:
○ prescribes the quarantine for 14 days after the last exposure, and informs the General Practitioner or Paediatrician from whom the contact is
assisted for the purposes of Social Security certification;
○ carries out active surveillance daily
Spain
Primary care setting:
Confirmed case: Home isolation (if cannot be guaranteed, use hotels or other facilities)
○ symptomatic: up to 3 days after resolution of fever and clinical presentation with a minimum of 10 days from onset of symptoms
○ asymptomatic: until 10 days from diagnosis
Suspicious case:
○ Identify and recommend house-members to avoid leaving home immediately
○ When the PCR result can be guaranteed within 24-48 hours (depends on corresponding Autonomous Community): wait for PCR confirmation.
●
confirmed case with active infection: see above and identification and control of the remaining close contacts (non-cohabitants)
●
PCR negative, the quarantine of contacts will be suspended.
Recommendations for quarantine: stay at home until 10 or 14 days after the last exposure to risk, i.e. the day of last contact with the case.
Residents in centres for the elderly or in other social health centres:
isolation in the centres (if clinical condition allows it)
isolation shall be maintained until three days after the resolution of the fever and the clinical picture, with a minimum of 10 days from the start of the
symptoms.
33
The follow-up and discharge will be supervised by the doctor who has done the follow-up in his centre or in the way that is established in each
autonomous community.
If the effective isolation of mild cases cannot be guaranteed, isolation in hotels or other facilities fitted for such use will be indicated if this possibility
exists.
Discharge from hospital of a COVID-19 patient:
✔ home isolation must be maintained with monitoring of the clinical situation for at least 14 days from the date of discharge from hospital. After these
14 days, and provided that three days have passed since the resolution of the fever and the clinical picture, the isolation may be terminated. In
any case, if a PCR is performed and a negative result is obtained (before these 14 days of home isolation from hospital discharge have elapsed)
the patient’s isolation may be terminated.
✔ If the last negative PCR is performed at the time of hospital discharge and there are no respiratory symptoms in the three days prior, the infection
is considered to have been resolved and the patient may be discharged without the need for home isolation. In any case, the provisions of each
Autonomous Region will be followed.
The
Quarantine strategies for 3 categories of contacts:
Netherlands
1.
Housemates (Category 1): The GGD informs all housemates (also children) orally and written with the following advice:
Quarantine at home during 14 days after the last contact with the confirmed patient i.e. telework, no public transportation, no visitors - especially not
with a high risk to be infected.
Taking care of cough- and hand hygiene.
To be alert, during 14 days, for clinical signs and symptoms of COVID-19 (coughing and/or nose cold and/or fever) and (i) in case of suspected fever (
≥38°C) measuring temperature (rectal or via the ear), (ii) call GGD immediately for appraisal and diagnostics.
GGD should be able to contact you during the period of quarantine.
In case the housemates show clinical signs/symptoms of SARS-COV-2 infection, the GGD is responsible for testing them asap.
Exit quarantine for housemates:
14 days after the last moment of contact with the confirmed case, or 14 days counting from the day the confirmed case is symptom free AND at least 7
days after the start of the symptoms (14 days in immunocompromised patients)
And the housemate is symptom free during this period.
Telephone call from the Municipal Health Service (GGD) to housemate at the beginning of the contact tracing, around day 7 (half-way) and day 14 (end) of
the monitoring period, to follow up quarantine measures and discuss symptoms. Transmission within members of the same family can lead to prolongation
of the monitoring period. The moments to call are adjusted.
People working in the vital sector / crucial professions stay at home in quarantine. There are exceptions in consultation with GGD and the company
physician, and only when they are asymptomatic.
2.
Other close contacts (Category 2): The GGD informs other close contacts orally and written with the following advice:
Quarantine at home during 14 days after the last contact with the confirmed patient i.e. telework, no public transportation, no visitors - especially not
with a high risk to be infected.
Children ≤ 12y can go to school and play sports.
Keep at least 1.5m distance from other persons if you come out of home.
34
Taking care of cough- and hand hygiene
To be alert, during 14 days, for clinical signs and symptoms of COVID-19 (coughing and/or nose cold and/or fever) and (i) in case of suspected fever (
≥38°C) measuring temperature (rectal or via the ear), (ii) call GGD immediately for appraisal and diagnostics
The GGD should test ‘other close contacts’ asap if they present symptoms of SARS-COV-2 infection. Pending test results, they stay strictly at home and
make an overview of their own contacts from 2 days prior to the symptoms.
Telephone call from the GGD around day 7 (half-way) and day 14 (end) of the monitoring period, to follow up measures and discuss symptoms.
People working in the vital sector / crucial professions also stay at home. An exception can be made for these groups in consultation with the GGD and the
company physician and only if they are asymptomatic. For care workers outside the hospital: see Testing policy and deployment of care workers.
If a contact 14 days after the last moment of contact with a COVID-19 patient has remained complaint-free, no infection has occurred and the contacts can
re-join society just like other citizens.
3.
Other contacts (category 3): The GGD ensures that contacts are informed about the determination of COVID-19 in a person in their environment.
The contacts are advised:
good cough and hand hygiene;
take general measures to prevent COVID-19 (social distancing);
be alert during the 14 days after the last contact for symptoms of infection, and
in case of suspected fever (≥ 38.0ºC), measure the temperature (rectal or through the ear)
call the GGD directly for assessment and use diagnostics;
to stay at home at the moment of symptoms.
The GGD ensures that contacts are tested for SARS-CoV-2 as soon as possible if symptoms fit COVID-19.
In anticipation of the test results, they stay strictly at home and make an overview of their own contacts from 2 days prior to the symptoms.
Quarantine strategies for contacts of specific groups:
1. For contacts in child care and primary education:
If an adult or pupil in primary education or child care is diagnosed with COVID-19, colleagues and peers are informed in accordance with policy category
3 (other (not close) contacts), and are tested in case of symptoms.
Exceptions are intensive contacts between children and adults, such as during the care of very young children at a children's centre or lowest groups
in primary education. In these cases, the child and the adult are considered to be category 2 contacts (other close contacts).
Adult category 2 contacts in childcare and primary education are in principle not allowed to work.
Children designated as category 2 contacts in childcare and primary education are in principle allowed to go to a childcare centre or primary school,
provided they have no complaints
2. Health care practitioners outside hospitals (different sectors)
Suspected health care practitioner with symptoms:
Everyone should stay home when having symptoms of COVID
35
Health care practitioners and housemates should let them test immediately when having symptoms
The symptomatic person stays home until the test results are available. If the person has fever / dyspnoea, the housemates should stay also home until
the results are known.
Test negative: health care practitioner with mild symptoms and NO fever can work again.
Test positive: source and contact tracing GGD. Index and housemates stay home until 2 weeks after last contact at home. Index stays at hom e at least 7
days after the start of the symptoms (or test) AND 48h fever free (<38°C without t° control medication) AND 24h symptom free.
Asymptomatic health care practitioner (different scenarios):
Housemate COVID 19 positive: stay home until 14 days after last contact (exceptionally the health care practitioner may work in communication with
the GGD or company doctor, with the use of type II mask and gloves.
Close contact COVID 19 positive: health care practitioner may work (till 14 days after last contact, the health care practitioner should use mask of type
II and gloves)
Housemate with respiratory complaints and fever / dyspnoea: health care practitioner may work (till test result is known, the health care practitioner
should use mask of type II and gloves)
3. Foreign travellers in the Netherlands
If foreign travellers staying in the Netherlands test positive for COVID-19, the Dutch guidelines are used.
The GGD of the region where the traveller is staying carries out the contact test in the Netherlands.
If the index was also abroad during the infectious period, the GGD informs the Centre of Infectious Diseases (LCI
) (https://cib.healthandsafety.nl/). Foreign travellers in home isolation or quarantine are not allowed to travel, not even to their country of origin. If this is nevertheless necessary, the
Centre of Infectious Diseases will be consulted. If a tourist leaves the Netherlands without permission, the GGD will inform the LCI.(more info
https://cib.healthandsafety.nl/)
4.
Aircraft Contact Policy
Contact research of aircraft contacts is started:
1) if the index has been on board of an aircraft during the infectious period
The following aircraft contacts are defined as 'other close contact' (category 2):
Passengers seated within 2 seats away from the front, back and side of the index (max 24 contacts), where the aisle is considered as a row of seats
and aircraft compartments/sections as a boundary. (see also
www.seatguru.com)
Crew members who have had intensive contact with the index (e.g. because extra care has been provided).
If the index is a passenger, the data of the index will be transmitted to the GGD of the airport of arrival via secure mail connection.
2) If a crew member was contagious:
The following aircraft contacts are defined as 'other close contact' (category 2):
passengers with whom this crew member had intensive contact (e.g. because extra care was provided)
directly cooperating colleagues who had > 15 min of continuous contact at a distance < 1.5 m. In practice, these will often be the crew members who
worked in the same compartment or section.
Other crew members are considered to have had other non-high level contact if they have had non-intensive contact with the index (category 3)
36
If the index is a crew member who has flown during the contagious period, the contact tracing shall be coordinated with the arrival airport GGD. (more info
https://cib.healthandsafety.nl/)
Monitoring of source and contact tracing:
To monitor the effects of source and contact tracing the transfer of daily information from the electronic patient file (checkbox) to the National Institute of
Public Health and the Environment is done and used already at the beginning of the pandemics. In the electronic patient file the following data is reported:
personality characteristics (gender, year of birth, postal code);
link to index (Osiris number) or situation;
contact category;
first and last day of exposure;
monitoring period;
call contacts during monitoring period;
occurrence of complaints including first day of illness and type of complaints;
collected diagnostics;
GGD region.
Regular evaluation will take place to adjust policy where necessary and possible.
link to page 41 link to page 39
37
6.4.1 Isolation strategies
The criteria for discharging patients from isolation i.e. discontinuing transmission-based precautions,
differ by country
(Table 8). Often a difference is indicated for severe cases who have been admitted
to hospital (minimum 14 days) versus mild cases at home (7 to 10 days). Because of the large
discrepancies between countries we consulted the guidance from WHO and ECDC and compared
these with the countries.
When testing capacity is sufficient, WHO stipulates that countries can choose to continue to use a
laboratory testing algorithm as part of the release criteria in (a subset of) infected individuals if their
risk assessment gives reason to do so. Without retesting, a distinction is made between symptomatic
and asymptomatic patients (see
Table 7). Fever has to be assessed when the patient is no longer
using antipyretics. It has also been noted that respiratory symptoms may linger on in the form of a
post viral cough beyond the period of infectivity. WHO states that further research is needed to clarify
this.
Examples explaining the WHO rule are: if a patient had symptoms for two days, then the patient
could be released from isolation after 10 days + 3 = 13 days from date of symptom onset; for a patient
with symptoms for 14 days, the patient can be released (14 days + 3 days =) 17 days after the date
of symptom onset; for a patient with symptoms for 30 days, the patient can be released (30+3=) 33
days after symptom onset).
Table 7 – WHO and ECDC guidance on isolation strategy
Criteria for discharging patients from isolation
WHO June 17th 2020
Regardless of isolation location or disease severity.
https://www.who.int/ne
1. With retesting: if two PCR tests with at least 24 hours apart are negative, the
ws-
patient can be released.
room/commentaries/d
2. Without retesting:
etail/criteria-for-
○
releasing-covid-19-
For symptomatic patients: 10 days after symptom onset, plus at least 3
patients-from-isolation
additional days without symptoms (including without fever and without
respiratory symptoms)
○ For asymptomatic cases: 10 days after positive test
ECDC April 8th
The latest advice was in the context of discharging patients from hospitals to free
https://www.ecdc.eur
beds as soon as possible during the peak of the epidemic. Testing capacity was
opa.eu/en/publications
similarly stretched.
-data/covid-19-
guidance-discharge-
Hospitalised patients:
and-ending-isolation
1. Conditions for all:
○ two negative RT-PCR tests at 24 hours interval at least eight days after
onset of symptoms
OR
○ discharged based on clinical criteria AND self-isolate at home or in a safe
place until resolution of fever for at least three days and clinical
improvement of other symptoms AND until eight days after the onset of
symptoms for mild cases or for 14 days (severe cases) if these criteria
have not been fulfilled in hospital. Follow-up visits, or monitoring via phone
or other electronic device can be considered. These patients should be
prioritised for testing
2. Discharged to long-term care facility, prison, children with special needs etc.; to
a single room until eight days after the onset of symptoms AND resolution of
fever for at least for three days AND clinical improvement
3. Immunocompromised patients: Self-isolation until 14 days after symptom onset
AND resolution of fever for at least three days AND clinical improvement of
symptoms other than fever.
Mild or probable cases at home:
1. All: self-isolation eight days after onset symptoms AND resolution of fever AND
clinical improvement of other symptoms for at least for three days
2. Critical workers (e.g. healthcare workers, law enforcement, firefighters etc.);
resolution of fever three days AND after eight days from the onset of symptoms
38
have passed. Return to work using a surgical mask until 14 days after the onset
of symptoms. If testing capacity allows, this is a priority group for testing during
the pandemic
For confirmed cases, the isolation is performed at home in all countries but in France and Spain
there is the possibility to go or to be referred to an
isolation structure (hostels, detention centres).
It should also be noted that in France, voluntary isolation of populations at risk is promoted, with
the development of aid services for these populations.
39
Table 8 – Isolation strategy by country
WHO
Belgium
Denmark
France
Germany
Italy
Spain
The Netherlands
Mandatory isolation
-
No
No
Yes
Yes
Yes
?
?
Isolation days minimum
10*
7
not specified
seems 14
14
not specified
10
7
days**
Lift restriction if no more
Yes, wait 3
Yes
No, wait 2
No, wait 2
No, wait 2
Yes, and PCR
No, wait 3 days
No, wait 1 day, and
symptoms (after isolation days
days
days
days
days
twice negative
2 days after fever
minimum)
Lift restriction Health Care
Personnel
-days after symptom onset
7
-
seems min
-
min 10
14*
-days without fever
3
-
-
-
-days without symptoms
-
2
2
-
3
-PCR negative before going back to
No
Yes, repeat
No
Yes, twice
Yes
work
2nd time
information
negative 24
before
found
hours apart
working with
high risk
*When PCR test is available: if two PCR tests with at least 24 hours apart are negative, the patient can be released irrespective of time since symptoms; ** In the guideline, only
two days of symptoms free is mentioned but in the incapacity for work certificate example, a minimum period of 14 days is mentioned.
link to page 44
40
6.4.2 Quarantine strategies
Quarantine at home is applied in all countries for a duration of 14 days, from the last day of contact.
In Germany there are some slight differences by region. In Belgium, when a second test is negative,
the quarantine is shortened to a minimum of 10 days. In France, contacts at risk with symptoms are
treated as confirmed cases even if the test is negative and must be isolated (min 14 days and at
least 2 days symptom free) and close contacts without symptoms must remain in quarantine for 7
additional days after a negative test result (performed 7 days after the last risk contact) but are
authorised to go outside for basic needs and following strictly barrier measures. In Denmark,
asymptomatic contacts are allowed to go out 7 days after taking a negative test. Although Spain does
advice not to test asymptomatic contact persons, a consideration can be made to test carers of high
risk persons. In Belgium, Denmark, France and Germany where close contacts are tested,
quarantine turns into isolation when a test is positive.
Quarantine is also currently imposed when changing from a higher endemic to a lower endemic area
(people arriving from Lisbon, Llerida, and A Marina in Belgium) or when going to a more vulnerable
area (e.g. all persons going to an overseas area in France). In France, symptomatic travellers
identified during border health checks are quarantined, regardless of their nationality.
6.4.3 Monitoring of compliance
Even if isolation and quarantine are
mandatory, the non-compliance does not always lead to
consequences. In Italy, for example, fines are imposed (the police has a list of persons in isolation).
For France and Belgium, while fines were given during the lock-down in the event of non-compliance
(and increased in the event of recidivism), the situation is less clear now. Nevertheless, a close
monitoring is performed.
Indeed, in France and Italy, a monitoring of compliance is done by the regional health authorities,
which organise an active and regular telephone follow-up of isolated patients and contacts in
quarantine (1-2x per day in France) to ensure compliance with the isolation/quarantine instructions
and to help with difficulties of daily living by giving social support if needed.
In Germany, a close contact of a confirmed case has to report daily to the contact tracer about his
health status (body temperature twice a day and symptoms), general activities and contacts with
other people. In the Netherlands, the GGD is allowed to contact you to ask for your health status.
6.5 Outbreak detection and control strategies
6.5.1 Surveillance systems
Countries use national and regional general surveillance activities to follow up new cases and identify
outbreaks. Next to the indicators, monitoring the evolution of the epidemic, several indicators are
able to monitor the identification of clusters. For example date and municipality or province, context
of cluster (company, school, nursing home, etc.) (see the section “Early case detection methods” in
each country for details).
In Denmark, a ‘signal group’ under the leadership of the Statens Serum Institut continuously
assesses the incidence of local spread of infection, with the aim of being able to swiftly initiate
preventive measures if there is evidence in the surveillance of the spread of infection via a cluster or
an outbreak. If the group assesses that in an area there is a spread of infection, that cannot be
immediately explained by a local outbreak at a particular institution or the like, the Danish Agency for
Patient Safety enters into a dialogue with the municipality and their infection hygienic unit for the
purpose of initiating regular testing of health and care personnel in the area in question.
Healthcare
professionals should be tested every 7 days for 2 months or until the spread of infection in the area
where the chains of infection are not covered.
In Denmark, a website with voluntary self-reporting of symptoms where voluntary citizens report
influenza-like symptoms (https://influmeter.dk and COVIDmeter) has been started.
Testing characteristics in collectivities by country is discussed below and i
n Table 9 (see also the
section “Early case detection methods” in each country for details).
link to page 45
41
6.5.2 Systematic testing in nursing homes and high risk groups
The French strategy to prevent a second wave (gradual and low-noise resumption of the epidemic -
scenario 3) advises to proactively inform precarious populations (e.g. in hosting structure) and
actively invite them for testing. This is done in collaboration with associations specialised in
precarious populations with the help of interpreters. Advice for nursing homes when one positive
case is detected (also scenario 3 of the epidemic) in France, is weekly testing of staff working and
testing of all residents. Currently, in the same homes, a test is proposed to new residents or staff,
people returning from leaves, or people with symptoms. In Denmark, continuous testing of health
care personnel in general practice, hospitals, and personnel in nursing homes etc. with no symptoms
is being initiated. Residents of nursing homes and collectivities are NOT screened but fall under the
contact tracing procedures.
6.5.3 Outbreak or cluster identification and investigation
An overview for the countries is presented i
n Table 10. A new outbreak, suspected of a cluster, is
mostly defined as 2 or 3 or more epidemiologically linked cases. In collectivities one case is an
outbreak. To identify outbreaks, France follows the density of incidence in their districts (cases/100
000 inhabitants/week) and the context in which clusters occur: companies, school, nursing homes
for older people, precarious population, etc. France is currently investigating the creation of mobile
contact tracing and isolation teams in the event of an outbreak or cluster.
In Denmark, the prevention of the spread of infection will be set up by regular staff testing (July 13th).
In case of spread of infection with COVID-19 in a municipality or another geographically delimited
area in Denmark, regular testing of health and care professionals in that area should be conducted.
42
Table 9 – Testing characteristics in collectivities by country
Belgium
Denmark
France
Germany
Italy
Spain
The Netherlands
Precarious Population
Preventive screening
No
No
Advised: Proactive
No information
No information
No
Not yet
testing campaigns
found
found
in case of gradual
resumption of the
epidemic (scenario
3)
Outbreak
definition
2
No information
3
No information
No information
3
(number of confirmed or
found
found
found
plausible cases)
Schools
Preventive screening
No
No
No
No information
No information
No
No
found
found
Outbreak definition
2
3
3
3
(number of confirmed or
plausible cases)
Nursing homes
Preventive screening
Yes:
No
Yes: new workers,
No information
No information
No
Not yet,
performed in
new residents,
found
found
researched
first wave,
after leaves.
new
Advised: weekly
residents,
testing of staff in
returning
case of gradual
after
resumption of the
discharge
epidemic (scenario
from
3)
hospital.
Outbreak definition
2 (1 positive
3 (1 in case of
1 (confirmed)
1
(number of cases)
and 1
scenario 3)
suspected):
screening of
43
the home
can be
initiated by
the regional
health
authority
Table 10 – Outbreak and early case detection strategies by country
Nursing homes
Schools
Precarious populations
Belgium
Any possible case is tested, especially residents No systematic screening.
Mobilisation
to
find
accommodation
and staff of collective residential facilities.
The Health Promotion Services of each school are in
solutions
If allowed by a sufficient testing capacity: charge of contact tracing and of defining the No systematic screening but voluntary
systematic screening of each new resident (with
modalities of eviction, in collaboration with the
initiatives are happening
the possibility of a second test in case of
Federated entities.
negative result).
At the Federal level, high risk/close contacts concern
As of two cases: management by regional the whole class for children < 6 years old and only
health authorities
neighbours for children ≥ 6 years old.
From 10 cases, management by the Governor
of the Province
Denmark
Continuous testing of health care personnel and
No screening as schools are closed. Guidelines for Since testing opportunities are now broadly
personnel in nursing homes etc. with no symptoms
schools and child care facilities were published with
available, no specific measures for early case
is being initiated. - July 13th – as described below:
the reopening of schools etc in April/May and revised
detection methods in populations at increased
In case of spread of infection with COVID-19 in a
prior to the new school year starting in August.
risk of serious COVID-19 disease exist apart
municipality or another geographically delimited
from the contact tracing strategies etc. included
area, regular testing of health and care
in the guidelines for nursing homes, home
professionals in that area should be conducted.
nurses, continuous testing of personnel etc.
This is for the purpose of preventing the spread of
infection
If there is a spread of infection in an area that
cannot be immediately explained by a local
outbreak at a particular institution or the like, the
Danish Agency for Patient Safety should enter into
a dialogue with the municipality and their infection
hygienic unit for the purpose of initiating regular
testing of health and care personnel in the area in
question. Healthcare professionals should be
tested every 7 days for 2 months or until the spread
44
of infection in the area where the chains of infection
are not covered.
France
Currently:
No systematic screening.
Planned in case of gradual and low-noise
New staff and new residents;
Regional health agencies are in charge of contact
resumption of the epidemic:
tracing-testing and of defining the modalities of
Proactive information and testing campaign
After returning from leave;
eviction, i.e. close a class, an entire level or the
(e.g. in hosting structure), in collaboration
Staff and residents with symptoms
whole school, in collaboration with the academic
with associations specialized in precarious
populations and other specific professionals
Planned in case of gradual and low-noise
authorities.
such as interpreters.
resumption of the epidemic:
Weekly testing of the whole personnel (with a 7-
days interval, including at least 2 days of
symptom-free, for positive cases).
Systematic testing of all residents if a positive
case is detected (among the staff or the
residents).
Germany
Serial testing can be performed on the staff and
No information found
the residents if there is a confirmed case, with
the objective to identify the chain of
transmission and interrupt it at an early stage.
Italy
In case of outbreaks in hospitals, long-term Schools are still closed and will reopen in No specific information found
residential facilities and other residential
September.
facilities for old people, all related patients and
health staff are tested.
Spain
The detection of a SINGLE case in these Any cluster of 3 or more confirmed or probable No specific policy reported in case of
institutions will be considered an outbreak for
cases with active infection in which an
outbreak
the purposes of implementing action measures.
epidemiological link has been established is sent
Any cluster of 3 or more confirmed or
In addition to general actions, PCR will be
at start and weekly to CCAES and NEC according
probable cases with active infection in which
carried out on close contacts or, depending on
to a specific form.
an
epidemiological
link
has
been
the circumstances, on all residents and workers
There is a guide for Prevention and Control of
established is sent at start and weekly to
of the centre, in the manner established by each
Infection at Schools available, as they open in
CCAES and NEC according to a specific
Autonomous Region.
September 2020 and attendance of all students is
form.
guaranteed. It is based on two main goals:
Strategy for migrants arriving to the coasts
1. Creation of healthy and safe school
is being implemented including systematic
environment by (i) limiting contacts, (ii)
testing.
personal prevention measures, (iii) cleaning
and ventilation, (iv) case management.
45
2. Early detection of cases and appropriate
management of them.
Transversal actions:
Reorganisation of the school
Coordination and participation
Communication and health education
Equity
The
No policy in case of outbreak reported, only:
If the child's complaints are recognizably unrelated to
No policy in case of outbreak reported, only:
Netherlands
The GGD and institutions should pay attention a pre-existing disorder (such as hay fever or asthma), The GGD and institutions should pay
at clustering of confirmed cases.
the child may attend school or children's centre.
attention at clustering of confirmed cases.
Asymptomatic testing could be useful in the Any child with newly developed rhinitis symptoms Asymptomatic testing could be useful in the
future (research phase)
or a change in the pattern of symptoms can be
future in specific groups.
tested at the request of the parents.
When an employee of a school or a child is
reported to the GGD as confirmed COVID-19,
contact tracing is started and symptomatic
contacts between children and staff tested.
If in a group of a primary school 3 or more children
or staff have complaints that fit COVID-19, it is
considered a cluster/outbreak.
○ The GGD in cooperation with the
management of the children's centre /
elementary school, carries out source and
contact research on the positive staff
members and/or children.
○ Under the guidance of the IZB-doctor, the
GGD in question starts an outbreak
investigation to map out the situation at
school.
○ The GGD advises the school on the
provision of information to the parents.
○ Other staff members and children are
registered whether they have complaints and
whether they have been or can be tested.
Depending on the context, only the
group/class or several groups/classes are
questioned.
46
○ In case of an outbreak with > 3 confirmed
children/adults, consider further outbreak
diagnostics (and/or also whole genome
sequencing).
○ Policy for children's centres/schools can be
tailored to the results of the outbreak
investigation.
○ Consider also testing asymptomatic children
and staff in case of a large outbreak. GGD's
can consult with the LCI to make a choice.
47
7 DISCUSSION AND CONCLUSIONS
The main objective of this fast review was to describe policies and implementations in a selection of
countries and point out interesting practices during this COVID-19 epidemic either from the start,
currently or planned for the immediate future. Evaluating the identified practices or collecting
information about their key performance indicators, was not the objective of this study. Based on the
experience of the investigated countries, key points can be highlighted and can thus serve as the
basis of discussion for international researchers and public health authorities in general. The key
points are generic and the ‘theoretically’ described strategies from countries are given as examples
only. Each country can decide if the example would be appropriate for application depending on the
stage of the epidemic in the country and the healthcare context and organisation. It is also possible
that in some countries authorities are already working on or preparing (some of) the suggestions
below.
7.1 Having a national testing and tracing plan adapted to the spread of the
epidemic
Testing strategies adapted to the stage of epidemic will protect at risk populations and identify early
cases and clusters and fore come further spread of COVID-19, using the available resources in an
optimal way. All countries developed testing strategies to curb the epidemic. The following strategy1
describes how to take different epidemiological scenarios into account while adapting testing
strategies:
1. Epidemic under control, based on available indicators, with occurrence of localised clusters
that can be controlled: testing - tracing - isolation as usual.
2. Existence of critical clusters, raising fears of a loss of control of the chains of
contamination, and therefore of the control of the epidemic itself: strengthening of the
testing - tracing - isolation within the perimeter of the cluster of asymptomatic people;
active information campaign for people to get tested.
3. A gradual more difficult to identify low-noise resumption of the epidemic. Indicators
deteriorate without the chain(s) of contamination being identified nor controlled. This
scenario would require strict measures as well as the rapid activation of several prevention
measures either on a regional scale if the indicators allow it or at the national level:
systematic weekly testing of staff in nursing homes (and all residents once there is a
positive case); health care professionals proactive informing and testing persons of
precarious populations; specific protocol for high-density large metropolitan regions; a
protocol on hospital preparedness, etc.
4. A loss of control of the epidemic that would require difficult decisions, i.e. a choice between
generalised national lock-down, which minimises direct mortality, and other collective,
economic and social objectives.
Key points for international researchers and public health authorities:
While countries define their (national) testing and tracing plan, an adaptation of these strategies
according to the spread of the epidemic could be planned. This also implies having in place a
central coordination, real-time data, analysis and communication of results which would allow
identification of outbreaks and clusters in the community and high risk collectivities. The updates in
the strategies are to be broadly communicated to the general population, health professionals and
stakeholders.
1 Based on the documen
t https://solidarites-sante.gouv.fr/IMG/pdf/avis_conseil_scientifique_2_juin_2020.pdf
48
7.2 An attention on stocks as well as on laboratory capacity and rapidity
Testing capacity has increased rapidly in all studied countries in the past months. Nevertheless, it is
unclear if the daily capacity will be sufficient for a new infection peak and if reagents and testing
material will be available in sufficient quantity, requiring a close monitoring of these aspects.
Several strategies have been implemented in the selected countries to improve testing capacity (see
6.1.3). The use of pooling of samples, the production of testing material locally, and the use of saliva
have also been explored and launched. In the Netherlands, for example, the following possible
solutions for shortage of sampling materials and extraction and PCR reagents are discussed:
Pool the throat and nose swab from one patient at the laboratory and perform one PCR only
(save PCR extraction and reagents). (Pooling at the laboratory level can also be considered on
a larger scale e.g. preventive testing of health care staff in a nursing home or residents residing
on one floor or section of a building).
Use one tube of virus transport medium and combine the throat and nose swab from one patient
at the sampling site.
Use a classic cotton swabs (tear-off packaging or as dry cotton in 'tube') and cut to fit collection
tube when shortage of the synthetic fiber swab with plastic applicator (e.g. Copan Nylon®). Never
use swabs with a wooden or metal carrier (PCR inhibition leading to false negative or unreadable
results).
Locally produced test material, such as swabs in Italy and Belgium or tests in Denmark, may allow
anticipating shortages in the coming months. Belgium, through the University of Liège, also produced
RNA extraction reagents and the accompanying plastics for use on the federal platform.
Key points for international researchers and public health authorities:
The monitoring and assessment of material availability for testing should be performed and the
ongoing development process, validity and use of other tests such as rapid tests would ideally be
investigated.
7.3 A rapid information system for improved surveillance and outbreak detection
The rapidity in which the test results are processed and transmitted to the patients and the local or
national health authorities allows infected people to be alerted as soon as possible, isolate
themselves, and for the health authorities to start the contact tracing.
In some countries, test results from laboratories are available in real-time in the “COVID-19
database” and results are (or should be) communicated within 24 hours to the patients and to the
national surveillance system. Indicators on the number of contacts and on the speed of the whole
process, including contact tracing, are also monitored in some countries (e.g. in Italy). Outbreak
detections and cluster investigations in specific settings / collectivities are also monitored (e.g. in
France, Germany, and Belgium) and the determination of critical thresholds are for example under
discussion in France (e.g. 50 cases per 100 000 population).
Key points for international researchers and public health authorities:
The rapidity of the health information system should ideally result in providing the result within 24
hours to the patient and to the national surveillance system. Indicators to monitor the identification of
outbreaks and clusters or to monitor the performance of the process (e.g. for the contact tracing
process) should also be considered.
7.4 A focus on monitoring of nursing homes or specific populations
A high state of alert is needed for all closed collectivities, especially in nursing and care homes for
older people. Infection and prevention measures are the best method to contain the spread of the
virus within these closed facilities. In case of an outbreak, testing can be intensified to contain it.
Regular testing of healthcare workers can also be performed, as initiated in Denmark, but an
evaluation of the resources available needs to be considered. A plan for specific populations, such
as precarious populations, could also be elaborated (such as in France).
49
Key points for international researchers and public health authorities:
The following actions were set up in some of the investigated countries and could be considered:
Systematic testing of staff in homes for older people in case of resurgence of the epidemic;
An action plan for precarious population, especially in case of resurgence of the epidemic;
Systematic testing of health care workers in specific municipalities with ongoing infection
spread when no transmission chain can be identified.
7.5 An application to improve contact tracing?
Currently, most of the applications developed (or planned to be developed) in the selected countries
had the following characteristics: voluntary use, anonymous data use, the compliance with the
general data protection regulation, no geolocalisation, and Bluetooth technology. The countries that
have an application currently in use have nevertheless so far not provided any evidence of the
performance or capacity to contain transmission. Some countries have recommended an evaluation
or evaluation trials are ongoing.
Key point for international researchers and public health authorities:
While planning the implementation of an application to help in the contact tracing, compliance with
the general data protection regulation, evaluation of performance indicators, and international
compatibility within Europe should also be considered.
7.6 Measures for recalcitrant people and an increased monitoring
Because hygiene measures, isolation and quarantine may be detrimental (e.g. for precarious
populations, self-employed, informal caregivers, etc.), ignoring or disobeying the rules is not
uncommon. Countries have reflected on mechanisms to improve the population compliance and
participation including for the contact tracing:
Key points for international researchers and public health authorities:
Actions identified in the selected countries that may have potential and can be studied are the
following:
The possibility to go to an isolation structure (e.g. hostels, detention centres) to support the
socially vulnerable.
The provision of social support to reduce the impact of isolation (see the measures
developed to reduce the impact of isolation for precarious populations in France).
The organisation of close monitoring and support of people in isolation or quarantine by the
regional health agencies. For people in quarantine, this will also benefit the faster
identification of contacts developing symptoms.
The promotion of the voluntary use of the (future) application(s) via information campaigns
specifying their confidential character: no geolocalisation and no identification (to reach
people that are reluctant with the traditional contact-tracing system).
The permission for individuals to contact the tracing centre directly. This ‘nudging’ strategy
puts the control by the persons themselves.
The follow-up of population symptoms through voluntary self-reporting of influenza-like
symptoms via an application.
7.7 Study limitations
The timeframe of the study was very short. An in-depth analysis was therefore not possible and some
information could not be found within the time limits. Additionally, not all information could be
validated by other countries within this timeframe (France and Germany are not validated) or was
only partially validated. Because of the limited timeframe, only a limited number of countries could
be investigated.
All the information included in this report was found available online through official websites and/or
media reporting. If additional internal information is available at a country level but not published
online, we had no access and it was therefore not reported in this document.
50
The situation is evolving and changing rapidly. The description corresponds to the situation at the
time of writing this report, between June 8th and July 15th, depending on the country, and may no
longer be up to date.
The report is based on the experience of other countries as described online and did not aim to
evaluate and report the effectiveness and cost-effectiveness of these practices. Although, the key
points highlighted in this report are theoretic and experience-based rather than evidence-based, the
researchers think they are worth to be considered. Nevertheless, the health care context and specific
situation of every country is different. It is up to the health authorities of every country to decide on
the most appropriate measures in their country.
One important factor that was not part of the scope of the project, was the evaluation of capacity in
responding to the epidemic and the human resource and expertise constraints. As reported by the
WHO in 2017
(WHO mission report Belgium), Belgium for example continues to face challenges in
preparing and retaining trained health personnel specialised in infectious diseases, epidemiology
and public health at the level of the different health authorities. A lack of human resources may
explain the difficulties faced by health authorities in some countries implementing national and
international best practices. This topic could be part of future research.
7.8 Conclusion
Several interesting practices from the selected countries were highlighted in the previous sections.
Nevertheless, the costs incurred by some of these practices can be high. Their implementation will
therefore be based on the resources and human capacity available. Because their (cost)-
effectiveness has not been and could not be assessed, no prioritisation can be done.
51
■ APPENDIX
1 RESULTS FOR BELGIUM
1.1 Existence of a plan to prevent the second wave
Date
report(ed)
and
Statement / definition
reference
https://covid-
The testing strategy evolved according to the case definition from the start of the epidemic (January 18th 2020).The chronology of testing
19.sciensano.be/sites/default
strategy was as follows:
/files/Covid19/20200608_Chr
18/01: (Symptomatic) travellers returning from Wuhan. 1
onology_Case%20definition.
3/02-10/03: Symptomatic cases with travel history. Progressive extension of travel criteria adapted to the epidemiological data
pdf
available by country. No testing of contacts (capacity not sufficient) from 5/3 onwards (too many).
11/03: Circulation confirmed in Belgium, removal of travel history as criteria for testing. Testing for symptomatic cases (respiratory
https://covid-
tract infection) who need hospitalisation and for HCW (all, also mild disease). Insufficient PPE to allow sample taking by any GP and
19.sciensano.be/sites/default
not possible to send all suspected cases to the emergency wards anymore.
/files/Covid19/Testing_Advic
13/03: Testing capacity insufficient because circulation of a lot of respiratory pathogens. Inclusion of fever as testing criteria for HCW
e_20200324_Testing%20pri
with respiratory tract infection.
ority_uitbreiding.pdf
04/04: Increase in daily testing capacity. First priority group added are symptomatic cases (including mild) in collectivities, until 5 (then
https://covid-
circulation of virus is confirmed, all symptomatic cases confirmed as COVID).
19.sciensano.be/sites/default
09/04: Extensive testing in nursing homes (symptomatic and asymptomatic) through federal platform.
/files/Covid19/Testing_Advic
16/04: Further increase capacity: fever removed as testing criteria for HCW.
e_20200420_Testing%20str
22/04: Still sufficient capacity, testing expanded to all new residents in collectivities (even asymptomatic) and new hospitalisations (for
ategy.pdf
non-COVID) because not enough for all symptomatics while systematic testing in nursing homes not yet finished.
04/05: Testing all suspected cases (enlarged case definition). Start contact tracing. Testing of contacts at end quarantine for those
working with persons at risk of developing a severe manifestation of the disease. If testing capacity still enough: further testing of new
persons admitted in collectivities/hospitals
As of March 23th, the strategies for testing are described on the website of Sciensano.
5e Nota aan Eerste Minister
The Group of Experts on the Exit Strategy (GEES) listed measures to be included in the action plan for the exit of the first wave and prevention
en Kern ter voorbereiding van
of a second wave. The following aspects should be included:
de Nationale Veiligheidsraad
First line of defence: individual testing and contact tracing: Infected people need to be identified and tested, the persons with whom they
dd.
03/6/2020 GEES
have been in contact identified and when needed isolated.
52
https://www.health.belgium.b
Second line of defence. Monitoring of the evolution nationwide of the virus in real-time with the aim to identify cluster outbreaks at the
e/nl/news/interministeriele-
geographical, household, professional, collectivity, school level or others. Based on this a quick coordinated (federal, community/region,
conferentie-
provincial and municipal authorities) response with local health resources should take place.
volksgezondheid-van-20-
Activities and sectors can re-open only when measures of contact limitation, physical distancing and hygiene are described in
protocols,
mei-2020
approved by the relevant authorities and followed-up over time. Certain activities that are liable to ‘super spreading’ remain on a ‘closed
list’. This list is re-evaluated with a positive evolution of the epidemic.
The Inter-Ministerial Conference (IMC) (May 20th) for Health has taken steps or is on the way to ensure
The right legal context for required data gathering and management;
https://www.health.belgium.b
Overall set-up and responsibilities of virus resurgence management with details for each level;
e/nl/news/interministeriele-
Sufficient resources at each level to deal with 500-1000 new cases per day and 10-20% of these requiring cluster investigation and
conferentie-
additional testing in the context of the cluster;
volksgezondheid-van-1-juli-
Simplified guidelines in case of outbreak in collectivities;
2020
More elaborate guidelines for local cells and the first line;
Strengthen the data teams of Sciensano;
Broaden the data collection and registration for effective virus resurgence management;
Necessary budgets to enable the above at the various decision levels.
The Inter-Ministerial Conference (IMC) (July 1st) discussed the following:
contact tracing application: Ministers confirmed their joint commitment to this dossier.
The dossier comprises several components - technology, regulatory basis and communication - which will be developed in a coordinated
manner. With regard to the technological part, there is agreement on the choice of DP-3T / bluetooth. A specific timeline has already been
agreed by the IMC, with an award to be made in July. Smals will launch the contract, but does not play a role in the developm ent or audit
of the contact follow-up application.
Sciensano provides surveillance based on multiple data sources. Health inspection of the regional authorities plan surveillance on the basis
of signals from Sciensano and by means of protocols that they agree with non-structural collectivities (such as a youth movement camp)
or other settings (e.g. a company). These protocols must guarantee rapid detection and action. Further fine-tuning will take place in the
coming days, including with regard to the emergency planning systems coordinated by the National Crisis Centre.
Resurgence measurements: federal government preparation of the hospital sector, medicines and medical devices and protective
equipment. The Flemish authorities and the Walloon Region explained the preparedness plans established within their respective
governments.
53
1.2 Testing strategy
1.2.1 Indications for PCR testing
Date report(ed) and
Statement / definition
reference
July
16th
2020 Who needs to be
tested with a molecular test (in order of priority)?
https://covid-
1. Any person who meets the definition of a
possible case* (see below) of COVID-19, with particular focus on:
19.sciensano.be/nl/co
Care personnel (persons providing assistance or care)
vid-19-gevalsdefinitie-
en-testing
Occupants and staff of collective residential facilities (e.g. residential care centre, accommodation centre for people with disabilities, reception
centres, prisons...). As of two cases in the same facility, the responsible Federated entity will further decide on the most appropriate further testing
strategy, adapted to the local conditions.
and
2.
High-risk contacts of a case of COVID-19 (If the contact person underwent an initial test within 7 days of exposure, the doctor may in consultation
with the patient deciding to perform a second PCR test. This second test must be carried out for at least 5 days after the first PCR test and at the
https://covid-
earliest 9 days after the last risk contact).
19.sciensano.be/sites/
A person who has cumulative contact of at least 15 minutes within a distance of <1.5 m ("face to face") in a conversation, for example.
default/files/Covid19/
A person who was in the same room/closed environment for more than 15 minutes with a COVID-19 patient, where a distance of 1.5 m was not
COVID-
always respected and/or where objects were shared. This includes roommates, all classmates for children 3 to 6 years (kindergarten), children
19_procedure_contact
from the same group living in a residential collectivity, possibly neighbours in a classroom with children ≥ 6 years old or at work (except when
_NL.pdf
plexiglas divisions were used).
A person who has had direct physical contact with a COVID-19 patient.
and
A person who has been in direct physical contact with excretions or body fluids of a COVID-19 patient, such as during kissing and mouth-to-mouth
ventilation, or contact with vomit, bowel movements, mucus, etc.
https://covid-
A caregiver in contact with a COVID-19 patient during care or medical treatment or examination within a distance of 1.5 m, without the use of
19.sciensano.be/sites/
personal protective equipment (according to protocol/activity).
default/files/Covid19/
A person who has travelled with a COVID-19 patient for more than 15 minutes, in any means of transport, seated within two seats (in any direction)
COVID-
from the patient. In an aircraft also crew members serving in the section of the plane where the case was. If the severity of the symptoms or the
19_procedure_childre
displacement of the patient on the aircraft indicates a potentially greater exposure, passengers who were in the same compartment or all
n_NL.pdf
passengers on the aircraft are considered to be high risk contacts (assessment by the Infectious Disease Control Department).
A person returning from a country or region with a high transmission risk: red or orange zone
If the capacity allows it, the following persons can also be tested:
3. Any person requiring hospitalisation, including an initial admission in the day hospital, according to the rules drawn up by each hospital, taking
into account local context and the specific nature of the concerns. If the test proves negative, the test can be repeated onc e depending on the
clinical need, as a negative result is also possible in a person who is already infected but still in the incubation period.
1.
Each new resident of a collective residential facility (e.g. residential care centre, accommodation centre for people with disabilities, reception
centres, prison...). If the test proves negative, the test may be repeated once depending on the clinical outcome to cover the incubation period.
54
The following definition shall be used as a guideline, on the one hand, for persons who may have COVID-19 identification, so that a PCR test can be
carried out, and on the other hand to enable monitoring of the disease.
*A possible case of COVID-19 is a person with
at least one of the following main acutely occurring symptoms, without an obvious cause: cough; dyspnoea; thoracic pain; acute anosmia or
dysgeusion;
OR
at least two(1) of the following symptoms, with no other apparent cause: fever; muscle pain; fatigue; rhinitis; sore throat; headache; anorexia;
watery diarrhoea(2); acute confusion(2), sudden fall(2)
OR
worsening of chronic respiratory symptoms (COPD, asthma, chronic cough...), with no other apparent cause.
A
radiologically confirmed case is a person whose PCR for COVID-19 is negative, but who is diagnosed with COVID-19 on the basis of a suggestive
clinical presentation AND a compatible CT thorax.
A
confirmed case is defined as a person where the diagnosis of COVID-19 infection was confirmed by a molecular test(3).
(1) In children, only fever with no apparent cause is sufficient to consider the diagnosis of COVID-19 during this epidemic.
(2) These symptoms are more common in the elderly, where an acute infection can express itself atypically.
(3) Molecular test: PCR or antigen rapid test. A PCR test should be performed additionally when a negative result was obtained with an antigen rapid test (Rapid Antigen
Test).
55
https://covid-
19.sciensano.be/sites/
default/files/Covid19/
COVID-
19_Lab_form_NL.pdf
June 11th 2020
56
1.2.2 PCR testing conditions: how and by whom?
Date report(ed) and reference
Statement / definition
https://covid-
The GP is the first point of contact for all suspicious patients. All patients with symptoms must contact a GP, which will determine if a
19.sciensano.be/sites/default/file
test should be performed (based on a telephone anamnesis). All possible cases (see the definition above) should be tested and
s/Covid19/d%C3%A9claration%2
identified via an electronic form (eForm "Notification and lab application in case of suspicion of SARS-CoV-2 infection").
0obligatoire%20et%20suivi%20d
Either the GP performs the test himself (only if appropriate protective and testing equipment) or sends the patient to a triage centre (or
es%20contacts.pdf
“sampling centres”).
Sampling centres are specific sites organised by GPs, hospitals, municipalities, etc. and coordinated by the GPs circles. Since March
12 June 2020 NIHDI
23rd 2020, these initiatives have received funding from the NIHDI, i.e. the same fee for all physicians working in these centres, a flat
rate for nurses, paramedics and care coordinators (per half day) and a flat rate for administrative staff. Sampling in these centres can
https://www.inami.fgov.be/fr/covid
either be done by a physician or by a nurse.
19/Pages/retribution-soutenir-
postes-triage.aspx
On May 7th, the IMC decided that 120 sampling centres should remain operational (i.e. one sorting centre per 100,000 inhabitants)
with each federated entity being responsible for ensuring an adequate distribution of centres on its territory.
57
25 May 2020
Two procedures are described:
https://covid-
A nasopharyngeal swab (in one nostril)
19.sciensano.be/sites/default/file
Oro-pharyngeal swab combined with a superficial nasal smear (of both nostrils)
s/Covid19/COVID19_procedure_
The nasopharyngeal swab is the preferred option but if no suitable material is available, the combined throat and superficial
sampling_FR.pdf
nasopharyngeal swab is also permitted.
58
1.2.3 Indications and conditions for serological testing
Date report(ed) and reference
Statement / definition
https://covid-
Who can be tested through
serology (reimbursement conditions)?
19.sciensano.be/nl/covid-19-
1. Hospitalised patients who meet the definition of a possible case AND where the CT Thorax is suggestive for COVID-19 but the PCR
gevalsdefinitie-en-testing June 12th
test is negative. The serology is performed at least 7 days after the onset of symptoms.
2020
2. Hospitalised or ambulatory patients who show a prolonged clinical picture suggestive of COVID-19, but whose PCR test is negative,
or who could not be tested within the 7 days following the onset of COVID-19. The serology shall be carried out at least 14 days after
https://covid-
the onset of the symptoms.
19.sciensano.be/sites/default/files/Co
3. In the context of differential diagnosis in an atypical clinical presentation. The serology is performed at least 14 days after the onset
vid19/COVID-
of symptoms.
19_Case%20definition_Testing_NL.p
4. To examine the serological status of health care personnel and personnel in hospitals/services and other collectivities with a high
df
risk of exposure to COVID-19 (COVID departments or rest homes) in the context of local risk management.
RIZIV/INAMI website
Determining antibodies in patients with a suspicion of a COVID-19 infection is not recognised as a primary diagnostic test in acute
disease. The RIZIV/INAMI reimbursement includes the following target groups:
366: care providers and personnel, working in hospitals, clinical laboratories or collectivities, with a high degree of infection (COVID-
19 services, residential care centres or clinical laboratories)
365: patients with an atypical clinical presentation, taken at least 14 days after the onset of symptoms under differential diagnosis
364: patients with prolonged clinical picture suggestive of COVID-19 with negative PCR result or without PCR test within 7 days of
onset of symptoms, taken at least 14 days after onset of symptoms
363: hospitalised patients with a suggestive clinical picture for COVID-19 where there is a discrepancy between the molecular
detection test and a CT scan, taken at least 7 days after the onset of symptoms
The provision can be charged a maximum of 2 times per period of 6 months.
Only serum is required for the determination. In order to comply with the requirements drawn up by the NIHDI, it is necessary to state
explicitly within which target group and indication the patient falls. If the analysis is requested outside the indications, it will be charged
to the patient at € 9,60.
59
1.2.4 Laboratory capacity
Date report(ed) and reference
Statement / definition
Communication federal taskforce
Extra test capacity was created by the Federal Government in collaboration with Sciensano, the Federal Agency for Medicines and Health
Products (FAMHP) and the National Reference Centre as an overflow mechanism to the classical clinical labs through a platform with
biotech/pharma industries and two universities (KU Leuven and the University of Liège).
At the peak of the first wave the laboratory test capacity was around 35 000 tests a day. Further upscaling the capacity, to 80 000 per
day, is planned by October 2020. This will be done through incentives to upscale the installed base of the classical clinical laboratories
in Belgium together with a government funded upscale of the installed base in a selection of 5 to 7 laboratory settings (combination of
classical clinical laboratory together with a university / biopharma entity).
Currently, mid-July, the capacity in Belgium is around 30 000 tests a day. In September 2020, the laboratory test capacity will be around
45.000.
Belgium has invested in locally produced virus transport medium, 3D-printed collection swabs, assembling collection kits, filling of tubes
in Belgium with inactivated transport medium, virus extraction reagents and associated plastics,
The pooling of samples at the patient level (combination of the throat and nose swab from one patient at the sampling site in one
tube) is performed and some labs use as an alternative a classic cotton swabs.
Sciensano 19th June 2020
The PCR-testing capacity for COVID-19 was originally limited to one national reference lab (UZ Leuven). On February 21st, Sciensano
Karin Rondia (May 2020)
did an inventory among other labs, to assess their preparedness: four labs answered to have currently at that moment the protocol for
the COVID-PCR in place, whereas 19 labs answered to have concrete plans the implement the COVID-PCR soon (Sciensano, private
https://www.covid19healthsystem.
communication).
org/countries/belgium/countrypage
.aspx
Rapidly, other clinical laboratories developed the technique on their own initiative in collaboration with the national reference laboratory,
which led to a national network of clinical labs (mostly hospital labs, and some private non-hospital labs). The list of participating labs is
And
updated daily (https://epidemio.wiv-isp.be/ID/Documents/Covid19/COVID-19_Diagnostic_Labs_FR.pdf).
Personal communication with the
On June 19th, 90 laboratories were registered on this list.
“Cliniques
Universitaires
de
Bruxelles”: Pr Frédéric Cotton ;
University research units also joined the effort by using an ‘old’ technique requiring less reagents but more workforce. At the beginning
of April, veterinary laboratories of Sciensano and other pharmaceuticals and veterinary laboratories joined the efforts.
And
A governmental working group (task force) was created mid-March 2020 to increase the testing capacity. This working group set up a
Sciensano (3 April 2020)
parallel platform gathering some biotech/pharma industries and two universities (KU Leuven and the University of Liège). By the end of
https://www.sciensano.be/en/press
April, this platform was essentially devoted to a large campaign of testing in homes for older people and nursing homes, launched by the
-corner/veterinary-laboratories-
federal and federated entities. As of mid-May 2020, the samples from roughly 40 to 50% of the triage centres were analysed on the
sciensano-start-covid-19-tests
federal platform.
At the beginning of April, veterinary laboratories of Sciensano and other pharmaceuticals and veterinary laboratories joined the efforts.
The estimated daily capacity in the classical clinical labs was early July around 17 000 a day. The total estimated capacity on July 13th
was 30 000 a day.
60
NRC information session – 25 June
In preparation of the second wave, it should also be considered that Influenza- and RSV-testing will become more important during
2020
coming autumn and winter, as an alternative diagnosis for COVID-19-like symptoms, that make COVID-19-infection less likely (but can
never completely exclude COVID-19).
COVID-19 testing capacity during the season of other respiratory viruses, will highly depend on the epidemic of these other respiratory
viruses.
GEES June 2th 2020
Measures have been taken to increase the capacity and organise testing in the laboratories. In case of a second wave, additional tests
to broadly test potential new clusters should be foreseen, which could amount to ~1,6 mio € per week or ~€ 80 million on an annual basis
for 5,000 tests per day. If the outbreak is more under control, the amount of tests could of course be significantly less and the total annual
cost of the tests reduced proportionally.
61
1.2.5 Communication of test results to the patient
Date report(ed) and reference
Statement / definition
https://covid-19.sciensano.be/nl/covid-
The GP is the central person in the whole process, given his unique relationship of trust with the patient.
19-procedures procedure for GP for
The treating physician must inform the patient when the lab result is known.
patient with suspected COVID-19
June 12th 2020
https://covid-19.sciensano.be/nl/covid-
The lab result is communicated to the physician (e.g. GMD patient) in the usual way if the physician/test/triage centre cooperates with
19-procedures procedure for GP for
a clinical lab.
patient with suspected COVID-19
In the start-up of this first phase, many test/triage centres cooperated with the so-called
'federal platform'. Since 16/4/2020, the
June 12th 2020
results of the federal platform are sent to the CoZo hub through which all physicians with a therapeutic relation can search the results.
Since 6/5/2020 results are also sent to the GMD holder (and since 25/5/2020 to the prescribing doctor if mentioned) through the
eHealthBox. Hence, any physician with a therapeutic relationship with the patient can consult the results in the hub (
CoZo, but also
Flemish Hospital Network, Brussels Health Network and Réseau Santé Wallon).The prescribing physician that acts as the responsible
of the triage centre or the coordinating physician of the nursing home/ residential collectivity can also find the results in the
CyberLab
application (real time results) (only when the triage centre/ nursing home/ residential collectivity sends the samples to the federal
platform).
1.2.6 Recording and surveillance of test results
Date report(ed) and reference
Statement / definition
https://covid-19.sciensano.be/nl/covid-19-
The mandatory reporting of all possible cases to the health inspectorate of the Federated entity is done via the eForm.
procedures procedure for GP for patient with
Additionally, General Practitioners must report the subsequent information:
suspected COVID-19
Deaths caused by suspected or confirmed COVID-19 outside the hospital or residential care centre (see below)
June 12th 2020
Clusters of confirmed COVID-19 in collective facilities (prison, reception centre...), with the exception of nursing care centres
that already have their own surveillance system. These clusters have to be notified immediately, so that the necessary
control measures can be taken.
All data are grouped in a COVID-19 database managed by Sciensano, responsible for the epidemiological follow-up of the
COVID-19 epidemic in collaboration with its partners and other healthcare actors
Sciensano July 3th 2020
Belgian data on mortality encompass both the deaths of patients who were confirmed COVID-19 cases and those who were
https://covid-
suspected of being infected.
19.sciensano.be/sites/default/files/Covid19/
All settings are included: hospitals, residential care centres for elderly, other residential care centres and deaths occurring at
COVID-19_FAQ_FR_final.pdf
home.
As details, data comes from the following sources:
62
and
Daily reports from the
hospitals to Sciensano; deaths due to COVID-19 confirmed by a
laboratory test or chest CT scan
https://epistat.wiv-isp.be/covid//
and possible cases.
Daily reports from
residential facilities (e.g. nursing homes and homes for older people) to the federated entities:
confirmed and possible cases of COVID-19. Possible deaths involve patients who have not undergone a diagnostic test
for COVID-19, but who met the clinical criteria for COVID-19 as judged by the physician. This is the case for the vast majority
of people who die outside the hospital.
Compulsory reporting of
general practitioners to the federated entities (for deaths outside the hospital):
confirmed and
possible cases of COVID-19. Possible deaths involve patients who have not undergone a diagnostic test for COVID-19,
but who met the clinical criteria for COVID-19 as judged by the physician. This is the case for the vast majority of people
who die outside the hospital.
Additionally, it should be noted that for people living in residential facilities: if they die in a hospital, they are included in hospital
deaths. COVID-19 deaths are classified by region of death, as information on postal codes of residence is more difficult to
obtain during the crisis.
https://covid-
From two cases in a collective facility: management by federated entities
19.sciensano.be/sites/default/files/Covid19/
Registration of:
COVID-19_Seroprevalentie%20SARS-CoV-
○ Confirmed cases by date, age, sex and province
2%20in%20bloeddonoren_NL.pdf
○ Cumulative number of confirmed cases by municipality
○ Confirmed cases by date and municipality
https://covid-
○ Hospitalisations by date and province
19.sciensano.be/sites/default/files/Covid19/
○ Mortality by date, age, sex, and province
COVID-19_Seroprevalentie%20SARS-CoV-
○
2%20bij%20gezondheidswerkers%20in%20
Total number of tests performed by date
Belgische%20ziekenhuizen_NL.pdf
Four indicators are used to monitor the evolution of the epidemic: confirmed cases, new hospitalisations of laboratory-
confirmed COVID-19 cases, intensive care unit occupancy, and deaths (now presented with the 7-day moving average).
Seroprevalence on blood donation samples (n=1500) organised by the Red Cross and Sciensano
Measure and follow-up of prevalence, seroprevalence and seroconversion in healthcare workers (n=785) in Belgian
hospitals (Sciensano and the Institute of Tropical Medicine) between March and September 2020
1.2.7 How is testing reimbursed
Date report(ed) and reference
Statement / definition
https://www.inami.fgov.be/fr/covid19/Pages/c
PCR tests are fully reimbursed in the conditions described above (no co-payment and no extra-billings). The limit of
onditions-remboursement-tests-detection-
maximum 2 PCR tests per patient was removed from April 22th. While previously, PCR tests could not be performed in
coronavirus-pandemie-covid19.aspx
they do not respected the conditions defined by Sciensano, they are authorized since 22 June 2020 but are at the patient’s
charge.
Antigen tests are reimbursed since April 1th (also with a limit of maximum 2 tests, which was removed on April 22th) and
according to the procedures defined by Sciensano. Negative or doubtful results must be followed by a molecular test. No
63
molecular tests can be performed in case of a positive result. These tests are fully reimbursed (no co-payment and no
extra-billings).
Serologic tests are reimbursed since June 3th (maximum 2 tests per 6 months period) but only in the conditions described
above (as complementary diagnosis or to assess the serologic status of health professionals working in care facilities with
a high risk of transmission. In these conditions, these tests are fully reimbursed (no co-payment and no extra-billings).
Otherwise, people have access to serologic tests but have to pay a maximum amount of €9.60.
1.3 Isolation strategies and monitoring of confirmed cases
1.3.1 Suspected cases (having symptoms)
Date report(ed) and reference
Statement / definition
https://covid-19.sciensano.be/nl/covid-19-
Patients who meet the definition of a possible (suspected) case should contact their general practitioner by telephone.
procedures procedure for GP for patient with
All patients who meet the definition of a possible case (see indications for PCR testing) should be tested.
suspected COVID-19
Individuals are most contagious right before and after symptoms appear. It is therefore important that patients contact their
June 12th 2020
GP as soon as possible so that he or she can isolate the patient and his or her housemates if necessary.
1.3.2 Confirmed cases
Date report(ed) and reference
Statement / definition
https://covid-19.sciensano.be/nl/covid-19-
Asymptomatic care staff with a positive PCR test = confirmed case
procedures procedure for GP for patient with
The person must remain in home insulation until 7 days after the date of sampling. This means that if, for example, the result
suspected COVID-19
is only known after 2 days, the person only has to stay at home for 5 days.
June 12th 2020
The sampling must therefore be organised in such a way that the result is known as soon as possible.
During the (past) peak of the epidemic: If the availability of personnel is limited, the person can continue to work provided
that he wears a mask and has enhanced hand hygiene, but only in a COVID-19 department or in a COHORTE team
(healthcare providers that only provide home care for positive patients with COVID).
https://covid-19.sciensano.be/nl/covid-19-
1. SYMPTOMATIC TREATMENT
procedures procedure for GP for patient with
Paracetamol remains the first choice for treatment of pain and fever, the usual (contra-) indications for NSAIDs remain valid.
suspected COVID-19
Off-label use of medications or experimental treatment against COVID-19 is reserved for hospitalised patients.
June 12th 2020
Guidelines on the use of anticoagulants in COVID-19 patients have been drawn up by the Belgian Society of Thrombosis
and Haemostasis and are available on the Sciensano website.
Guidelines are also available for the proper use of oxygen in COVID-19 patients following discharge from hospital or staying
https://covid-
in residential care centres.
19.sciensano.be/sites/default/files/Covid19/
2. HOME ISOLATION:
64
COVID-
Write a certificate for work incapacity for 7 days;
19_procedure_hygiene_case%20%26hous
Explain to the patient that leaving the house is to be avoided;
hold_NL.pdf
Hand over the hygienic measures that can prevent the spread of the virus;
Ask the patient to contact you again by telephone:
○ if symptoms worsen;
○ if new symptoms occur;
○ at the end of the period of inability to work. The isolation can be lifted if the patient no longer shows symptoms of
COVID-19.
If the patient is a member of the healthcare personnel, the isolation will be lifted at the earliest 7 days after the onset of
https://epidemio.wiv-
symptoms AND up to at least 3 days without fever AND with improvement of respiratory symptoms. When returning to work,
isp.be/ID/Documents/Covid19/COVID19_pr
a surgical mouth mask must still be worn at all times until the symptoms have completely disappeared AND at least 14 days
ocedure_contact_NL.pdf
after the onset of the symptoms.
3. CONTACT SUPPLEMENT
The patient's roommates should be placed in home isolation for 14 days. For this purpose, the general practitioner draws up
a certificate of quarantine. More information about the contact measures can be found in the specific guideline.
The call centre is automatically informed of the test result and will contact the patient in order to map out his close contacts
that then also be contacted.
1.4 Contact tracing strategy
1.4.1 Contact definition
Date report(ed) and reference
Statement / definition
https://covid-19.sciensano.be/nl/covid-
A contact person is any person who has had contact with a confirmed COVID-19 case within the following timeframe:
19-gevalsdefinitie-en-
Contacts of symptomatic COVID-19 case: within a period of
2 days before the onset of symptoms until the end of the
testing#accordion6
period of infectivity of the case (generally 7 days after the beginning of the symptoms, or longer if symptoms persist).
June 12th 2020
Contacts of asymptomatic COVID-19 case: a contact person defined as someone who has had contact with this person within
a time span of 2 days before the sample was taken, until 7 days after.
N.B. If a person was himself a confirmed case of COVID-19 (PCR+) in the previous 8 weeks, he is not considered as a contact.
https://covid-
High risk contacts or
close contacts
19.sciensano.be/sites/default/files/Covid
For the following persons the risk of infection is considered to be "high". If the contact person underwent an initial test within 7 days
19/COVID-
of exposure, the doctor may in consultation with the patient decide to perform a second PCR test. This second test must be carried
19_procedure_contact_NL.pdf
out at least 5 days after the first PCR test and at the earliest 9 days after the last risk contact. At a second negative PCR result can
65
terminate the isolation (i.e. 10 days at the earliest after the last risk contact). The doctor informs the patient that the isolation may
and
be stopped.
These are further referred to in this Directive as 'close contacts':
https://covid-
A person who has cumulative contact of at least 15 minutes within a distance of <1.5 m ("face to face") in a conversation, for
19.sciensano.be/sites/default/files/Covid
example.
19/COVID-
A person who was in the same room/closed environment for more than 15 minutes with a COVID-19 patient, where a distance
19_procedure_children_NL.pdf
of 1.5 m was not always respected and/or where objects were shared. This includes roommates, all classmates for children 3
to 6 years (kindergarten), children from the same group living in a residential collectivity, possibly neighbours in a classroom
with children ≥ 6 years old or at work (except when plexiglas divisions were used).
Version July 8th 2020
A person who has had direct physical contact with a COVID-19 patient.
A person who has been in direct physical contact with excretions or body fluids of a COVID-19 patient, such as during kissing
and mouth-to-mouth ventilation, or contact with vomit, bowel movements, mucus, etc.
A caregiver in contact with a COVID-19 patient during care or medical treatment or examination within a distance of 1.5 m,
without the use of personal protective equipment (according to protocol/activity).
A person who has travelled with a COVID-19 patient for more than 15 minutes, in any means of transport, seated within two
seats (in any direction) from the patient. In an aircraft also crew members serving in the section of the plane where the case
was. If the severity of the symptoms or the displacement of the patient on the aircraft indicates a potentially greater exposure,
passengers who were in the same compartment or all passengers on the aircraft are considered to be high risk contacts
(assessment by the Infectious Disease Control Department).
Low risk contacts
For the following persons, the risk of contamination is considered to be "low":
A person who has had contact with a COVID-19 patient for less than 15 minutes within a distance of 1.5 m ("face to face") (If
there was a complete separation by a wall made of plexiglass, this does not fall under a face to face.)
A person who was in the same room/closed environment with a COVID-19 patient, but was less than 15 minutes within a
distance of <1.5 m. This includes all children in a nursery (cribs), all classmates for children ≥ 6 years, people who work in the
same room, or were sitting together in a waiting room.
A caregiver who has been in the same room as a COVID-19 patient without the use adequate protective clothing, but never
within a distance of 1.5 m.
Care providers to COVID-19 patients and laboratory staff handling samples of COVID-19 cases and using the recommended
Personal Protective Equipment are not considered low-risk contacts. However, they are subject to a general recommendation to
strict hand hygiene.
66
1.4.2 Organisational process of contact tracing
Date report(ed) and reference
Statement / definition
https://covid-
Contact tracing procedures and testing of
Close contacts:
19.sciensano.be/sites/default/files/Cov
In order to be able to detect cases between asymptomatic contacts, all close contacts are tested (High risk contacts), as defined
id19/COVID-
above.
19_procedure_contact_FR.pdf
Testing
low-risk contacts:
Version June 12th 2020
A test to exclude infection in asymptomatic persons is not necessary.
When developing symptoms compatible with COVID-19 (see the “possible case” definition) the person becomes a possible case.
Next, this person has to telephone the GP to find out where present himself to be tested for COVID-19 so that a sample can be
taken.
https://covid-
All possible cases must be reported so that a contact follow-up can be started. This compulsory notification is made via the
eForm
19.sciensano.be/sites/default/files/Cov
1 (“Lab application in case of suspicion of SARS-CoV-2 contamination”) which was integrated in the electronic software packages
id19/COVID-
for general practitioners, reporting the information to the health inspectorate of the federated entity. The eForm MUST be
19_procedure_GP_NL.pdf
completed in order to start the contact follow-up.
A contact follow-up is then carried out by a central call centre (telephone calls to the patients in order to identify all their contacts).
June 23th
The contact follow-up only takes place after confirmation of a case with a positive lab result. If the general practitioner is of the
opinion that contact tracing and follow-up is still necessary in case of a negative lab result because of a very suggestive clinic
(CT-scan) or epidemiological suspicion, he should explicitly indicate this in the central database by filling in the specific
eForm 2
(Request of contact follow-up in case of negative test result).
Exceptionally, if the general practitioner wants to start contact tracing
and follow-up without waiting for the laboratory result (or if the test cannot be performed), he should fill in the
eForm 3 (Direct
application of contact follow-up in case of very strong suspicion of COVID-19 infection).
When following up contacts, the call centre may recommend a PCR test (i.e. if it is a close contact as defined above or if the
contact shows symptoms).
These close contacts receive an SMS with a 12-digit code from the call centre. This serves as evidence for the GP that a PCR
test should be taken. The GP can verify this code via the web application 'PCR Prescription validation' or via a direct link in the
GPs software package. Upon validation of this test, the call centre is informed that the person has indeed contacted a doctor. For
each valid test request, an eForm will be filled in and a test will be taken by the general practitioner or at the triage centre (as
described in PCR testing conditions).
The GP remains the central figure in the whole process, given his unique relationship of trust with the patient.
67
https://covid-
19.sciensano.be/sites/default/files/Cov
id19/COVID-
19_procedure_GP_NL.pdf
June 23th 2020
Flow of call centre for contact procedure:
These central systems are managed by the Federated entities. The IMC agreed that identical procedures should be followed in all
federated entities and a working group was created in order to set up a common platform and tools. Two thousand people were
recruited (with adaptation of the number according to the spread of the outbreak), with some of them already working in the
administration, and others through public tenders launched by the federated entities. A field supervisor is likely to go to the
patient/contact residence (e.g. if a contact by telephone was not possible).
68
1.4.3 Testing of contacts
Date report(ed) and reference
Statement / definition
https://covid-19.sciensano.be/nl/covid-
All close contacts are tested (High risk contacts, as defined above) within the following timeframe:
19-procedures
Asymptomatic close contacts, who have professional contact with persons at risk of a serious form of COVID-19, have to perform
Version June 23th 2020
between day 11 and 13 of the isolation period (after telephone contact with the GP). In agreement with the patient, the GP can
also already carry out a PCR test earlier in the first week after exposure. If the result is positive, the patient will begin a 7-day
isolation and a search for close contacts will be initiated. If the result is negative, the quarantine period of 14 days remains valid.
This also applies for the close contacts who will continue to work due to staff shortages (for essential professions).
All other asymptomatic close contacts will be tested immediately at identification. If the result is negative, the isolation period of
14 days remains valid. In agreement with the patient, the physician may perform a second PCR test if the first test was performed
within 7 days after exposure. A 5-day interval between the two tests must be observed and this second test must be carried out
at least 9 days after the last risky contact. If this second PCR test is negative, the quarantine may be stopped (therefore no
sooner than 10 days after exposure). The physician will inform the patient that the quarantine has been stopped.
1.4.4 Contact tracing Apps
Date report(ed) and reference
Statement / definition
June 30th 2020
Decision on the use of an Apps are in progress. The following important characteristics are taken into consideration: voluntary
basis, blue-tooth technology, anonymised data, and no geolocalisation.
This was communicated by Karine Moykens the chair of the Interfederal Committee Testing and Tracing.
69
1.5 Quarantine strategies and monitoring of contacts
Date report(ed) and reference
Statement / definition
https://covid-
If the test result is negative, quarantine follows 14 days after the last risk contact.
19.sciensano.be/sites/default/files/Covid19
If the test result is positive, this person becomes a confirmed case. It follows a home isolation for up to 7 days after taking the
/COVID-19_procedure_contact_FR.pdf
test.
June 23th 2020
Quarantine measures for
close contacts:
Stay at home for 14 days after the last risk contact (even in case of negative results). Going out is only authorised for small
essential purchases (food, pharmacy,...), provided that a textile mouth mask is used and strict compliance with hygiene
measures, whereby direct contact with other people is avoided.
In case of no professional contacts with people at risk of developing a severe form of the disease and if two PCR tests are
performed (with at least 5-day interval between both tests and at least 9 days after the last risked contacts for the second
test, see testing of contacts) and that both results are negatives, the quarantine may be stopped before 14 days (but no
sooner than 10 days after exposure).
If during the quarantine period a housemate develops symptoms and is COVID-19 confirmed, the 14-day period starts again
for all asymptomatic housemates exposed to this new patient.
For persons exercising an essential profession such as carers, work is exceptionally allowed if this is necessary to ensure
continuity of service guarantees, provided:
○ observing strict hand hygiene;
○ active monitoring of body temperature and possible symptoms of COVID-19;
○ maintaining a distance of at least 1.5 m from colleagues;
○ avoiding social contacts outside of work;
○ not travelling.
Other measures for
close contacts:
Extra attention should be paid to the basic hygiene measures (see Directive hygiene advice for high-risk contact).
For 14 days, all close contacts must themselves monitoring (self-monitoring), by measuring their temperature twice a day.
Persons professionally in contact with persons who have a risk of a serious form of COVID-19 will be contacted every 3 days
by the call centre, to record the state of health.
https://covid-19.sciensano.be/nl/covid-19-
Quarantine measures for
low-risk contacts:
procedures
Quarantine at home is not required for asymptomatic low-risk contacts.
June 12th 2020
However, it is recommended to keep social contacts to a minimum, while respecting from a distance of 1.5m.
Other
measures for
low-risk contacts: Extra attention should be paid to the basic hygiene measures (see Directive hygiene advice for low-risk contact).
A textile mouth mask should be worn for all outdoor movements for persons > 12 years old.
70
1.6 Early case detection methods
1.6.1 Surveillance based indicators used to detect early cases
Date report(ed) and reference
Statement / definition
Sciensano 27 May 2020
Data reported by GPs, hospitals and collective facilities are grouped in a COVID-19 database managed by Sciensano, responsible for
https://covid-
the epidemiological follow-up of the COVID-19 epidemic in collaboration with its partners and other healthcare actors.
19.sciensano.be/sites/default/files/C
Example of data reported:
OVID19/COVID-
Confirmed cases by date, age, sex and province
19_FAQ_FR_final_0.pdf (in French
Cumulative number of confirmed cases by municipality
and Dutch)
Confirmed cases by date and municipality
Hospitalisations by date and province
and
Mortality by date, age, sex, and region
Total number of tests performed by date
https://epistat.wiv-isp.be/covid/
Four indicators are used to monitor the evolution of the epidemic: confirmed cases, new hospitalisations of laboratory-confirmed
COVID-19 cases, intensive care unit (ICU) occupancy and deaths. These indicators are now presented with the 7-day average to
illustrate a trend. One of the consequences of this is that the curve is smoothed and daily variations are reduced.
1.6.2 Identification of clusters
Date report(ed) and reference
Statement / definition
As of two cases in the same collective facility, the federated entities (health directorate) will further decide on the most appropriate
further testing strategy, adapted to the local conditions.
1.6.3 In hospitals
Date report(ed) and reference
Statement / definition
https://covid-
Depending on the testing capacity and the hospital, any new person requiring hospitalisation can be tested (according to the
19.sciensano.be/sites/default/files/Covid19
rules drawn up by each hospital, taking into account local context and the specific nature of the concerns). If the test is negative,
/COVID-19_procedure_hospitals_FR.pdf
the test can be repeated once, depending on the clinical evaluation.
For each hospitalised patients with COVID-19, hospitals are asked to fill-in a questionnaire at admission (with questions on age,
CIM 17/06/2020
gender, location (postcode) and other information such as being a health care professional, living in a collective residential facility
(and which one), etc.) and at discharge (with question on the severity, complications, treatments, etc.) and transmit it to Sciensano
for epidemiological research.
71
https://www.health.belgium.be/fr/news/conf
Hospitals also report daily information to Sciensano on deaths due to COVID-19 confirmed by a laboratory test or chest CT scan
erence-interministerielle-sante-publique-
and possible cases.
du-17-juin-2020
Proposals for strengthening hospitals and their mutual cooperation within local-regional networks, particularly with regard to
strengthening infection prevention and control, were discussed at the IMC. These proposals concern not only the hospitals
themselves, but also transmural cooperation with actors in the first line of care and residential facilities such as nursing homes.
1.6.4 In nursing homes and other collective residential facilities
Date report(ed) and reference
Statement / definition
https://covid-
Collectivities have been recognised as places where grouped cases can occur and where transmission chains are maintained,
19.sciensano.be/sites/default/files/Covid19
especially where social distance and hygiene measures are difficult to be respected. Nursing homes have been identified as an
/COVID-19_strategie_testing_NL.pdf
at risk collectivity group. Other collectivities that have been in confinement applying very strict rules are settings where children
April 24th
are admitted with medical conditions, in temporary homes or boarding schools, chronically ill, with learning issues. For adults the
different settings of the sectors youth care, people with disabilities, psychiatric collectivities, prisons, and lodgings for seasonal
workers have been identified.
https://covid-19.sciensano.be/nl/covid-19-
Any person who meets the definition of a possible case of COVID-19 is tested, especially residents and staff of collective
gevalsdefinitie-en-testing
residential facilities. As of two cases in the same collective residential facility, the responsible Federated entity will further decide
June 12th 2020
on the most appropriate further testing strategy, adapted to the local conditions.
Depending of the testing capacity, each new resident of a collective residential facility could also be tested (e.g. residential care
centre, accommodation centre for people with disabilities, reception centres, prison...). If the test is negative, the test may be
repeated once depending on the clinical evaluation.
AVIQ (12 May 2020)
As of May 12th, and in order to standardise data collection in all regions (decided at an the IMC), each collective residenti al
https://www.aviq.be/fichiers-
facility has been required to complete a daily declaration regarding:
coronavirus/Note%20information%20d%C
The total number of cases among residents or staff;
3%A9claration%20en%20ligne.pdf
The number of new cases per day
The number of hospitalisations are collected in addition to the total number of cases.
Between March and May 12th, these data were already collected on the regional level and each region has its own monitoring
tool. For example in Wallonia: The monitoring of facilities with more than 10 cases automatically comes under the coordination
of the Governors of the Province. The monitoring of institutions with less than 10 cases is done at the level of the Federated
entities, with the possibility, however, of activating the emergency mechanism set up with the Governors of the Provinces if the
situation is critical. Particular attention is also paid to the state of stocks of equipment and the level of staff available.
Nursing homes and homes for the elderly also report mortality data to the Federated entities for confirmed and possible cases of
COVID-19. Deaths of possible cases involve patients who have not undergone a diagnostic test for COVID-19, but who meet the
clinical criteria for COVID-19 as judged by the physician.
72
1.6.5 In schools
Date report(ed) and reference
Statement / definition
French Community 18/05/20
Children belonging to at-risk groups should not attend the school in the first phase of deconfinement. Parents of children with
http://enseignement.be/upload/circulaires/
serious chronic illnesses are advised to consult their GP to determine whether or not they can attend the community.
000000000003/FWB%20-
Children or staff with symptoms should stay at home. Children or staff living under the same place as a confirmed case (close
%20Circulaire%207587%20(7840_202005
contacts) must remain in quarantine at home for a 14 day period (14 days after the last high risk contact or 14 days after the
15_171752).pdf
confirmed case in the family has been authorised to stop the home isolation).
If a child develops a symptom while attending school :
He must be isolated in a dedicated space;
His/her parents must be contacted immediately to come and pick him up;
An adult from the school regularly inquires about the student's state of health (always the same one if possible);
If a temperature reading is necessary, a digital remote thermometer will be used. If this is not possible, an axillary thermometer
could be used by children who are old enough to use it themselves. Otherwise, the temperature will be taken by the parent at
home;
After a sick student leaves, the area should be ventilated and disinfected;
Parents should contact the GP by phone.
The School Health Promotion Service (SHPS) must be warned. This service can make sure the GP has been contacted.
The school keeps the information confidential.
If the child is a confirmed case (positive result), the call centre (of the appropriate Federated entity) contacts the School Health
Promotion Services (SHPS) of the school. If the child attended school within the two days prior to the onset of symptoms (or
sample collection), the SHPS team, in collaboration with the school principal, conducts the contact tracing. A list of persons who
had contact with the case will be drawn up and divided into two parts: high-risk/close and low risk contacts (as defined in “contact
definition”). The SHPS team also has to identify among the contacts whether there are children belonging to a risk group (pre-
existing chronic pathology) who were attending school, in agreement with their GP. Telephone contact with the parents should
be made immediately, informing them whether the contact is high or low risk, and asking them to discuss it with their GP. The
communication with contacts will preferably be done by telephone, but e-mail or paper mail via the children’s school bags are
also allowed. If communication with the parents has not been established despite several attempts through various channels, the
SHPS team must report this to their Federated entity.
https://covid-
The COVID-19 Belgian Pediatric Task Force published advice for children and young people at increased risk and return to
19.sciensano.be/sites/default/files/Covid19
school.
/COVID-19_FAQ_paeds_NL.pdf
73
1.6.6 Precarious population
Date report(ed) and reference
Statement / definition
https://kce.fgov.be/sites/default/files/atoms
Persons not benefiting from the health insurance of RIZIV-INAMI can be covered by other schemes:
/files/KCE_313C_Performance_Belgian_h
Uninsured Belgian citizen (e.g. not in order with their social security contributions) can obtain help from the social assistance
ealth_system_Report.pdf
(OCMW-CPAS).
Service de lutte contre la pauvreté 09/04/20 Prisoners are covered by the Federal Public Service Justice.
https://www.luttepauvrete.be/wp-
For asylum seekers, health care costs are either covered by the Federal Agency for the Reception of Asylum Seekers (Fedasil)
content/uploads/sites/2/2020/04/200409-
or by the Ministry of Social Integration via the local welfare centres (OCMW-CPAS)
aper%C3%A7u-covid-19-FR.pdf
Undocumented migrants are entitled to receive care via Urgent Medical Aid (UMA). During the COVID-19 crisis, measures have
been taken to facilitate the administrative procedures and all care provided to undocumented migrants
Service de lutte contre la pauvreté 09/04/20 An inter-federal Task Force on Vulnerable Groups has been set up and resources have been made available to broaden the
https://www.luttepauvrete.be/wp-
range of shelters for the homeless (for other measures, out of scope for this report (e.g. financial help), see the pdf).
content/uploads/sites/2/2020/04/200409-
Many humanitarian volunteer initiatives (from NGOs like Médecins sans Frontières, Médecins du Monde, Croix Rouge, etc.) were
aper%C3%A7u-covid-19-FR.pdf
also set up for the precarious populations (mobile teams, creation of structures providing information, testing, care, isolations,
etc.). In Brussels, a telephone line was set up by the GPs’ organisations to direct sick people to the local GP circles where a
doctor
will
answer
the
call.
Prisons, shelters for asylum seekers and the homeless, and equivalent residential facilities also received general hygiene and
prevention advice from their respective supervisory authorities and were asked, whenever possible, to increase their capacity
and to develop collaborative arrangements with health care facilities and alternative care sites where people with respiratory
illnesses could receive appropriate care.
1.7 Coordination and responsibility of testing and tracing
Date
report(ed)
and
Statement / definition
reference
https://www.info-
Belgium has been in the “federal phase of crisis management” from March 12th 2020. In the usual context, public health threats are monitored
coronavirus.be/en/what-is-
by the following two bodies:
the-government-doing-about-
The Risk Assessment Group (RAG) analyses the risk to the public based on epidemiological and scientific data, under the coordination of
it/
Sciensano. The core group is made up of experts from Sciensano and representatives of the health authorities. Depending on the topic,
accessed June 13th
other experts are invited. For COVID-19 these experts include clinicians (GPs, infectiologists, paediatricians), hygienists and
microbiologists.
74
The Risk Management Group (RMG) takes measures to protect public health, based on the advice of the RAG. This group is chaired by
the Federal Public Services (FPS) Public Health and is made up of representatives of the health authorities, both from the federal state
and the federated entities.
In the context of the COVID-19 pandemic, a Scientific Committee for Coronavirus was set up in addition, to assist the health authorities in
controlling the coronavirus. The Committee provides scientific advice on the evolution of the virus and helps ensure our country is optimally
prepared for the spread of this new pulmonary virus
When the National Security Council (consisting of the Prime Minister and the Deputy Prime Ministers, the Ministers-President of the Regions
and Communities) makes policy decisions, the various interministerial, interdepartmental and interregional crisis units concretise these
decisions, coordinated by a Federal Coordination Committee. The Federal Coordination Committee (COFECO) is chaired by the National
Crisis Centre (NCCN). Management of the medical aspects is specifically coordinated by the FPS Public Health (hospital capacity, personal
protective equipment, testing, etc.).
COFECO is made up of the Chair of the RMG and representatives of the Prime Minister, the Federal Ministers for Home Affairs, Justice,
Finance, Foreign Affairs, Public Health, Budget, Mobility, Defence, Employment and Labour, as well as the Ministers-President of the Regions
and Communities. The following administrations are also represented: the FPSs Public Health, Mobility, Economy and Defence as well as the
regional crisis centres and the federal police. The committee prepares and coordinates the implementation of the policy decisions of the NSC
at strategic level.
The evaluation Unit, CELEVAL, chaired by the FPS Public Health, is made up of representatives of Sciensano, the Scientific Committee for
Coronavirus, the Superior Health Council, the administrations responsible for public health at the level of the Regions and Communities, and
the FPS Home Affairs and Mobility. It advises the authorities on matters of public health, so they can take decisions to tackle the pandemic.
Finally, beginning of April, a group of 10 experts was constituted by the Prime Minister to prepare the end of the confinement (Group of experts
for the exit strategy or GEES).
75
2 RESULTS FOR DENMARK
2.1 Existence of a plan to prevent the second wave
Date
report(ed)
and
Statement / definition
reference
June 9
None reported in early June (complaints of medical doctors in the general press)
July
13,
personal
No written plan exists per se for a “second wave”, because a number of initiatives have been taken in order to control the spread of the virus
communication
in general.
On June 9th,
The Danish Health Authorities published a strategic document with description of initiatives for prevention of spread of the
virus, identification of people infected, contact tracing and prevention of outbreaks etc.
A comprehensive
contact tracing system has been put in place and
guidelines for containment in areas with high risk of virus spread
and vulnerable populations, e.g. nursing homes, have been issued, extensive population based information initiatives with information of
measures to prevent spread of infection, guidelines for people with symptoms and close contacts etc.
2.2 Testing strategy
2.2.1 Indications for PCR testing
Date report(ed) and reference
Statement / definition
July 7th
Testing can be done through two tracks:
https://www.sst.dk/en/english/corona-eng/faq
1. The health care track
https://www.covid19healthsystem.org/countri
Symptomatic people (even with mild symptoms)
es/denmark/livinghit.aspx?Section=1.5%20T
Close contacts of a confirmed case
esting&Type=Section
Asymptomatic inhabitants of nursing care homes (and other institutions) as well as frontline nursing home personnel in
https://www.regionh.dk/til-fagfolk/presse-og-
case of infection among inhabitants or colleagues. From 30/06, systematic testing of nursing staff working at nursing homes
nyt/pressemeddelelser-og-nyheder/nyt-til-
and in home care.
ansatte-i-region-
Patients expected to be hospitalised for 24 hours or more, independently of the patient’s condition (referral by the hospital)
hovedstaden/Sider/Personnel-information-
Out-patients who presumably will undergo one or more procedures which constitute a serious risk of exposure to COVID-
on-the-coronavirus.aspx
19
https://www.sst.dk/covid-turist
76
Workers caring for patients with a very high risk of becoming seriously ill as a consequence of COVID-19 infection2
2. The public track:
Anyone who wants to be tested3
2.2.2 PCR testing conditions: how and by whom?
Date report(ed) and reference
Statement / definition
25/06
1. The health care track:
https://www.coronaprover.dk/Account/WhoCa
In general: the doctor (family doctor, nursing home doctor, etc.) creates a referral for testing at a hospital testing clinic.
nBookTime
The patient subsequently returns to coronaprover.dk and books an appointment.
29/06
Close contacts: all persons with a positive test result are contacted by telephone by Corona Tracking (DK:
“Coronaopsporing”), with is a unit under The Danish Patient Safety Authority. The unit helps with contact tracing and can
https://www.coronaprover.dk/lib/coronainform
refer those falling under the definition of close contacts for testing. Close contacts can also be referred by their family
ation-2020-06-29_ENG.pdf
doctor. Close contacts are referred for two tests at TestCentre Denmark at an interval of two days after exposition to
https://www.sst.dk/covid-turist
infection4. The individual subsequently returns to coronaprover.dk and book an appointment.
Other people falling under testing in the health track: Can be referred by a doctor, e.g. the nursing home doctor
2. The public track:
All Danes aged over 18 and resident in Denmark and migrant workers with an administrative civil registration number may
book an appointment for a coronavirus test in TestCentre Denmark (coronaprover.dk).
All travellers and tourists entering Denmark via the airport or the most popular border crossings can get tested on site.
Also, testing can take place at a mobile test station that will be present at certain strategic locations, e.g. travel hotspots
and amusement parks during the summer time etc.
2
“on the basis of the prudence principle you should be tested again 48 hours after symptoms cease, and if this test is negative, you must be tested yet again after an
additional 24 hours. If this test is also negative, you can return to work. You will possibly be reassigned to a less sensitive field of work from when you have been
asymptomatic for 48 hours, and until there are two negative tests
.” https://www.regionh.dk/til-fagfolk/presse-og-nyt/pressemeddelelser-og-nyheder/nyt-til-ansatte-i-region-
hovedstaden/Sider/Personnel-information-on-the-coronavirus.aspx
3
You may choose to take a test even though you have no symptoms or are not a close contact of someone infected with novel coronavirus. You can schedule a test online
at coronaprover.dk, where you will find everything you need to know in Danish about booking a test, the test itself, test results and what you should do if your test is
positive. You may also be called in for testing as part of government monitoring.
4
Individuals with an administrative civil registration number who have been in close contact with an infected person, must first get a referral before booking a test
appointment. They can get a close contact referral by calling the contact tracing centre Coronaopsporing
77
2.2.3 Indications and conditions for serological testing
Date report(ed) and reference
Statement / definition
25/06
Individuals can currently only book an antibody test appointment on coronaprover.dk if they participate in a random sampling
https://www.coronaprover.dk/Account/WhoCan
survey on the incidence of COVID-19 in the Danish population or if they participate in a research project.
BookTime
However, on the same website, it is explained how to book a test appointment and access results (same procedures as for
https://www.coronaprover.dk/lib/InformationAnt
PCR testing)
ibodyENGELSK.pdf
2.2.4 Laboratory capacity
Date report(ed) and reference
Statement / definition
01/06
Whole country (TestCenter Denmark): 10,000 tests per day
https://www.healthcaredenmark.dk/news/public-
Hospital testing clinics: 10,000 per day, which is being expanded further
private-cooperation-increases-denmark-s-covid-
Capital Region: 1 500 tests per day to be extended to 5 000 tests per day in June
19-test-capacity-by-100/
https://www.dtu.dk/english/news/2020/06/covid-
Public-private cooperation: government & pharmaceutical industry labs.
19-test-14-timer-i-doegnet-7-dage-om-
ugen?id=e19f4b88-eefb-492d-a33a-
04cd7e5ecba2
2.2.5 Communication of test results to the patient
Date report(ed) and reference
Statement / definition
29/06
●
Individuals with a NemID5 will be able to see their test result on sundhed.dk and in the MinSundhed app. Most people
https://www.coronaprover.dk/lib/coronainformati
can expect to be able to see their test results the day after the sample is taken, but in some cases, it may take up to
on-2020-06-29_ENG.pdf
72 hours (three days).
●
lndividuals without a NemID can contact their doctor to get the results (also from sundhed.dk) or by calling the contact
tracing centre Corona Tracking (Coronaopsporing) 48 hours after test
●
Coronaopsporing calls all individuals with a positive test result.
●
Non-Danish residents can get their test result from the clinic where they were tested.
5
NemID (literally: EasyID) is a common log-in solution for Danish Internet banks, government websites and some other private companies. ... Everyone in Denmark who is
over 15 years old and has a CPR-Number is eligible for a NemID that can be used with their bank as well as public institutions.
78
2.2.6 Recording and surveillance of test results
Date report(ed) and reference
Statement / definition
https://www.covid19healthsystem.org/countr
The system appears to be quite centralized. All appointments for testing must be booked TestCentre Denmark (on-line
ies/denmark/livinghit.aspx?Section=1.4%20
coronaprover.dk) and Corona Tracking (Coronaopsporing) which is a division of the Danish Patient Safety Authority contacts
Monitoring%20and%20surveillance&Type=
by phone any individual tested positive to track close contacts
Section
Systems used for surveillance of COVID-19 include:
○ national-level tracking of tests, hospital admissions, patients needing ventilator assistance for breathing and deaths
○ a website with voluntary self-reporting of symptoms where voluntary citizens report influenza-like symptoms
https://www.sundhed.dk/borger/corona/covi
(https://influmeter.dk and COVIDmeter)
dmeter/
○ a panel testing surveillance system is initiated by the Statens Serum Institut (SSI) based on a sample of GPs and a
sample of their patients who are tested on a weekly basis.
https://sum.dk/Aktuelt/Nyheder/Coronavirus/
2020/April/Ny-digital-loesning-til-borgere-
○ Blood banks testing for antibodies
skal-COVIDmeter.aspx
○ testing of random samples of the total population (PCR and antibodies)From May 7, monitoring of the development of
COVID-19 infections in the population based on the testing of random samples of the total population.
2.2.7 How is testing reimbursed?
Date report(ed) and reference
Statement / definition
02/06
All legal residents and foreign visitors are entitled to health care including COVID-19 related care. No-one pays out-of-pocket
https://www.covid19healthsystem.org/countr
for COVID-19 care (testing, treatment, transport, etc.). On April 2nd 2020 a guideline was published specifically stating that non-
ies/denmark/livinghit.aspx?Section=4.2%20
documented immigrants also have the right to free acute and continued hospital care in case of acute illness, including COVID-
Entitlement%20and%20coverage&Type=Se
19.
ction
https://www.sst.dk/da/Udgivelser/2020/Haan
dtering-af-COVID-19-uregistrerede-
migranters-ret-til--sygehusbehandling
79
2.3 Isolation strategies and monitoring of confirmed cases
2.3.1 Suspected cases (having symptoms)
Date report(ed) and reference
Statement / definition
29/06
Immediate self-isolation at home until test comes back negative and there are no longer symptoms of COVID-19.
https://www.sst.dk/en/English/Corona-
Within the household: Isolation of the the person suspected of infection from other household members, including
eng/FAQ#uk-corona-faq-syg
maintaining a distance of at least 2 meters and staying in separate rooms, as well as maintaining a high standard of
hygiene and cleaning.
Same guidelines for children as for adult.
If you choose not to get tested, you should stay isolated until 48 hours after your symptoms disappear (similar to a
confirmed case)
2.3.2 Confirmed cases
Date report(ed) and reference
Statement / definition
29/06
With symptoms: continue self-isolation until 48 hours after the symptoms are gone (if only a loss of taste and smell remains,
https://www.sst.dk/en/English/Corona-
the individual is considered symptom-free)
eng/FAQ#uk-corona-faq-syg
No symptoms: self-isolation until 7 days after taking the test. If symptoms appear during the 7 days, self-isolation home for
up to 48 hours after you are symptom-free (except the loss of taste and smell).
2.4 Contact tracing strategy
2.4.1 Contact definition
Date report(ed) and reference
Statement / definition
25/06
Close contacts are defined as:
https://politi.dk/en/coronavirus-in-
People you live with
denmark/frequently-asked-questions
People you have had direct physical contact with (e.g. hug)
People who have had unprotected and direct contact with infectious secretions from you (for example, if you have
https://www.sst.dk/en/English/Corona-
accidentally coughed or sneezed at them, or if they have touched your used handkerchief, etc.)
eng/FAQ#uk-corona-faq-syg
People you have had close "face-to-face" contact with within 1 meter for more than 15 minutes (for example, during a
conversation)
80
Healthcare professionals and others who have participated in your care and have not used the recommended protective
equipment.
Those with whom you have not been nearer than 1 meter for a continuous period of more than 15 minutes, are not considered
close contacts.
2.4.2 Organisational process of contact tracing
Date report(ed) and reference
Statement / definition
29/06
An employee from Corona Tracking (Coronaopsporing) which is a division of the Danish Patient Safety Authority contacts by
https://www.sst.dk/en/English/Corona-
phone any individual tested positive to track close contacts.
eng/FAQ#uk-corona-faq-syg
For individuals with symptoms: close contacts from 48 hours before symptoms started to 48 hours after cessation of
symptoms must be traced
https://www.covid19healthsystem.org/cou
For individuals without symptoms: close contacts met 48 hours before the test to 7 days after the test must be traced
ntries/denmark/livinghit.aspx?Section=1.4
From June 10, the Danish Patient Safety Authority will contact all infected persons with an offer to assist in tracing and contacting
%20Monitoring%20and%20surveillance&T
close contacts.
ype=Section
Contact tracing is strongly recommended, but voluntary.
https://www.sum.dk/Aktuelt/Nyheder/Coro
On June 18th 2020 the app SmitteStop was launched allowing for contact tracing using cell phone data.
navirus/2020/Juni/Nu-er-appen-
smittestop-klar-til-danskerne.aspx
http://smittestop.dk
2.4.3 Testing of contacts
Date report(ed) and reference
Statement / definition
25/06
Coronaopsporing (Contact Tracking) will refer close contacts for testing, even if they have no symptoms. Their GP can also
https://www.coronaprover.dk/Account/WhoC
refer them for testing if they call him/her.
anBookTime
Close contacts: the doctor creates two referrals for testing at TestCenter Denmark, to be tested twice at an interval of two days
29/06
after exposition to infection6. The individual subsequently returns to coronaprover.dk and books an appointment7.
6
Individuals with an administrative civil registration number who have been in close contact with an infected person, must first get a referral before booking a test
appointment. They can get a close contact referral by calling the contact tracing centre Coronaopsporing
7
If one close contacts has previously tested positive, we recommended that the close contact is tested and self-isolate only if more than eight weeks have gone by since
the close contact first tested positive.
81
https://www.coronaprover.dk/lib/coronainfor
mation-2020-06-29_ENG.pdf
https://www.sst.dk/en/English/Corona-
eng/FAQ#uk-corona-faq-syg
2.4.4 Contact tracing Apps
Date report(ed) and reference
Statement / definition
17/06
The Danish Health Authority asks everyone (on a voluntary basis) who has been tested positive for coronavirus to contact
https://www.covid19healthsystem.org/count
persons that they have been in close contact with, so they too can be tested. This can be done also automatically and
ries/denmark/livinghit.aspx?Section=1.5%2
anonymously with the app “SmitteStop”8.
0Testing&Type=Section
2.5 Quarantine strategies and monitoring of contacts
Date report(ed) and reference
Statement / definition
29/06
The Danish Health Authorities recommend that individuals self-isolate until the first negative test result is available, i.e. usually
https://www.sst.dk/en/English/Corona-
within 48 hours.
eng/FAQ#uk-corona-faq-syg
If test is positive, then see recommendations in 1.3.2
2.6 Early case detection methods
2.6.1 Surveillance based indicators used to detect early cases
Date report(ed) and reference
Statement / definition
https://www.sst.dk/-
Surveillance measures are described above.
/media/Udgivelser/2020/Corona/Retni
Continuous testing of health care personnel and personnel in nursing homes etc. with no symptoms is being initiated.
ngslinjer/Retningslinjer-for-
Prevention of infection by regular staff testing - Denmark July 13th (translated with google)
haandtering-af-COVID-
19.ashx?la=da&hash=BE6BE868AA
In case of spread of infection with COVID-19 in a municipality or another geographically delimited area, regular testing of health and
care professionals in that area should be conducted. This is for the purpose of preventing the spread of infection
8
If a user tests positive for the Coronavirus, they can log into the app using their NemID, upon which a notification will be prompted to users who have been in contact with
infected users for more than 15 minutes at a distance of 1 meter.
82
53E335DD6F7003AD134D5E5D8AD
A cross-cutting group ‘signal group’ under the leadership of the Statens Serum Institut and with Representatives from the National
122
Board of Health and the National Board of Patient Safety continuously assess the incidence of local spread of infection, with the aim
https://www.sst.dk/da/Udgivelser/202
of being able to initiate quickly preventive measures if there is evidence in the surveillance of the spread of infection via chains of
0/Vejledning-om-forebyggelse-af-
infection or outbreaks. If the group assesses that in an area there is a spread of infection, there cannot be immediately explained by a
spredning-af-COVID-19-paa-
local outbreak at a particular institution or the like, the Danish Agency for Patient Safety should enter into a dialogue with the
plejecentre-bosteder
municipality and their infection hygienic unit for the purpose of initiating regular testing of health and care personnel in the area in
question. Healthcare professionals should be tested every 7 days for 2 months or until the spread of infection in the area where the
chains of infection are not covered.
2.6.2 Identification of clusters
Date report(ed) and reference
Statement / definition
The Danish Patient Safety Authority contacts all individuals with a positive test result and assists in contact tracing with the purpose of
identifying clusters and preventing spread.
The Danish Patient Safety Authority also can also assist in contact tracing etc. in case of outbreaks in public institutions, e.g. nursing
homes.
2.6.3 In hospitals
Date report(ed) and reference
Statement / definition
July 13th
On April 1st it was added to the guideline for management of COVID-19 in the health care system that doctors should test for COVID-
https://www.sst.dk/da/Udgivelser/202
19 whenever it was clinically suspected and that also individuals with mild symptoms should be tested.
0/Retningslinjer-for-haandtering-af-
On April 21st it was added that all patients who required admission more than 24 hours and all patients who had to undergo certain
COVID-19
procedures with a high risk of virus transmission should be tested within 48 hours before admission/procedure.
Continuous testing of health care personnel and personnel in nursing homes etc. with no symptoms is being initiated.
2.6.4 In nursing homes and other collective facilities
Date report(ed) and reference
Statement / definition
April 8th
Guideline issued on handling of suspected and confirmed cases of COVID-19 in nursing homes and other collective facilities.
https://www.sst.dk/da/Udgivelser/202
Continuous testing of health care personnel and personnel in nursing homes etc. with no symptoms is being initiated.
0/Vejledning-om-forebyggelse-af-
spredning-af-COVID-19-paa-
plejecentre-bosteder
83
July 13th
https://www.sst.dk/da/udgivelser/202
0/vejledning-om-forebyggelse-af-
spredning-af-covid-19-paa-
plejecentre-bosteder
2.6.5 In schools
Date report(ed) and reference
Statement / definition
16/4
Guidelines for schools and child care facilities were published with the reopening of schools etc in April/May and revised prior to the
https://www.sst.dk/da/Nyheder/2020/
new school year starting in August.
Vejledningerne-for-den-gradvise-
kontrollerede-genaabning-af-skoler-
og-daginstitutioner-er-opd
13/7
https://www.sst.dk/da/Nyheder/2020/
Hvordan-skal-skoler-og-
daginstitutioner-haandtere-tilfaelde-
af-COVID-19_
2.6.6 Precarious population
Date
report(ed)
and
Statement / definition
reference
Since the beginning, individuals in increased risk of serious COVID-19 disease have been prioritized in the testing strategy and in the public
information, individuals at increased risk have been encouraged to contact a doctor and get tested, even when experiencing mild symptoms.
Since testing opportunities are now broadly available, no specific measures for early case detection methods in populations at increased risk
of serious COVID-19 disease exist apart from the contact tracing strategies etc. included in the guidelines for nursing homes, home nurses,
continuous testing of personnel etc.
84
2.7 Coordination and responsibility of testing and tracing
Date
report(ed)
and
Statement / definition
reference
29/06
Testing: All demands for testing are centralized by Testcenter Danmark (coronaprover.dk)
https://www.sst.dk/en/English
Tracing: Corona Tracking (Coronaopsporing) which is a division of the Danish Patient Safety Authority coordinates contact tracing
/Corona-eng/FAQ#uk-
The National authorities (Ministry of Health, Danish Health Authority, Danish Medicines Agency, Statens Serum Institut, etc.) have established
corona-faq-syg
a “COVID-19 Intensive Task Force” together with the Danish Regions (that are responsible for specialized health care and general practice).
https://www.covid19healthsys
The task force is in charge of assessing and governing resources needed during the pandemic.
tem.org/countries/denmark/liv
inghit.aspx?Section=5.1%20
Governance&Type=Section
85
3 RESULTS FOR FRANCE
3.1 Existence of a plan to prevent the second wave
Date
report(ed)
and
Statement / definition
reference
02 June 2020
France has established a plan to prevent the second wave based on 4 scenarios:
Scientific Council (n°7)
1. Epidemic under control (based on available indicators), with occurrence of localised clusters that can be controlled.
https://solidarites-
2. Existence of critical clusters, raising fears of a loss of control of the chains of contamination, and therefore of the control of the epidemic
sante.gouv.fr/IMG/pdf/avis_c
itself. This scenario would require strict, early and localised measures to avoid a wider loss of control of the epidemic.
onseil_scientifique_2_juin_20
3. A gradual and low-noise resumption of the epidemic, more difficult to identify. Indicators would then deteriorate without the chains of
20.pdf
contamination being identified nor controlled. This scenario would require strict measures as well as the rapid activation of several P2R-
COVID measures (see below). The measures to be taken could still be considered on a regional scale if the indicators allow it or at the
national level.
4. A loss of control of the epidemic that would require difficult decisions, i.e. a choice between generalised national lock-down, which minimises
direct mortality, and other collective, economic and social objectives.
A new generalised lock-down is not desirable and probably not acceptable considering its health and socio-economic consequences. They
therefore consider it is essential to do everything possible to avoid such a situation. They have drawn up a 7-part “Enhanced Prevention and
Protection” Plan (P2R COVID) to prepare measures that can be activated gradually or massively depending on the characteristics of the
epidemic in the coming weeks and months.
1. A protocol for the strengthening of barrier and physical distancing measures in the general population;
2. A protocol to reinforce testing, tracing, and isolating strategies;
3. A protocol for the reinforced containment and protection of persons at risk: this protocol aims to protect the persons most at risk, in particular
by encouraging voluntary containment and accompanying measures to adapt daily life (carrying meals, domestic help at home, etc.
managed by collective authorities), including teleworking if possible or the provision of surgical masks every 4 hours and the strict respect
of barrier measures if teleworking is not possible (under the monitoring of the occupational physician). Target population are: people with
a chronic disease, people receiving a long term treatment, people from 65 years old, or people with high blood pressure, diabetes, coronary
heart disease, or overweight. The risk is assessed by the GP.
4. A protocol for the protection of nursing homes for older people: the Scientific Council has already given its opinion on several occasions
on the necessary protection of residents in nursing homes. In this post-confinement period, the Scientific Council proposes a new strategy
for these establishments, based on the triptych "Screening - Family visits - Early and adapted care".
5. A protocol for populations in very precarious situations: this protocol is necessary in order to allow the most precarious populations to
serenely have recourse to screening. Special assistance is offered to them so that they can adhere to the generalised testing policy. The
measure concern:
○ Mobilization of all public and private accommodation solutions in order to increase access to accommodation allowing isolation in
single rooms.
86
○ Organizing gathering points, providing water, food but also health and social support, masks and hydroalcoholic solutions, information
on barrier measures, etc.), managed by the municipalities in collaboration with the regional health authorities and the associations.
○ Proactively informing the population and invite them for testing (e.g. in hosting structure), in collaboration with association specialized
in precarious population and other professionals such as interpreters
○ Reducing the consequences of a positive result, for example by ensuring that, during the isolation period, their place in collective
housing is retained, that all members of the household are taken care of (e.g. for single-parent families), that their animals are taken
care of, and that a specific allowance is granted (for precarious people who cannot provide proof of a regular income allowing them
to have access to other forms of compensation).
○ A prolongation of the specific rights acquired during the lock-down period (e.g. access to state medical assistance, postponement of
procedures relating to residence rights).
6. A "Large metropolitan areas" protocol: this protocol is in line with the need already expressed by the Scientific Council to adapt the
measures according to local epidemiological situations. The history of the epidemic in France has shown that metropolises, particularly the
“Ile de France” region, were faced with different challenges from those in rural areas. This protocol responds to these specific needs. This
protocol is particularly linked to the protocol relating to the precarious population..
7. A protocol for hospital preparation: this protocol aims to strengthen the response capacity of public and private hospital structures, but also
of medico-social establishments in case of a second wave. Particular attention is paid to the health care workers who have been in high
demand over the last two months, as well as to the strategic stocks of drugs, materials and protective equipment that have been
replenished.
In the scenario 1 (outbreak under control):
Barrier measures: Compulsory wearing of masks in all confined spaces, use of hydroalcoholic gel at the entrance and exit of these confined
spaces, strict respect of social distancing (1m), suppression of unnecessary gatherings.
Contact tracing : testing - tracing - isolation (as described below)
Travel restrictions and the obligation to telework could be gradually lifted and a more comprehensive reopening of schools could be
achieved, with very close monitoring of the various surveillance indicators.
In the scenario 2 (One or more critical clusters showing signs of a local resumption of the epidemic):
A strengthening of barrier measures (protocol 1)
A strengthening of the testing-tracing-isolation strategy: within the perimeter of the cluster, testing will not be limited to symptomatic cases
and an active information campaign encouraging people to get tested will be done (managed by the regional health agencies in conjunction
with the GPs and local authorities).
A focus on precarious population (protocol 5)
A localized lock down, accompanied by compensatory measures
In the scenario 3 (A diffuse and low-noise resumption of the epidemic):
Activation of the 7 protocols. The level of intensity of the measures must be determined according to the epidemiological situation and its
geography.
In the scenario 4 (The epidemic is reaching a critical stage):
Increase of hospitals’ capacities (protocol 7).
87
Authorities would have to choose between a generalised national lock-down, which minimises direct mortality, and other collective,
economic and social objectives.
3.2 Testing strategy
3.2.1 Indications for PCR testing
Date report(ed) and reference
Statement / definition
02 June 2020
All persons presenting symptoms of Covid-19, including shortness of breath, fever, cough, unusual tiredness, headache,
Scientific Council (n°7)
muscle pain, sore throat, loss of taste or smell. A prescription is required.
https://solidarites-
All people identified as having had a contact, with a high risk of transmission, with a person tested positive (contacts at risk,
sante.gouv.fr/IMG/pdf/avis_conseil_scientifiq
see the contact tracing strategy). No prescription is required.
ue_2_juin_2020.pdf
Preventive testing of specific groups. Specific screening campaigns are planned for (i) the precarious populations, (ii)
residents of collective facilities and of staff working in these facilities in the event of a first case confirmed within the facility,
and
and (iii) in areas identified as vulnerable due to their density or the remoteness of access to care. See details in “early
6 May 2020
detection methods.
Jean Castex
Systematic testing is not recommended in companies, public services, or for all patients admitted to hospital (Jean Castex).
https://www.gouvernement.fr/sites/default/file
s/rapport_jean_castex_-
_preparation_de_la_sortie_du_confinement.
pdf
3.2.2 PCR testing conditions: how and by whom?
Date report(ed) and reference
Statement / definition
https://www.gouvernement.fr/info-
Up to June 15, only nasopharyngeal RT-PCR tests were considered reliable enough to confirm the presence of the virus in
coronavirus/tests-et-depistage (Last update:
the body. To avoid false negatives, both nostrils are explored during sampling.
10 May 2020, accessed on 10 June 2020)
On June 15, market authorization of a saliva test was approved in France. Reimbursement conditions are not yet determined.
https://lejournal.cnrs.fr/articles/un-test-
salivaire-ultra-rapide-pour-depister-le-covid-19
(last update: 15 June 2020, accessed 19 June
2020)
6 May 2020; Jean Castex
Two types of health professionals are allowed to take the sample: nurses, and biologists - whether pharmacists or doctors.
88
https://www.gouvernement.fr/sites/default/files
/rapport_jean_castex_-
_preparation_de_la_sortie_du_confinement.p
df
3.2.3 Indications and conditions for serological testing
Date report(ed) and reference
Statement / definition
20 April 2020
Serologic tests will be used as a priority not for the determination of individual status but rather for epidemiological
Scientific Council (n°6)
investigations in order to determine the level of herd immunity achieved. These investigations should be conducted at the
regional and national levels, and will be repeated regularly to monitor the progress of population immunity.
https://solidarites-
sante.gouv.fr/IMG/pdf/avis_conseil_scientifiqu
They can be carried out on a large scale using ELISA or similar techniques (possible throughput of more than >100,000 tests
e_20_avril_2020.pdf
per day). The usefulness of unit field tests (TROD, Tests unitaires de terrain) at the individual scale is relative, but there is
likely to be a high demand. It should be remembered that these tests can only be performed on medical prescription (Scientific
and
Council, N°6).
These tests may also be used to identify health workers who have developed an immune response and, if the protective
6 May 2020
nature of the antibodies is confirmed, will make it possible to reorganise the services of the health establishments concerned
Jean Castex
(Jean Castex).
https://www.gouvernement.fr/sites/default/files/
Reimbursement conditions of serologic tests are described below (How is testing reimbursed?)
rapport_jean_castex_-
_preparation_de_la_sortie_du_confinement.pd
f
3.2.4 Laboratory capacity
Date report(ed) and reference
Statement / definition
02 June 2020
After the lock-down period (May, 11), the objective is to carry out at least 700,000 tests per week. To increase testing
Scientific Council (n°7)
capacity, all research and veterinarians labs, in addition to private laboratories, are now requested to support public
laboratories.
https://solidarites-
sante.gouv.fr/IMG/pdf/avis_conseil_scientifique
Three types of structures are used:
_2_juin_2020.pdf
1.
Hospital laboratories providing PCR diagnosis (capacity: 35 000 tests/day). The diagnoses carried out by these
laboratories will mainly concern people presenting in emergency departments or hospitalised patients.
2.
Dedicated high-intensity PCR diagnostic laboratories: 21 sites created during the crisis, financed by public authorities,
being in connection with hospitals or private establishments. They operate 7/7, were equipped by high intensity
machines bought in China and are associated with dedicated sampling sites, most of the time with a doctor on site to
89
prescribe the test. Access can therefore be made independently of the treating physicians. Their diagnostic capacity is
estimated at 40 000 tests/day.
3.
Private city laboratories providing PCR diagnosis. These laboratories and their sampling centres are spread throughout
the country. In total, the capacity of these laboratories appears to exceed 60 000 tests/day, and may increase further.
Results generated by these 3 structures are directly reported into one database in real time (the SI-DEP).
https://sante.fr/recherche/trouver/DepistageCovi
A total of 3314 sample points are spread over the territory (on 15 July).
d (Last update: accessed on 15 July 2020)
3.2.5 Communication of test results to the patient
Date report(ed) and reference
Statement / definition
10 May 2020
Results must be available no later than 24 hours after the test has been performed (maximum time limit of 24 hours between
https://www.gouvernement.fr/info-
the consultation of an individual and the receipt of his or her test result).
coronavirus/tests-et-depistage (Last update: 10
Results are sent:
May 2020, accessed on 10 June 2020)
by the laboratory (by phone, or on the internet);
and/or by SI-DEP (the national information system for the follow-up of Covid-19 screening set up from May 2020).
3.2.6 Recording and surveillance of test results
Date report(ed) and reference
Statement / definition
10 May 2020
The SI-DEP is their national information system for the follow-up of Covid-19 testing (set up from May 2020). All results
https://www.gouvernement.fr/info-
generated by the 3 types of laboratory structures (see above) are directly reported into this database in real time.
coronavirus/tests-et-depistage (Last update:
All data collected may be reused for health surveys (follow-up of patient’s diagnosed positive for Covid-19 and/or search for
10 May 2020, accessed on 10 June 2020)
"contact cases"), epidemiological surveillance and research via the health data platform. Data are kept for a maximum of one
02 June 2020; Scientific Council (n°7)
year. Patient cannot refuse the processing of his/her data in the SI-DEP tool but may access his/her own data, rectify them, and
refuse the re-use of his/her data for research purposes.
https://solidarites-
sante.gouv.fr/IMG/pdf/avis_conseil_scientifi
A surveillance is done by regional health agencies to identify potential chains of transmission and clusters of cases at the local
que_2_juin_2020.pdf
area level, in collaboration with the National Public Health Institute and the Ministry of Health. If a cluster is identified, testing
will not be limited to symptomatic cases and an active information campaign encouraging people within the perimeter of the
cluster to be tested will be done (managed by the regional health agencies in conjunction with the GPs and local authorities).
90
3.2.7 How is testing reimbursed?
Date report(ed) and reference
Statement / definition
Decree of 28 May 2020
While in the past PCR-tests were only fully reimbursed if performed in hospitals, they are now (since May) also fully reimbursed
Opinion of the HAS of 20 May 2020
when performed ambulatory (according to the indications defined and updated by the health authorities, see above).
(https://www.has-
Serological tests are ful y reimbursed if prescribed by a physician in the following conditions, as defined by the “Haute Autorité
sante.fr/jcms/p_3186099/fr/la-has-est-
de la Santé” (HAS):
favorable-au-remboursement-des-tests-
As initial diagnosis for severely symptomatic hospitalised patients who are PCR negative but whose clinical symptoms or
serologiques-a-la-fiabilite-validee-et-dans-
CT scans are suggestive of COVID-19.
les-indications-definies)
As catch-up diagnosis for severely symptomatic hospitalised patients who have not had a PCR tests within the first seven
days;
As initial diagnosis of symptomatic ambulatory patients without signs of severity whose PCR test is negative but whose
clinical picture is suggestive of COVID-19;
As catch-up diagnosis of symptomatic ambulatory patients without signs of severity but for whom a PCR test could not be
performed within the 7 days;
As deferred diagnosis for patients who had been clinically diagnosed since the implementation of phase 2 (from March 2,
2020) but who had not undergone PCR;
As antibody detection in non-symptomatic healthcare professionals, in addition to screening and contact tracing procedures
by PCR, if the PCR is negative.
As antibody detection in non-symptomatic staff of collective facilities (social and medical-social establishments, prisons,
barracks, university residences, boarding schools, etc.) in addition to screening and contact tracing procedures by PCR, if
the PCR is negative.
A list of 23 serologic tests has been validated by the national reference centre. Tests validated by the centre (RT-PCR,
serological, rapid test) can be found at : https://covid-19.sante.gouv.fr/tests
91
3.3 Isolation strategies and monitoring of confirmed cases
3.3.1 Suspected cases (having symptoms)
Date report(ed) and reference
Statement / definition
10 May 2020
The patient suspected of being infected because of symptoms must follow the same isolation procedure as confirmed cases,
https://www.gouvernement.fr/info-
even if test results are negative.
coronavirus/tests-et-depistage (Last update:
10 May 2020, accessed on 10 June 2020)
and
6 May 2020
Jean Castex
https://www.gouvernement.fr/sites/default/files
/rapport_jean_castex_-
_preparation_de_la_sortie_du_confinement.p
df
3.3.2 Confirmed cases
Date report(ed) and reference
Statement / definition
10 May 2020
In case of a positive result, the contact tracing procedure is initiated (see above).
https://www.gouvernement.fr/info-
Positive patients should isolate themselves until a complete recovery (at least 2 days of symptom free). If symptoms worsen,
coronavirus/tests-et-depistage (Last update:
they should call the 15 (or 114). (The duration of isolation is not specified but in the examples of work incapacity certificates, a
10 May 2020, accessed on 10 June 2020)
duration of 14 days is mentioned).
and
The possibilities for isolating cases and contacts will be reinforced by offering dedicated accommodation (such as hostels,
Scientific Council (n°7)
detention centres, etc.), while respecting individual choice. Human rights associations will be authorised to visit these isolation
facilities. Isolation in a dedicated facility should be preferred when this is necessary to prevent the spread of disease.
https://solidarites-
sante.gouv.fr/IMG/pdf/avis_conseil_scientifi
If isolation within the household is decided, the other members of the household should also isolate themselves, except to
que_2_juin_2020.pdf
respond to basic needs if asymptomatic (limited frequency and following strictly barrier mesures).
The duration of this isolation should be extended if further cases are detected in the household.
6 May 2020
Regional health authorities are responsible for organising an active and regular telephone follow-up of isolated patients and
contacts to ensure that they comply with the isolation instructions and do not encounter difficulties in their daily lives (Jean
Jean Castex
Castex): i.e. the patient is contacted once or twice a day by the services of their regional health agency to ensure that the
isolation (or quarantine for contacts) is respected and that the associated measures are correctly applied. When this is not
92
https://www.gouvernement.fr/sites/default/fil
possible, the patient may indicate a need for specific support (social, logistical, psychological) and will be redirected to the
es/rapport_jean_castex_-
appropriate services (Ameli).
_preparation_de_la_sortie_du_confinement
.pdf
15 July 2020
https://www.ameli.fr/assure/covid-
19/isolement-principes-et-regles-
respecter/isolement-principes-generaux
6 May 2020
Modalities for home monitoring of confirmed cases:
Jean Castex
Self-monitoring, by the patient himself or his entourage;
https://www.gouvernement.fr/sites/default/fil
Medical monitoring, with or without the help of a self-monitoring or remote monitoring tool;
es/rapport_jean_castex_-
A reinforced follow-up at home by nurses, in addition to the medical follow-up;
_preparation_de_la_sortie_du_confinement
Hospitalisation at Home (HAH).
.pdf
3.4 Contact tracing strategy
3.4.1 Contact definition
Date report(ed) and reference
Statement / definition
Contacts at risk are defined as:
6 May 2020
a person who has shared the same living space
Jean Castex
a person who has had direct contact, face to face, at less than 1 metre, for any length of time (e.g. conversation, eating,
https://www.gouvernement.fr/sites/default/fil
flirting, hugging, kissing). On the other hand, people who are crossed in the public space in a fleeting way are not considered
es/rapport_jean_castex_-
as risk contacts.
_preparation_de_la_sortie_du_confinement.
a person who has given / received hygienic / care acts
pdf
a person who has shared a confined space (office, meeting room, personal vehicle...) for at least 15 minutes or has been
face to face during several episodes of coughing or sneezing
a student or teacher in the same school class
However, persons who have benefited from the following protective measures shall not be considered as contact at risk :
hygiaphone or other physical separation such as glass;
surgical mask or FFP2 worn by the sick person or the contact;
masks for the general public manufactured according to the AFNOR standard or equivalent, worn by the sick person and
the contact.
93
For people identified via the StopCovid19 application, if the “confirmed case” is unknown (i.e. the contact was not identified
simultaneously via the standard contact tracing procedure) and therefore the circumstances are unknown, the contact is
automatically considered as at risk.
For asymptomatic cases, only very close regular contact (e.g. same household) are considered at risk.
3.4.2 Organisational process of contact tracing
Date report(ed) and reference
Statement / definition
02 June 2020
The following steps are followed:
Scientific Council (n°7)
1) Contact tracing within family members by
health professionals in primary care (mostly GPs and nurses) and hospital care:
https://solidarites-
A higher fee (€55 instead of €25 for a regular consultation) is foreseen for this “contact-tracing consultation”.
sante.gouv.fr/IMG/pdf/avis_conseil_scientif
2) Further (outside family members) contact tracing is done by
specifically-trained agents of the national health insurance
ique_2_juin_2020.pdf
fund (Ameli). Health squads/platforms were set up in each department to track the list of contacts. A team of 6500 agents
(medical, administrative or social staff), subject to medical confidentiality, received ad hoc training from regional health agencies
and local branches of the National Public Health Institute. They must contact by phone within 24 hours all identified contacts of
and
every single confirmed case, in order to inform them regarding the potential contamination risk, and the measures to follow:
isolation and testing. These ‘squads’ work every day from 8am to 7pm, even on weekends. Some agents from local territorial
03 June 2020
public agencies may be called upon to back up the national health insurance fund. Regional health agencies are in charge of
contact tracing when a case is detected in a collective place (school, nursing home…).
Coralie Gandre, Zeynep Or
3) Creation of registries: Two national registries were created, i.e. (1) the cases tested positive (The SI-DEP repertory, ‘Système
https://www.covid19healthsystem.org/coun
d’information national de dépistage’) and (2) the contacts of all confirmed cases (Contact Covid) to ease tracing. The National
tries/france/livinghit.aspx?Section=1.4%20
Commission for Data Protection and Liberties (CNIL) was consulted on the creation of such registries (see digital tools). On May
Monitoring%20and%20surveillance&Type=
11, the Constitutional Council banned the access of social care providers (notably community social welfare centres /‘centres
Section
communaux d’action sociale’, CCAS) to this database.
4) The surveillance by regional health agencies to identify potential chains of transmission and clusters of cases at the local area
level, set up since the beginning of the epidemic, must continue (in addition to the local and national surveillance carried by the
National Public Health Institute and the Ministry of Health).
5) The “Stop-COVID” mobile application will also be an important additional tool for tracing contacts.
Guide méthodologique d'investigation des
Details of the interview:
cas et des ...
As soon as possible after diagnosis.
If the confirmed case cannot answer, the interview can be conducted with a trusted person.
https://www.santepubliquefrance.fr/content/
The interviewer first gives information on whether the approach is in compliance with the GDPR and on the conditions of access
download/230089/file/20200513_Guide-
to and rectification of data.
CT.pdf
Data collected for each contact: identity, email address and telephone number, circumstances and date of contact. If several
contacts have taken place with the same person, the frequency of contact (daily or less frequent), the duration and date of the
last contact at risk, or the fact that the person is still in contact with the case at the time of the interview should be collected. For
94
minors, their identity must be collected but the contact information (telephone, email) is that of the minor's parent(s) or legal
representative.
If the case refuses to give the identities and contact details of the contact persons, an alternative may be offered to warn these
persons and give them a number to contact at the platform level, depending on the organisation set up locally. The case must
also be able to refuse to have its identity communicated to the contact persons.
Various means can be used to facilitate the compilation of this list: mentioning typical circumstances (contacts at home, family
outside the home, colleagues, people who have travelled with the case), and significant events during the period at risk (public
holidays, weekends, etc.). It is strongly recommended that the interviewer use a calendar.
If the contact person is a hospital caregiver or intervenes in a medico-social institution, and the contact with the case took place
in the professional context, the investigation and evaluation of the contact should be referred to the occupational physician and
the operational hygiene team of the health care institution. For the others, the investigation is carried out in the same way as for
the community contacts.
The interview may be grouped for several contact persons living under the same place (except for collective living places such
as nursing homes or prisons), especially for children, but a questionnaire must be completed for each person.
3.4.3 Testing of contacts
Date report(ed) and reference
Statement / definition
All contacts at risk are tested.
6 May 2020
The test is performed:
Jean Castex
immediately for people living in the same place and being symptomatic
https://www.gouvernement.fr/sites/default/fil
7 days after the last contact for other people.
es/rapport_jean_castex_-
_preparation_de_la_sortie_du_confinement.
pdf
3.4.4 Contact tracing apps
Date report(ed) and reference
Statement / definition
The app StopCovid, used on a voluntary basis. The application will use pseudonymized data, without the use of geolocation,
02 June 2020
and will not lead to the creation of a registry of contaminated persons. Its purpose is to inform users of the risk of contamination
when they have been in close proximity to another user who has tested positive. It is a "contact tracing" device based on Bluetooth
Scientific Council (n°7)
technology. The Apps inform the “contact” person about the quarantine instructions and recommend him/her to contact the
https://solidarites-
contact-tracing platform.
sante.gouv.fr/IMG/pdf/avis_conseil_scientifi
The National Commission for Data Protection and Liberties (CNIL) made a series of recommendations, mainly on the fact that
que_2_juin_2020.pdf
processing responsibility should be entrusted to the ministry in charge of health policy or that there should be no negative legal
95
consequences attached to the choice not to use the application. They also advise on the implementation of some technical
Advice of the CNIL 25 May 2020
security measures. In their latest opinion, they also recommended improving the information provided to users, in particular
regarding the conditions of use and on how to erase personal data, providing specific information for minors and parents of
https://www.cnil.fr/fr/la-cnil-rend-son-avis-
minors, allowing a right of opposition and a right to erase recorded pseudonymised data and giving free access to the entire
sur-les-conditions-de-mise-en-oeuvre-de-
source code of the mobile application and server. The CNIL notes that its main recommendations have been taken into account
lapplication-stopcovid
and believes that this temporary system, based on voluntary work, can legally be implemented. This technology will be assessed
and its continuity will depend on such an assessment. According to the advice of the scientific council of 2 June 2020, the issues
of protecting the identity of individuals and the confidentiality of data concerning them must be controlled with the highest level
of security, as for any medical activity.
The Council stresses the importance of working on devices also designed to benefit the people that are not used with digital
applications and highlight that efficiency will only be achieved through ownership, inclusion and transparency. Because of their
sensitive nature, the Council considers that these tools must be steered by the public health authorities and that their deployment
must be limited to the period of a state of health emergency and be framed by clear, open and transparent governance that will
encourage our fellow citizens to support their public health objectives. This governance could be constituted by the mobilization
of doctors, paramedical staff, volunteers and staff to be recruited. An operational training course providing the prerequisites in
terms of data confidentiality, risk assessment on the basis of references, guidelines on how to deal with isolation and referral to
local diagnostic and clinical care (general medicine, etc.). This service must be known and understood by the entire population,
particularly the less socially privileged. Transparent and appropriate communication, particularly in the area of literacy, will be
necessary. It will have to use multiple complementary approaches with, in particular, the active involvement as far upstream as
possible from the entire medical community, in particular community medicine.
3.5 Quarantine strategies and monitoring of contacts
Date report(ed) and reference
Statement / definition
10 May 2020
The contact person (at risk as defined above) must remain confined in his/her home and strictly adhere to all barrier measures
https://www.gouvernement.fr/info-
up to the results of the test.
coronavirus/tests-et-depistage (Last update:
Once test results are obtained:
10 May 2020, accessed on 10 June 2020)
If the test is positive => see management of confirmed cases (isolation procedure)
If the test is negative but people are symptomatic => same management as for confirmed cases (isolation procedure)
and
If the test is negative and people are asymptomatic => quarantine procedure for 7 additional days. The isolation is softened
6 May 2020
and going outside is allowed to respond to basic needs, in a limited frequency and following strictly barrier mesures.
Jean Castex
Because the test of asymptomatic patients is performed 7 days after the last contact with the confirmed case, the total
quarantine lasts 2 weeks.
https://www.gouvernement.fr/sites/default/files
/rapport_jean_castex_-
Regional health authorities are responsible for organising an active and regular telephone follow-up of contacts to ensure that
_preparation_de_la_sortie_du_confinement.p
they comply with the quarantine instructions and do not encounter difficulties in their daily lives (Jean Castex).
df
96
https://www.service-
Concerning travelling, a quarantine is also mandatory for:
public.fr/particuliers/actualites/A14060
anyone going to the overseas regions (Guadeloupe, French Guiana, etc);
any person arriving on national territory with symptoms of Covid-19 infection identified during health checks.
3.6 Early case detection methods
3.6.1 Surveillance based indicators used to detect early cases
Date report(ed) and reference
Statement / definition
02 June 2020
In their last plan to prevent a second vagues, the following monitoring indicators were cited:
Scientific Council (n°7)
Mortality of COVID-19 hospitalised patients (per day and in total);
https://solidarites-
Mortality of COVID-19 patients in homes for the elderly and nursing homes (per day and in total);
sante.gouv.fr/IMG/pdf/avis_conseil_s
Overall and excess mortality;
cientifique_2_juin_2020.pdf
The number of new hospitalised patients for COVID-19 and the total number of people hospitalised for COVID-19;
The number of new patients admitted to intensive care unit (ICU) for COVID-19 and the total number of persons admitted to ICU
for COVID-19;
The number of tests performed;
The number of confirmed case (PCR-positive);
The deadline of the testing-tracing-isolating strategy;
The effective reproduction number (R) and the doubling time of the epidemic;
9 July 2020 Santé Publique France
The Public Health institution (Santé Publique France) publish the following data:
https://www.santepubliquefrance.fr/m
Number of new confirmed cases of COVID-19 (SI-DEP)
aladies-et-traumatismes/maladies-et-
Positivity rate (%) for SARS-COV-2 (SI-DEP)
infections-respiratoires/infection-a-
Number of SOS Doctor acts for suspicion of COVID-19
coronavirus/documents/bulletin-
national/covid-19-point-
Number of emergency visits due to suspicion of COVI-19 (OSCOUR® network)
epidemiologique-du-9-juillet-2020
Number of new patient hospitalisations COVID-19 (SI-VIC), + cumulative data
Number of new admissions in resuscitation unit for COVID-19 (SI-VIC)
Number of deaths related to COVID-19 (including inpatient deaths and deaths in nursing homes and other collectivities) +
cumulative data
Number of (tele)consultations for acute respiratory infections + the percentage of those tested (via sentinel network acute
respiratory infections)
Test positivity rate and number of new patients positive for CoV2-SARS per 100 000 population (incidence rate) per region or
department
97
Proportion of participants reporting symptoms suggestive of COVID-19 per week (via sentinel network influenza)
Identification of outbreaks / transmission sites (see the definition below: 3 cases within 7 days), with a specific analysis for homes
for older people and other medical facilities.
Effective reproduction number
Estimation of seroprevalence of CoV-2-SARS infection by sex, age and region (based on random samples of anonymised sera
from the serotheques, i.e. tube bottoms)
The number of reported paediatric multisystemic inflammatory syndromes
The number of departments in situation of vulnerability (estimation based of the whole set of indicators, including the investigation
of clusters)
They also carry out surveys on the monitoring of the adoption of protective measures and on mental health.
3.6.2 Identification of clusters
Date report(ed) and reference
Statement / definition
02 June 2020
A surveillance is done by regional health agencies to identify potential chains of transmission and clusters of cases at the local area
Scientific Council (n°7)
level, in collaboration with the National Public Health Institute and the Ministry of Health. If a cluster is identified, testing will not be
limited to symptomatic cases and an active information campaign encouraging people within the perimeter of the cluster to be tested
https://solidarites-
will be done (managed by the regional health agencies in conjunction with the GPs and local authorities).
sante.gouv.fr/IMG/pdf/avis_conseil_s
cientifique_2_juin_2020.pdf
Regional health agencies are also in charge of contact tracing when a case is detected in a col ective place (school, nursing home…)
09 July 2020
An outbreak is defined by the occurrence of at least 3 confirmed or suspicious cases, within a period of 7 days, and who belong to the
Santé Publique France
same community or have participated in the same gathering of people, whether they know each other or not.
https://www.santepubliquefrance.fr/m
aladies-et-traumatismes/maladies-et-
infections-respiratoires/infection-a-
coronavirus/documents/bulletin-
national/covid-19-point-
epidemiologique-du-9-juillet-2020
02 June 2020
In process:
Scientific Council (n°7)
The creation of mobile contact tracing and isolation teams, particularly to target isolated or precarious populations or in the event of
https://solidarites-
transmission outbreaks.
sante.gouv.fr/IMG/pdf/avis_conseil_s
cientifique_2_juin_2020.pdf
02 June 2020
How to identify a "critical cluster" is not yet defined but the scientific council recommend to base the definition on a set of indicators:
Scientific Council (n°7)
The absolute number of cases included in the cluster and a very rapid, quasi-explosive dynamic.
98
https://solidarites-
The density of incidence in the district where the epicentre of the cluster is located, which makes it possible to normalise the number
sante.gouv.fr/IMG/pdf/avis_conseil_s
of cases to the population density. As an indication, the figures usually retained in particular abroad are 50 cases/100 000
cientifique_2_juin_2020.pdf
inhabitants/week in the zone concerned.
The context in which this cluster occurs: company, school, EHPAD, precarious population
The fact that without additional resources we may soon be unable to follow the chains of contamination due to the rapid
development of the epidemic in this sector.
3.6.3 In hospitals
Date
report(ed)
and
Statement / definition
reference
02 June 2020
The scientific council does not advise a systematic screening: only persons presenting symptoms of Covid-19 must be tested.
Scientific Council (n°7)
A protocol for hospital preparation has been established to strengthen the response capacity of public and private hospital structures (e.g.
https://solidarites-
development of software to determine the number of available and mobilisable beds in each region, managed by regional health authorities in
sante.gouv.fr/IMG/pdf/avis_c
order to know the capacity situation in real time, promoting hospital at home for patients under oxygen, organization of early transfer of patients
onseil_scientifique_2_juin_20
to post-resuscitation rehabilitation care, organization of inter-regional transfers, etc.) but also of medico-social establishments in the event of
20.pdf
the occurrence of a second wave. Particular attention is paid to the health care workers (mental support, respite period & holidays, training of
all caregivers in the management of serious patients requiring intensive care and resuscitation, etc.) who have been in high demand over the
last two months, as well as to the strategic stocks of drugs, materials and protective equipment that have been replenished.
3.6.4 In nursing homes and other collective facilities
Date
report(ed)
and
Statement / definition
reference
02 June 2020
Regional health agencies will be in charge of contact tracing when a case is detected in a collective place (school, nursing home…).
Scientific Council (n°7)
Currently, the following protocol is in place (16 June): Tests must be proposed to:
https://solidarites-
New permanent and temporary professionals working in the institution, 2 days before their arrival in the institution;
sante.gouv.fr/IMG/pdf/avis_c
The professionals of the institution upon return from leave;
onseil_scientifique_2_juin_20
To residents or employees presenting the slightest evocative symptom;
20.pdf
To any persons requesting admission to the facility, at the pre-admission stage (i.e. new residents).
Additionally:
and
Barrier measures must continue to be respected;
03 June 2020
The presence of a COVID-19 cell in each establishment must be maintained (monitoring of the situation, in liaison with the regional health
Coralie Gandre, Zeynep Or
agency and meeting at least once a week);
Individual rooms for the cases must be preserved;
99
https://www.covid19healthsys
Time slots for visits without appointment may be established (but respecting a secure circuit of visit and a physical distance with
tem.org/countries/france/livin
materialization, prohibiting the exchange of objects or goods, with a self-questionnaire.
ghit.aspx?Section=1.4%20M
The procedure of preventive confinement in the room is stopped (except for new admissions: 7 days).
onitoring%20and%20surveill
Other restrictions may also be gradually lifted (e.g. exits) depending on the context of each establishment.
ance&Type=Section
The scientific council has advised specific measures for nursing homes in case of scenario 3 of the epidemic (A diffuse and low-noise
resumption of the epidemic):
and
A systematic testing, each week, for the whole personnel (caregivers and non-caregivers) of nursing homes, even if they have only a
distant relationships with residents. Positive personnel (by definition asymptomatic) will be subject to a 7-day eviction from the test or an
https://solidarites-
eviction of 7 days with at least 2 days of symptom-free if they become symptomatic.
sante.gouv.fr/IMG/pdf/deconfi
A systematic testing of all residents if a positive case is detected (among the staff or the residents).
nement-retour-normale-
Family visits should be maintained, with a strict respect of barrier measures and if possible in ventilated areas or outdoors.
etablissements-
hebergement-pa-covid-19.pdf
The potential staff reserves of these establishments should be assessed by region (or even at best by department).
The links with the reference hospital structures must be contractually reinforced to define the conditions of case management: transfer to
the geriatric services, organisation of COVID- / COVID+ sectors, identification of downstream structures in post-hospitalisation, supply of
medicines or medical devices, etc. A specific organisation must be anticipated under the responsibility of the hospitals and Regional Health
Authorities.
3.6.5 In schools
Date report(ed) and reference
Statement / definition
8 June 2020,
No systematic screening.
Ministry of education
Regional health agencies will be in charge of contact tracing when a case is detected in schools.
https://www.education.gouv.fr/coronavirus-
The modalities of identification and tracing of contacts and the modalities of eviction will be defined by the regional health
covid-19-informations-et-recommandations-
authorities in collaboration with the academic authorities. Decisions to close a class, an entire level or the whole school may
pour-les-etablissements-scolaires-les-274253,
be taken by the latter.
(last update 8 June 2020, accessed 11 June
2020).
100
3.6.6 Precarious populations
Date
report(ed)
and Statement / definition
reference
02 June 2020
A protocol for populations in very precarious situations has been established in order to allow them to serenely have recourse to screening.
Scientific Council (n°7)
Special assistance is offered to them so that they can adhere to the generalised testing policy. The measures concern:
https://solidarites-
Mobilization of all public and private accommodation solutions in order to increase access to accommodation allowing isolation in single
sante.gouv.fr/IMG/pdf/avis_c
rooms.
onseil_scientifique_2_juin_20
Organizing gathering points, providing water, food but also health and social support, masks and hydro alcoholic solutions, information on
20.pdf
barrier measures, etc.), managed by the municipalities in collaboration with the regional health authorities and the associations.
Proactively inform this population and invite them for testing (e.g. in hosting structure), in collaboration with association specialized in
precarious population and other professionals such as interpreters
Reducing the consequences of a positive result, for example by ensuring that, during the isolation period, their place in collective housing
is retained, that all members of the household are taken care of (e.g. for single-parent families), that their animals are taken care of, and
that a specific allowance is granted (for precarious people who cannot provide proof of a regular income allowing them to have access to
other forms of compensation).
A prolongation of the specific rights acquired during the lock-down period (e.g. access to state medical assistance, postponement of
procedures relating to residence rights).
3.7 Coordination and responsibility of testing and tracing
Date
report(ed)
and
Statement / definition
reference
02 June 2020
One a whole, the Scientific Council stresses the need for clear, operational and partly territorialized governance. This governance should
Scientific Council (n°7)
include scientific and health competences, but also interministerial and more broadly institutional competences. The association of civil society
and economic actors is likely to strengthen its legitimacy and support for the measures envisaged in each scenario.
https://solidarites-
sante.gouv.fr/IMG/pdf/avis_c
Contact tracing is managed by regional authorities (regional health authorities), according to general rules determined at the national level.
onseil_scientifique_2_juin_20
20.pdf
101
4 RESULTS FOR GERMANY
4.1 Existence of a plan to prevent the second wave
Date report(ed) and reference
Statement / definition
5 May 2020
The country has a national COVID-19 pandemic plan which has been updated in March 2020.
https://www.rki.de/DE/Content/InfAZ/N/Neua
It is a document which summarizes the recommendations, handouts and preparations that have been made and adapted to
rtiges_Coronavirus/Ergaenzung_Pandemiepl
the situation. It also gives an outlook on the actions to put in place in case the situation in Germany and other countries
an_Covid.pdf?__blob=publicationFile
escalates.
6 April 202
This detailed response plan enabled the government to activate quickly, with no time wasted on disputes related to
https://www.spectator.co.uk/article/how-
governance, accounting, or costs.
germany-has-managed-to-perform-so-many-
covid-19-tests
Germany is a federal country and the responsibility for public health lies in the local public health authorities in 16 federal
states and approximately 400 counties.
The national Robert Koch institute is responsible for the prevention, control and investigation of infectious diseases. They
conduct surveillance, risk assessments and epidemiological studies, as well as preparing national guidelines, strategy
document and response plans. The states and counties adapt the national guidelines and recommendations to local needs.
National authorities facilitate nationwide exchange and negotiate standards and common procedures.
4.2 Testing strategy
4.2.1 Indications for PCR testing
Date report(ed) and reference
Statement / definition
16 January 2020
Researchers from the German Center for Infection Research (DZIF) at Charité – Universitätsmedizin Berlin were among the
https://www.charite.de/en/service/press_repo
first to developed a laboratory assay to detect the novel Chinese coronavirus. The assay protocol has been broadly used and
rts/artikel/detail/researchers_develop_first_di
has been published by WHO as a guideline for diagnostic detection. The fast testing capacity enabled Germany to quickly
agnostic_test_for_novel_coronavirus_in_chin
test all suspected cases from the start of the epidemic.
a/
Currently laboratory testing for SARS-CoV-2 should be performed for suspected cases according to the following criteria (12
26 June 2020
May 2020):
https://www.rki.de/DE/Content/InfAZ/N/Neuar
1. Acute respiratory symptoms of any severity and / or Loss of smell / taste in ALL patients regardless of risk factors
tiges_Coronavirus/Massnahmen_Verdachtsf
2. Contacts of confirmed COVID-19 case up to max. 14 days before the onset of illness AND any symptoms compatible
with COVID-19
102
all_Infografik_DINA3.pdf?__blob=publication
3. Clinical or radiological evidence of viral pneumonia AND related to an accumulation of pneumonia in nursing home /
File
hospital
4.2.2 PCR testing conditions: how and by whom?
Date report(ed) and reference
Statement / definition
16 June 2020
Testing is performed by a medical doctor during a visit of the doctor at the patient’s home, a referral to the hospital or during
https://www.rnd.de/politik/was-kostet-ein-
a special appointment to the family doctor’s office.
corona-test-preise-dauer-ablauf-so-
Patients who want to be tested can call their family doctor, the number 116 117 or the health department for more
funktioniert-der-test-auf-das-coronavirus-
information.
RB6MKQNM7VBKNM7A7YAYHKV4BQ.html
In a suspected SARS-CoV-2 patient, depending on the clinical situation, samples should be taken in parallel from the upper
and lower airways if possible (observe protective measures).
9 June 2020
Upper respiratory tract:
https://www.bundesgesundheitsministerium.d
○ Nasopharynx smear or lavage
e/corona-test-vo.html
○ Oropharynx smear
26 June 2020
○ Deep airways:
https://www.rki.de/DE/Content/InfAZ/N/Neuarti
Broncho alveolar lavage
ges_Coronavirus/Vorl_Testung_nCoV.html
○ Sputum (produced or induced according to instructions ; observe occupational safety)
○ Tracheal secretion
https://www.rki.de/DE/Content/InfAZ/N/Neuarti
ges_Coronavirus/Vorl_Testung_nCoV.html
All samples should reach the laboratory as soon as possible after collection. The test should take place within 72 hours from
collection and meanwhile it can be stored at 4 ° C, also during shipment.
In the majority of cases the results of the testing are available within 24h.
4.2.3 Indications and conditions for serological testing
Date report(ed) and reference
Statement / definition
26 June 2020
Antibody detection is primarily used for questions regarding the epidemiology of the infection.
https://www.rki.de/DE/Content/InfAZ/N/Neuarti
In the majority of patients, seroconversion takes place in the second week after the onset of symptom, therefore to
ges_Coronavirus/Vorl_Testung_nCoV.html
determine seroconversion during an acute infection, serum should be taken approximately 14 days after infection.
The sensitivity and specificity of the commercial antibody tests should be determined in dedicated studies and the
serological test results must be interpreted taking into account the pre-test probability, the respective epidemiological
situation and knowledge of the specificity/sensitivity values of the test system used.
Various test formats (ELISA, CLIA) with different virus antigens (recombinant S or N proteins) are available to detect a
previous SARS-CoV-2 infection, with which IgM, IgA, IgG or total antibodies can be detected. Due to low seroconversion
103
rates in the early phase (weeks 1 to 2 after the onset of symptoms) of the infection, they are not recommended for acute
diagnosis.
In the event of a negative or questionable PCR test with symptoms that are still compatible with COVID-19, the finding of a
seroconversion should give rise to a second PCR test. To date, there have been no systematic studies allowing an
assessment of the antibody titers associated with protection against reinfection. The detection of SARS-CoV-2-specific
antibodies does not exclude the fact that a patient might still be infectious.
Protective titers are not yet known.
The WHO currently recommends the use of rapid immuno-diagnostic tests only in the context of research projects.
4.2.4 Laboratory capacity
Date report(ed) and reference
Statement / definition
24 June 2020
So far, a total of over 200 laboratories have registered for the RKI test laboratory survey or in one of the other transmitting
https://www.rki.de/DE/Content/InfAZ/N/Neuartig
networks, and mostly transmit their numbers weekly.
es_Coronavirus/Testzahl.html
On week 25 there were 137 laboratories reporting SARS-CoV-2 data, with a capacity of 169 473 tests per day.
25 June 2020
It should be noted that the number of tests is not the same as the number of people tested, since the data may include
https://www.rki.de/DE/Content/Infekt/EpidBull/A
multiple tests of patients.
rchiv/2020/Ausgaben/26_20.pdf?__blob=public
ationFile
4.2.5 Communication of test results to the patient
Date report(ed) and reference
Statement / definition
No specific information found.
4.2.6 Recording and surveillance of test results
Date report(ed) and reference
Statement / definition
8 June 2020
The doctor who suspects that the patient has a disease with the novel coronavirus must report this to the local public
https://www.rki.de/SharedDocs/FAQ/NCOV2019
health department in accordance with the Infection Protection Act.
/gesamt.html?nn=13490888
The laboratory, which detects the novel corona virus in a human being, must report the results to the local public health
4 June 2020
department.
The notification to the local public health department needs to be done within 24h.
104
https://www.rki.de/DE/Content/InfAZ/N/Neuartig
COVID-19 cases that meet the Robert Koch Institute (RKI) case definition need to be transmitted electronically by the
es_Coronavirus/Meldepflicht_Nichtnamentlich.ht
responsible health authorities to the responsible state authorities and from there to the RKI no later than the next working
ml
day.
It is mandatory by law for all laboratories also to report all diagnosed SARV-CoV-2 cases to the national RKI. The
reporting should be done through the electronic reporting system for infectious diseases Deutsche Elektronische Melde-
und Informationssystem für den Infektionsschutz (DEMIS), which is still under development by RKI and the Ministry of
Health.
Results for negative tests also need to be reported to RKI.
4.2.7 How is testing reimbursed?
Date report(ed) and reference
Statement / definition
16 June 2020
If the test is prescribed by a medical doctor the costs are covered by the health insurance or department of health.
https://www.rnd.de/politik/was-kostet-ein-
The doctor must also test all suspected cases, defined as:
corona-test-preise-dauer-ablauf-so-funktioniert-
Anyone who has had contact with a confirmed case within the last 14 days
der-test-auf-das-coronavirus-
Anyone who has been in the risk area within the last 14 days and has symptoms (from mild cold to pneumonia)
RB6MKQNM7VBKNM7A7YAYHKV4BQ.html
Anyone who has been in the risk area within the last 14 days or who has had contact with a person from the risk area
(and has no symptoms).
If the test is not prescribed by a doctor, the patient has to cover the cost.
4.3 Isolation strategies and monitoring of confirmed cases
4.3.1 Suspected cases (having symptoms)
Date report(ed) and reference
Statement / definition
June 2020
People entering the Federal Republic of Germany by land, sea or air from any country or region outside of the Federal
https://www.bundesgesundheitsministerium.de/fi
Republic of Germany and who have spent time in a risk area, are required to proceed directly to their own home, or other
leadmin/Dateien/3_Downloads/C/Coronavirus/2
suitable accommodation, immediately after their arrival and remain there exclusively for a period of 14 days after their
020-06-12_regulations_for_travels_new.pdf
entry into the country.
6 May 2020
Quarantine of suspected cases, such as close contact to confirmed cases, is performed by local public health authorities
and might slightly differ from one state to the other. The suspected cases are normally quarantined for 14 days and need
https://www.rki.de/DE/Content/InfAZ/N/Neuartig
to report daily to the contact tracer about their health status.
es_Coronavirus/Quarantaene/Flyer.pdf?__blob=
publicationFile
105
If the person was previously reported as a COVID-19 case, no quarantine is required, self-monitoring should be carried
26 June 2020
out and, if symptoms occur, immediate self-isolation and testing should take place. If the test is positive, the contact
https://www.rki.de/DE/Content/InfAZ/N/Neuartig
person becomes a case. With this, all measures should be taken as in other cases (including isolation).
es_Coronavirus/Kontaktperson/Management.ht
ml#doc13516162bodyText1
4.3.2 Confirmed cases
Date report(ed) and reference
Statement / definition
15 May 2020
All SARS-CoV-2 confirmed cases need to self-isolate themselves in their homes according to the criteria below.
https://www.rki.de/DE/Content/InfAZ/N/Neuartig
a. Without previous hospitalisation (mild course of the disease)
es_Coronavirus/Entlassmanagement.html#doc1
At least 14 days after the onset of symptoms
3671260bodyText2
AND
if free symptoms for at least 48 hours related to the acute COVID-19 disease (after consultation with medical care)
Note: If the case still tests positive for SARS-CoV-2, the health department and the laboratory would need to consider
each case separately.
b. After previous hospitalisation (due to a severe course of the disease)
At least 14 days after discharge from the hospital after clinical improvement
AND
if free of symptoms for at least 48 hours related to the acute COVID-19 disease (after consultation with medical care)
4.4 Contact tracing strategy
4.4.1 Contact definition
Date report(ed) and reference
Statement / definition
15 May 2020
Since the beginning of the COVID-19 epidemic in Germany, the local health authorities, in collaboration with the Robert Koch
https://www.sciencedirect.com/science/articl
institute have done an extensive work in trying to track and trace all possible contacts of a confirm case, assess, quarantine,
e/pii/S1473309920303145?via%3Dihub
and monitor them.
26 June 2020
A contact is a person who was in contact with a confirmed case from two days before the symptoms onset of the confirmed
https://www.rki.de/DE/Content/InfAZ/N/Neua
cases. The end of the infectious period is currently not clear.
There are three categories of contact:
106
rtiges_Coronavirus/Kontaktperson/Manage
1. Category I: Higher risk of infection
ment.html#doc13516162bodyText1
People with cumulative face-to-face contact for at least 15 minutes, for example during a conversation. This includes, for
example, people from communities in the same household.
People with direct contact with secretions or body fluids, in particular with respiratory secretions of a confirmed COVID-19
case, such as kissing, contact with vomit, mouth-to-mouth ventilation, coughing up, etc.
People who have been exposed to aerosol-forming measures or aerosols (e.g. celebrating, singing together or playing
sports indoors)
Medical personnel in contact with the confirmed COVID-19 case as part of care or medical examination (≤ 2m), without
protective equipment used.
Contact persons of a confirmed COVID-19 case on the plane:
○ Passengers who were in the immediate seat of the confirmed COVID-19 case, regardless of flight time. If the COVID
19 case was in the aisle, the passenger in the same row across the aisle does not count as a category I contact person,
but as a category II contact person.
○ Crew members or other passengers, provided that one of the other criteria applies (e.g. a longer conversation, etc.).
2. Category II: Lower risk of infection
People who were in the same room as a confirmed COVID-19 case, e.g. classroom, workplace, but had no cumulative face-
to-face contact with the COVID-19 case for at least 15 minutes.
Family members who did not have face (or speech) contact for at least 15 minutes.
Medical personnel who were in the same room as the confirmed COVID-19 case without the use of adequate protective
equipment, but who never fell short of a distance of 2 meters.
Contact persons of a confirmed COVID-19 case on the plane:
○ Passengers who sat in the same row as the confirmed COVID-19 case or in the two rows in front of or behind it,
regardless of flight time, but not in Category I.
3. Category III
Medical personnel with contact ≤2 m (e.g. case in the context of nursing or medical examination), if adequate protective
clothing was worn during the entire time of contact according to category I.
Medical personnel with contact >2m without protective equipment, without direct contact with secretions or excretions of the
patient and without aerosol exposure
107
4.4.2 Organisational process of contact tracing
Date report(ed) and reference
Statement / definition
26 June 2020
The contact tracing is a responsibility of the states and each can choose the best approach to deal with it.
https://www.aerzteblatt.de/nachrichten/sw/
The local public health offices have one contact tracing team of five people per 20,000 inhabitants and are supported by mobile
COVID-19?s=&p=1&n=1&aid=213694
teams of scouts (medical students).
Management of contacts
1. Category I
https://www.rki.de/DE/Content/InfAZ/N/Neu
Determination, registration by name and notification of the telephone number of the contact persons of the health department.
artiges_Coronavirus/Kontaktperson/Manag
ement.html#doc13516162bodyText1
Informing contact persons about the COVID-19 clinical picture, possible disease courses and transmission risks.
Reduction of contacts with other people, segregation at home (possibly in another facility, considering the possibilities and
after risk assessment by the health authority)
Generally in the household, if possible, separate the contact person from other household members in terms of time and
space. A “time separation” can be done, for example, by not eating the meals together, but one after the other. A spatial
separation can take place, for example, by the contact person being in a different room than the other household members.
Frequent hand washing, compliance with a cough label.
Health monitoring until the 14th day after the last contact with the confirmed COVID-19 case in the following ways:
If a contact person becomes symptomatic within 14 days of the last contact with a confirmed COVID-19 case and if the
symptoms are compatible with a SARS-CoV-2 infection, they are considered suspect and a further diagnostic clarification
should be carried out. The following procedure is recommended:
○ Immediate contact the health department for further diagnostic clarification and discussion of the further procedure.
○ Consultation with the health department, medical consultation, including diagnostics using a suitable airway test in
accordance with the recommendations of the RKI on laboratory diagnostics ( www.rki.de/covid-19-diagnostik ) and, if
necessary, therapy.
○ Isolation according to the health department. This can include a home isolation during further diagnostic clarification in
compliance with infection hygiene measures or isolation in a hospital. Continuation of the "diary".
Asymptomatic contact persons should be tested for the early detection of pre- or asymptomatic infections. The test should
be carried out as early as possible on day 1 of the investigation in order to send possible contacts of the positive asymptomatic
contact persons to the quarantine in good time, and additionally 5-7 days after the first exposure, since then the highest
probability for a pathogen detection is. It should be emphasized that a negative test result does not replace health monitoring
and does not shorten the quarantine time.
2. Category II
If it is considered useful, according to the risk assessment of the health department, give optional:
○ Give optional information on COVID-19, especially on contact reduction and how to deal with symptoms.
Specific for contacts of a confirmed COVID-19 case on the plane:
108
○ Give information on COVID-19, especially on contact reduction and how to deal with symptoms.
The measures for medical personnel correspond to Category I (e.g. suspected aerosol exposure) or Category III, depending
on the assessment of the exposure risk by the health authority
3. Category III
Daily central documentation of the results of self-monitoring for symptoms and, if applicable, findings (test results) from the
day of the first contact until the 14th day after the last (potentially associated with a transmission) contact with patients with
confirmed COVID-19.
In the event of symptoms (including unspecific general symptoms), immediate release from work, interviewing employees
about possible exposure situations (e.g. problems with the use of PPE ), reporting to the health authority and isolation of
those affected until diagnostic clarification.
4.4.3 Testing of contacts
Date report(ed) and reference
Statement / definition
26
June
2020
The testing for contacts:
https://www.rki.de/DE/Content/InfAZ/N/Neua
1. Category I
rtiges_Coronavirus/Kontaktperson/Manage
○ Test as soon as possible, also asymptomatic contact persons, i.e. on day 1 after the determination and additionally 5–
ment.html#doc13516162bodyText1
7 days after the first exposure
2. Category II
○ Test only symptomatic contact person
3. Category III
○ Test only symptomatic contact person
4.4.4 Contact tracing Apps
Date report(ed) and reference
Statement / definition
17 April 2020
In April 2020 the Robert Koch Institute released the Corona-Datenspende (Corona Data Donation) smartwatch. It is a
https://corona-datenspende.de/#funktion
smartwatch that associated with a smartphone can measure physical activity and heart rate data which can be associated
with a postal code. The idea was to measure the movement and wellbeing of people for potential COVID-19 symptoms. The
app installation was voluntary and the data collected through it are being analysed by RKI.
26 April 2020
https://www.reuters.com/article/us-
Subsequently the government had the idea of a centralized contact tracing application which would allow health authorities
health-coronavirus-europe-
to alert others who may have come into contact with people who were confirmed positive. This proposal was not accepted to
tech/germany-flips-on-smartphone-
privacy concern.
109
contact-tracing-backs-apple-and-google-
Finally, on June 16, the federal government launched the new Corona-Warn-App. The app helps to notify users as quickly as
idUSKCN22807J
possible if they have been exposed to a person diagnosed with COVID-19 and to trace and identify infection chains of COVID-
19. The app installation is totally voluntary. It is based on technologies with a decentralized approach, notifying users if they
have been exposed to COVID-19 via Bluetooth and enabling them to retrieve test results electronically. The Bluetooth
16 June 2020
technology measure the distance and duration of the encounter between people who have installed the app. The smartphones
www.coronawarn.app
"remember" encounters if the criteria determined by the RKI on distance and time are met (people who have been in the
vicinity of the infected person for a period of at least 15 minutes within the last 14 days). The devices then exchange temporary
encrypted random IDs. If people using the app test positive for COVID-19, they can inform other users on a voluntary basis.
Then the random IDs of the person diagnosed with COVID-19 are made available to all people who are using the Corona-
Warn-App. The interfaces are provided by Google and Apple. The app must therefore be downloaded in the official Google
and Apple app stores and only runs on smartphones which have at least Android 6 or iOS (13.5).
The app was developed by SAP and Deutsche Telekom at a cost of around EUR 20 million and overseen by cyber security
experts from German research institutes. The data is automatically deleted after two weeks. If a testing lab supports the
electronic process, users can use the QR code they received during the test to retrieve their results. In case of a positive test
result, a specially generated QR code with the test result is sent to that person. This code then needs to be scanned into the
person's smartphone. Upon this, an alert can be transmitted by the phone by sending anonymized data of people who have
come into contact with the infected person to a central server. A push message is sent automatically to all those people, i.e.,
people who have been in the vicinity of the infected person for a period of at least 15 minutes within the last 14 days. People
who receive a warning will obtain recommendations on how to proceed: for example, to have a test themselves and putting
themselves in quarantine. However, not all laboratories and public health offices are equipped with the necessary digital
infrastructure to send test results to the system and generate QR codes. Hence, people who have been tested by such
laboratories and found to be infected must contact a telephone hotline. Those calling the hotline will have to answer test
questions to ensure that they have indeed been tested positive. However, questions and answers must not allow any
conclusions to be drawn about the Germany - Monitoring and surveillance Page 13/40 person's identity. The call canter is
meant to be able to handle about 1,000 calls per day.
4.5 Quarantine strategies and monitoring of contacts
Date report(ed) and reference
Statement / definition
26
June
2020
Monitoring of Contacts
https://www.rki.de/DE/Content/InfAZ/N/Neuart
1. Category I
iges_Coronavirus/Kontaktperson/Managemen
t.html#doc13516162bodyText1
Health monitoring until the 14th day after the last contact with the confirmed COVID-19 case:
Measurement of the body temperature twice a day.
Keeping a diary regarding symptoms, body temperature, general activities and contacts with other people:
Daily information from the health office on domestic quarantine and health status.
2. Category II
No monitoring
110
3. Category III
Daily self-monitoring
Daily central documentation of self-monitoring by hygienic staff
If the protective measures are impaired: notification to the company doctor and the hospital hygienist, information from the
GA; Measures see Contact persons I
If the patients develops symptoms:
Contact immediately the health authority
Notify the contact persons
4.6 Early case detection methods
4.6.1 Surveillance based indicators used to detect early cases
Date report(ed) and reference
Statement / definition
15 May 2020
The RKI continuously analyses various data sources in order to be able to record and assess the situation in Germany as
https://www.rki.de/SharedDocs/FAQ/NCOV20
precisely as possible. This includes, among other things, the official reporting data, but also information from existing
19/gesamt.html?nn=13490888
surveillance systems (e.g. on influenza) and from projects and studies that are being created as part of the COVID-19
pandemic - also in cooperation with other institutions. The total number of laboratory tests carried out in Germany on SARS-
CoV-2 - for which there is no obligation to report - is also recorded. All information is assessed and published in the daily
situation report.
4.6.2 Identification of clusters
Date report(ed) and reference
Statement / definition
3 June 2020
COVID-19 outbreaks have so far been observed in old people's and nursing homes, hospitals, meat processing companies,
https://www.rki.de/SharedDocs/FAQ/NCOV20
community accommodation (e.g. asylum seeker accommodation) and in church settings. Outbreaks are examined by the
19/gesamt.html?nn=13490888
responsible health authority, supported if necessary by the higher regional authorities or the Robert Koch Institute.
The health authorities therefore look specifically for cases of illness in the vicinity of the sick (active case finding) in order to
identify them as early as possible and to interrupt infection chains, but also to estimate the extent of the infection process. In
the context of SARS-CoV-2 outbreaks, it is important to also test asymptomatic people for SARS-CoV-2.
In addition, all data must be systematically recorded in order to identify correlations, understand infection chains and take
suitable infection protection measures (e.g. isolating sick people and quarantining close contact persons).
111
4.7.1 In hospitals
Date report(ed) and reference
Statement / definition
9 June 2020
All patients being admitted to hospitals will be tested for SARS-CoV-2 beforehand.
https://www.bundesgesundheitsministerium.
There are guidelines on the management of Outbreaks in healthcare setting but no information on early case detection
de/corona-test-vo.html
methods.
If SARS-CoV-2 is detected in patients or staff in an area that is not intended for COVID-19 patients, immediate action must be
17 April 2020
taken (proof is sufficient!). A common approach in coordination with the health department is important: cases, contacts and
suspected cases, as well as non-cases, should be treated in three spatially and personnel-separate areas: COVID-19 area,
https://www.rki.de/DE/Content/InfAZ/N/Neua
suspected case area, NOT-COVID-19 area. In order to be able to achieve this goal of separation promptly, appropriate plans
rtiges_Coronavirus/Management_Ausbruch_
and requirements should now be created in all health and care facilities. Personnel plans must be adjusted according to the
Gesundheitswesen.html
areas, the staff should be permanently assigned to individual areas. In facilities with frequent new admissions, an additional
spatial separation is necessary, because new admissions cannot be classified reliably at first (fourth area = new admissions).
Transit zones as a transition between the areas must be observed with as little crossing of the paths as possible.
4.7.2 In nursing homes and other collective facilities
Date report(ed) and reference
Statement / definition
27 May 2020
Very specific recommendations and guidelines are provided on how to deal with an outbreak in nursing homes, for residents,
https://www.rki.de/DE/Content/InfAZ/N/Neua
staff and visitors. Nevertheless no information is provided if there is an early case detection method for nursing homes.
rtiges_Coronavirus/Pflege/Dokumente.html
A ministerial decree has recommended that serial testing campaigns can be carried out in nursing homes, schools, day-care
9 June 2020
centres, rehabilitations facilities, dialysis centres, asylum seekers’ homes or prisons if there has been a case, in order to identify
chain of transmission and interrupt it at an early stage.
https://www.bundesgesundheitsministerium.
de/corona-test-vo.html
Nursing homes can also be tested regardless of cases. The responsible health authority decides whether such a series test
needs to be carried out.
4.7.3 In schools
Date report(ed) and reference
Statement / definition
9 June 2020
No specific strategy/tool for early case detection
https://www.bundesgesundheitsministerium.
de/corona-test-vo.html
A ministerial decree has recommended that serial testing campaigns can be carried out in nursing homes, schools, day-care
centres, rehabilitations facilities, dialysis centres, asylum seekers’ homes or prisons if there has been a case, in order to identify
chain of transmission and interrupt it at an early stage.
112
4.7.4 Precarious population
Date report(ed) and reference
Statement / definition
9 June 2020
No specific strategy/tool for early case detection
https://www.bundesgesundheitsministerium.
de/corona-test-vo.html
A ministerial decree has recommended that serial testing campaigns can be carried out in nursing homes, schools, day-care
centres, rehabilitations facilities, dialysis centres, asylum seekers’ homes or prisons if there has been a case, in order to
identify chain of transmission and interrupt it at an early stage.
4.8 Coordination and responsibility of testing and tracing
Date report(ed) and reference
Statement / definition
23 May 2020
The overall national strategy is coordinated from the Robert Koch Institute (RKI) in collaboration with the separate states.
https://www.bundesgesundheitsministerium.
Founding for testing is provided, with a decision of the Ministry of health, through funds released of the national statuary health
de/covid-19-bevoelkerungsschutz-2.html
insurance.
Testing and tracing is conducted locally with local capacity. The testing by general practitioners or hospital, and the contact
tracing by local field teams which report the local health authorities.
Testing data are transmitted nationally to the RKI which finally produces and shares national estimates, while contact testing
data are handles locally. The RKI handles also the national data of the tracing application.
113
5 RESULTS FOR ITALY
5.1 Existence of a plan to prevent the second wave
Date report(ed) and reference
Statement / definition
30 April 2020
Due to COVID-19 emergency Italy has published a legal decree that defines the surveillance activities to be put in place in order to monitor
http://www.trovanorme.salute.gov.
the health risk in the reopening Phase. The decree lists and explains the indicators that need to be used to fast detect an increasing
it/norme/renderNormsanPdf?anno
transmission rate of the coronavirus in the community, long term facilities, collectivities and hospitals. The monitoring system evaluates
=2020&codLeg=73981&parte=1%
the risk linked to the probability of infection/transmission and the impact or severity with particular focus on people over 50 years of age.
20&serie=null
The monitoring of these indicators should allow early detection of transmission hotspots and allow a fast reaction of the authorities to
contain it and prevent further spread of the virus.
The indicators are grouped into three classes:
1. process indicators on monitoring capacity;
2. process indicators on diagnostic capacity, research and management of contacts;
3. result indicators on transmission stability and resilience of health services.
They include:
1.1
Number of symptomatic cases per month in which the symptom onset date is reported / total of symptomatic cases reported to
the surveillance system in the same period.
1.2
Number of cases reported per month with a history of hospitalisation (in departments other than ICU) indicating the date of
hospitalisation / total of cases with history of hospitalisation (in departments other than ICU) notified to the surveillance system in the
same period.
1.3
Number of cases reported per month with history of transfer / hospitalisation in the intensive care unit (ICU) which indicates the
date of transfer or hospitalisation in ICU / total of cases with history of transfer / hospitalisation in intensive care notified to the surveillance
system during the same period.
1.4
Number of cases reported per month in which the municipality of residence or residence is reported / total of cases reported to
the surveillance system in the same period.
1.5
Number of checklists administered weekly to residential social-health facilities (optional).
1.6
Number of residential social-health structures responding to the checklist weekly with at least one problem encountered
(optional).
2.1
Percentage of positive swabs excluding as far as possible all screening activities and "re-testing" of the same subjects, overall
and by macro-setting, per month.
2.2
Time between start date of symptoms and date of diagnosis.
2.3
Time between symptom start date and isolation date (optional).
2.4
Number, type of professional profiles and person-time dedicated in each territorial service to contact-tracing.
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2.5
Number, type of professional profiles and person- time dedicated in each territorial service to the activities of collection/ sending
to the reference laboratories, and monitoring of close contacts and cases placed in quarantine and isolation respectively.
2.6
Number of confirmed cases of infection in the region for which a regular epidemiological investigation was carried out with tracing
of close contacts / total of new confirmed cases of infection.
3.1
Number of cases reported in the last 14 days.
3.2
Rt calculated on the basis of the integrated surveillance (two indicators are used, based on the beginning of symptoms and the
date of hospitalisation).
3.3
Number of cases reported to the sentinel surveillance COVID-net per week (optional).
3.4
Number of cases by diagnosis date and symptoms onset date reported to COVID-19 integrated surveillance per day.
3.5
Number of new clusters (2 or more epidemiologically linked cases or an unexpected increase in the number of cases in a defined
time and place)
3.6
Number of new confirmed cases by Region not associated with known transmission chains.
3.7
Number of accesses to the emergency unit with ICD-9 classification compatible with syndromic panels attributable to COVID-19
(optional).
3.8
Occupancy rate of total ICU beds for COVID-19 patients.
3.9
Bed occupancy rate for COVID-19 patients by province
For each indicator, a threshold condition is defined as well as an alert condition, and the source of data to be used.
5.2 Testing strategy
5.2.1 Indications for PCR testing
Date report(ed) and reference
Statement / definition
3 April 2020
The diagnosis and confirmation of COVID-19 is done through RT-PCR testing of the virus SARS-CoV-2, in regional laboratories.
http://www.trovanorme.salute.gov.
A test is recommended for the following suspected cases:
it/norme/renderNormsanPdf?anno
A person with an acute respiratory infection AND without another etiology to explain the cause AND history of travel in countries/areas
=2020&codLeg=73799&parte=1%
in which local transmission has been reported in the previous 14 days before symptoms onset
20&serie=null
OR
A person with any acute respiratory infection AND had contact with a probable or confirmed COVID-19 case in the 14 days before
symptoms onset.
OR
A person with a severe acute respiratory infection (SARI) AND need for hospitalisation AND without another etiology
Priority of testing is given the symptomatic and paucisymptomatic cases and their symptomatic contacts, seen in the 48h prior the onset
of symptoms.
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If the resources are adequate all the patients with respiratory infection should be tested.
In case of need, for example samples to be analyzed accumulate delays in the response, lack of reagents, impossibility of safe storage
of samples, overload working of laboratory personnel, it is recommended to apply, in carrying out the tests diagnostic, the priority criteria
listed below:
Hospitalised patients with severe acute respiratory infection (SARI)
All cases of acute respiratory infection hospitalised or living in nursing homes and other long-term care facilities
Health workers exposed to greater risk, operators of symptomatic essential public services, even if mildly affected symptomatology to
decide the possible suspension from work;
Operators, although asymptomatic, in nursing homes and other residential facilities for elderly
People at risk of developing a severe and fragile form of the disease, such as older people with comorbidities
First symptomatic individuals within closed communities
29 May 2020
RT PCR test is done in all cases and contacts developing symptoms, including mild symptoms, and in asymptomatic contacts at the end
http://www.trovanorme.salute.gov.
of quarantine whenever possible.
it/norme/renderNormsanPdf?anno
Two RT PCR tests are performed after clinical recovery, before discharge.
=2020&codLeg=74178&parte=1%
In case of outbreaks in hospitals, long-term residential facilities and other residential facilities for old people, all related patients and health
20&serie=null
staff are tested.
5.2.2 PCR testing conditions: how and by whom?
Date report(ed) and reference
Statement / definition
2 July 2020
If a person has flu symptoms or thinks they might be at risk of infection, they should stay at home, not go to the emergency room or the
http://www.salute.gov.it/portale/ma
doctor's surgery but call the family doctor, paediatrician or the ‘guardia medica’ (out-of-hours primary care service). Alternatively, they
lattieInfettive/dettaglioFaqMalattieI
can also call the regional information hotline or the Covid-19 information line at the number 1500.
nfettive.jsp?lingua=italiano&id=23
PCR testing in public health facilities and laboratories can be performed if only prescribed by a medical doctor or by a hospital.
0
The test is a single nasopharyngeal and oropharyngeal swab for each patient.
Multiple swabs from a single patient should be combined in a single diagnostic test.
3 April 2020
Patients who have already been confirmed positive should not undergo further diagnostic tests for COVID-19 until the time of clinical
http://www.trovanorme.salute.gov.
healing which must be supported by the absence of symptoms and negative nasopharyngeal swab repeated twice at least 24 hours
it/norme/renderNormsanPdf?anno
apart before discharge.
=2020&codLeg=73799&parte=1%
An indeterminate test in the presence of characteristic symptoms of COVID-19 must be considered as a case of COVID-19.
20&serie=null
Priority is given to tests of healthcare workers, who should be communicated within a maximum of 36 hours.
The Department of Prevention provides for the execution of diagnostic tests.
29 May 2020
http://www.trovanorme.salute.gov.
it/norme/renderNormsanPdf?anno
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=2020&codLeg=74178&parte=1%
20&serie=null
5.2.3 Indications and conditions for serological testing
Date report(ed) and reference
Statement / definition
3 April 2020
Serological tests are very important in research and in epidemiological evaluation of the viral circulation, but they are not used for
http://www.trovanorme.salute.gov.i
diagnosis.
t/norme/renderNormsanPdf?anno
The qualitative result obtained on a single serum sample is not sufficiently reliable for a diagnostic evaluation, since the detection of the
=2020&codLeg=73799&parte=1%
presence of antibodies through the use of rapid tests is not however indicative of an acute infection in progress, and therefore of the
20&serie=null
presence virus in the patient and risk associated with its spread in the community. In addition, for reasons of possible cross-reactivity with
other related pathogens such as other human coronaviruses, detection of antibodies may not be specific to SARS-CoV2 infection. Finally,
the absence of detection of antibodies (not yet present in an individual's blood due to the delay that physiologically connotes a humoral
response compared to the viral infection) does not exclude the possibility of an infection in progress in the early or asymptomatic and
relative phase risk of contagiousness of the individual.
6 May 2020
For serological tests, it is recommended to use CLIA and/or ELISA tests with a specificity not less than 95% and sensitivity lot less than
http://www.trovanorme.salute.gov.i
90%.
t/norme/renderNormsanPdf?anno
Serological tests (Antibody tests) cannot be used for replacing diagnostic molecular tests.
=2020&codLeg=74021&parte=1%
20&serie=null
5.2.4 Laboratory capacity
Date report(ed) and reference
Statement / definition
3 April 2020
Italy has a capacity of 152 laboratories able to test for SARS-CoV-2.
http://www.trovanorme.salute.gov.
it/norme/renderNormsanPdf?anno
As of 1st July 2020, there is a National Reference Laboratory (National Institute of Health) and 238 laboratories designated at regional
=2020&codLeg=73799&parte=1%
level for performing COVID-19 RT-PCR.
20&serie=null
The number of daily tests is almost around 80 000 per day for the whole country.
29 June 2020
The regional distribution is different for each region.
https://lab24.ilsole24ore.com/coro
navirus/en/
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5.2.5 Communication of test results to the patient
Date report(ed) and reference
Statement / definition
No specific information found
Most probably the results are communicated to the patient from their family doctor who prescribed the test.
5.2.6 Recording and surveillance of test results
Date report(ed) and reference
Statement / definition
27 February 2020
The Order of Chief of Civil protection Department entrusts epidemiological and microbiological surveillance to the National Institute of
http://www.trovanorme.salute.gov.i
Health and the surveillance of clinical features to the National Institute of Infectious Diseases in collaboration with the National Institute
t/norme/dettaglioAtto?id=73469
of Health.
The country has set up a new national and integrated surveillance system in order to record the COVID-19 information, since the beginning
of the pandemic.
9 March 2020
In Italy, a surveillance system on the new coronavirus has been active since the beginning of the pandemic. Monitoring of the epidemic
https://www.epicentro.iss.it/corona
of Covid-19 cases in Italy is carried out through two daily data flows:
virus/pdf/informazioni-privacy-iss-
sorveglianza-integrata-covid-
the flow of aggregate data sent by the Regions coordinated by the Ministry of Health (first with the sole support of Civil Protection)
19.pdf
and from 25 June 2020 also with the support of the national Institute of Health, to collect timely information on the total number of
positive tests, deaths, hospitalisations in hospital and ICU admissions in every Province of Italy;
the flow of individual data sent by the Regions to the national Institute of Health (Integrated surveillance Covid-19, ordinance 640 of
3 July 2020
the Civil Protection of 27/2/2020), which also includes demographic data, comorbidities, clinical status and its evolution over time, for
http://www.salute.gov.it/portale/nu
a more accurate analysis. The system is an online platform based on electronic questionnaires, which collects and processed the
ovocoronavirus/dettaglioContenuti
following categories of data: demographics and health data of the subjects positive for COVID-19, data on home and residence,
NuovoCoronavirus.jsp?area=nuov
laboratory information (date of collection and the laboratory that performed it), information on hospitalisation (date of hospitalisation,
oCoronavirus&id=5351&lingua=ita
hospital structure and ward) and on the clinical status (synthetic indicator of the severity of the symptoms), the presence of certain
liano&menu=vuoto
risk factors (basic chronic diseases) and the final outcome (healed or deceased and related dates).
From 25 June the data sheet with the daily update of the data has been integrated with the "cases identified by the diagnostic suspect"
(swab positive cases emerging from clinical activity) and "cases identified by screening activities" (investigations and tests, planned to
national or regional level, who diagnose positive swab cases).
All data can also be consulted on the interactive map (dashboard) of the National Department of Civil Protection.
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5.2.7 How is testing reimbursed?
Date report(ed) and reference
Statement / definition
3 April 2020
Testing can be performed only if prescribed therefore it is reimbursed from the national health system.
http://www.trovanorme.salute.gov.i
t/norme/renderNormsanPdf?anno
People can also refer to private laboratories to test for SARS-CoV-2, and in that case they would need to cover the price of the test.
=2020&codLeg=73799&parte=1%
Positive tests performed in private laboratories need to be communicated to the local health authority which would need to put in place
20&serie=null
the same isolation and contact tracing measures that apply to cases detected by public health laboratories.
12 May 2020
https://cdn.dday.it/system/uploads/
asset/file/141/Delibera_Regione_L
ombardia.pdf
5.3 Isolation strategies and monitoring of confirmed cases
5.3.1 Suspected cases (having symptoms)
Date report(ed) and reference
Statement / definition
7 March 2020
The types of subjects that must be placed in quarantine at home for 14 days and are monitored daily at home (or in a dedicated facility
https://www.epicentro.iss.it/corona
in case of inadequate domicile) are:
virus/pdf/rapporto-covid-19-1-
1. Close case contacts (see definition below)
2020.pdf
2. Patients who are discharged from the hospital clinically cured but still COVID-19 positive
3. Persons arriving in Italy from third countries (all countries except:
29 May 2020
a) Member States of the European Union;
http://www.trovanorme.salute.gov.i
b) States parties to the Schengen Agreement;
t/norme/renderNormsanPdf?anno
c) United Kingdom of Great Britain and Northern Ireland;
=2020&codLeg=74178&parte=1%
d) Andorra, Monaco;
20&serie=null
e) Republic of San Marino and Vatican City State)
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5.4.1 Confirmed cases
Date report(ed) and reference
Statement / definition
30 April 2020
All confirmed cases need to be isolated until the end of the symptoms and after two sequential negative tests 24 hours apart from each
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other.
t/norme/renderNormsanPdf?anno
=2020&codLeg=74178&parte=1%
20&serie=null
5.5 Contact tracing strategy
5.5.1 Contact definition
Date report(ed) and reference
Statement / definition
29 May 2020
A COVID-19 contact is any person exposed to a probable or confirmed COVID-19 case in a span of 48 hours before, up to 14 days after,
http://www.trovanorme.salute.gov.i
the onset of symptoms or until the time of diagnosis and isolation of the case. If the case does not show symptoms, the time span is to
t/norme/renderNormsanPdf?anno
be calculated from 48 hours before sample collection instead of symptoms onset.
=2020&codLeg=74178&parte=1%
A Close contact (high risk exposure) is:
20&serie=null
a person living in the same house as a COVID-19 case;
a person who has had direct physical contact with a COVID-19 case (eg handshake);
a person who has had unprotected direct contact with the secretions of a COVID-19 case (for example, touching used handkerchiefs
with bare hands);
a person who has had direct contact (face to face) with a COVID-19 case, at a distance of less than 2 meters and at least 15 minutes;
a person who has been in a closed environment (for example classroom, meeting room, hospital waiting room) with a COVID-19 case
in the absence of suitable PPE;
a healthcare professional or other person who provides direct assistance to a COVID-19 case or laboratory staff involved in handling
samples of a COVID-19 case without using the recommended PPE or by using unsuitable PPE;
a person who has travelled sitting in a train, plane or any other form of transportation within two places in any direction compared to
a COVID-19 case; travel companions and staff assigned to the plane / train section where the index case was sitting are also close
contacts.
The epi link has to have occurred within a period of 14 days before symptoms onset.
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5.5.2 Organisational process of contact tracing
Date report(ed) and reference
Statement / definition
29 May 2020
The Regions and Autonomous Provinces, through the local health structures, are responsible for contact tracing activities -
http://www.trovanorme.salute.gov.i
epidemiological surveillance and active contact surveillance. These activities are entrusted to the Prevention Department of the Local
t/norme/renderNormsanPdf?anno=
Health Authority, which can make use of the collaboration of other recruited personnel.
2020&codLeg=74178&parte=1%2
The key stages following the identification of a confirmed or probable case are described below.
0&serie=null
1. Interview with the index case
The Prevention Department interviews the index case to collect information on clinical history and possible contacts. This should be done
through a phone call where possible. If the cases are hospitalised and unable to cooperate, hospital staff or the attending physician can
collect the information directly from family members or caregivers.
2. Identification and list of close contacts
The Prevention Department identifies close contacts (personal data, address, telephone number) and lists them in a database. For
contacts:
regional
circuit by the ASL which identifies the case to the ASL of residence / domicile, or on the basis of any regional operational indications;
the case
to the Health Authority of the Region or Autonomous Province of residence / domicile and to the Ministry of Health, General Directorate
of Health Prevention - Office 5;
ional Health Authority to the Ministry of Health -
Directorate General for Health Prevention - Office 5, which will inform the State involved, through the platform of the European
Commission EWRS - "Early Warning Response System" or through the network of "National Focal Points" (NFP) provided for by the
International Health Regulations (IHR 2005).
In the collection of information, attention must be paid to the fact that the contact belongs to one of the groups at risk of developing serious
forms of COVID-19 and to the work carried out, such as assistance to the elderly, immunocompromised people and other vulnerable
populations.
3. Information/indications and surveillance
The Department of Prevention provides clear information and indications, also in writing, on the precautionary measures to be
implemented and any general educational documentation regarding SARS-CoV-2 infection, including the methods of transmission, the
prophylaxis interventions that are necessary (active surveillance, quarantine, etc.), the possible clinical symptoms and instructions on the
measures to be implemented in the event of the onset of symptoms.
121
5.5.3 Testing of contacts
Date report(ed) and reference
Statement / definition
29 May 2020
The Prevention Department monitors the evolution of the clinical situation of the contacts and carries out diagnostic tests in those who
http://www.trovanorme.salute.gov.i
develop symptoms, even mild ones, compatible with COVID-19.
t/norme/renderNormsanPdf?anno
If the test on the exposed person is positive, the case is notified and the contact search is started. For the re-entry into the community we
=2020&codLeg=74178&parte=1%
will have to wait for clinical recovery (i.e. the total absence of symptoms). The confirmation of healing needs two negative swabs 24 hours
20&serie=null
apart, otherwise fiduciary isolation will continue.
If the test is negative, the contact continues the fiduciary isolation for 14 days after the last exposure and the test is repeated before re-
entering the community. It is reiterated that in the event of a negative test for a patient highly suspected of being infected with SARS-
CoV-2, it is recommended to repeat the collection of biological samples at different times and from different sites of the respiratory tract.
If possible, asymptomatic contacts should be tested at the end of the quarantine. In the case of outbreaks involving hospitals, long-term
care, RSA or other residential structures for the elderly, the test must be offered to the residents and to all the health workers involved.
5.5.4 Contact tracing Apps
Date report(ed) and reference
Statement / definition
29 May 2020
In the COVID-19 emergency context, Italy has chosen the IMMUNI application as an instrument to assist traditional contact tracing. The
http://www.trovanorme.salute.gov.i
adoption of a single national application for contact tracing, also interoperable at European level, has the objective of identifying individuals
t/norme/renderNormsanPdf?anno
increasingly exposed to SARS-CoV-2 in an ever more complete way and, through health surveillance measures, help to break the
=2020&codLeg=74178&parte=1%
transmission chain.
20&serie=null
The application is based on the voluntary installation and its operation will cease as soon as the emergency phase has ended, with the
elimination of all data generated during its operation.
The main features of the App are:
otification to people who may have been exposed to a COVID-19 case - close contacts - with indications on pathology,
symptoms and public health actions to be implemented;
explaining that they have received a notification of close
contact of COVID-19 from Immuni.
To achieve these goals, the app uses proximity tracking (also known as contact tracking) based on Bluetooth Low Energy technology,
without resorting to geolocation. When a user installs Immuni on his smartphone, the app begins to exchange anonymous identifiers
(random codes) with other devices that have installed the same app. These are anonymous codes that do not allow to trace the
corresponding device, much less to the identity of the person, in full compliance with the recommendations issued by the European
Commission on April 16, 2020 regarding the proximity tracing apps.
122
The Immuni App, coupled with the traditional system is intended to facilitate the tracing of contacts, provides for close collaboration
between citizens, General Practitioners, Pediatricians and the Departments of Prevention.
Personal data will be used for the sole purpose of alerting people who have come into close contact with people who have resulted
positive Covid-19 and protecting their health. The same information, in aggregate and anonymous form, may be used for public health,
prophylaxis, statistics or scientific research purposes.
5.6 Quarantine strategies and monitoring of contacts
Date report(ed) and reference
Statement / definition
29 May 2020
The Department of Prevention provides clear information and indications, also in writing, on the precautionary measures to be
http://www.trovanorme.salute.gov.
implemented and general health education materials regarding SARS-CoV-2 infection, including methods of transmission, prophylaxis
it/norme/renderNormsanPdf?anno
interventions (active surveillance, quarantine, etc.), clinical symptoms and instructions on the measures to be implemented in the event
=2020&codLeg=74178&parte=1%
of the onset of symptoms.
20&serie=null
In particular, the public health operator of the territorially competent Prevention Department:
r or Pediatrician from whom the
contact is assisted for the purposes of Social Security certification;
-mails or text messages) to obtain information on the clinical conditions of the
contact.
Close contacts of COVID-19 cases must comply with the following measures:
edicated
room with good ventilation, preferably with a dedicated bathroom, and limit movement to other common areas of the home as much as
possible. In the presence of other people, a distance of at least one meter must be maintained;
ature twice a day and in any case of perceived increase in temperature;
-19, even mild, in particular fever or at least one of pharyngodynia,
cough, runny nose / nasal congestion, breathing difficulties, myalgias, anosmia / ageusia / dysgeusia, diarrhea, asthenia must:
1) immediately call the general practitioner or pediatrician and the Prevention Department;
2) self-isolation, i.e. staying at home in a room with a closed door, ensuring adequate natural ventilation;
3) if symptoms allow, wear a surgical mask when the first symptoms appear;
4) coughing and sneezing directly onto a tissue or in the crease of the elbow.
The Department of Prevention provides contacts with surgical masks and thermometers, if they do not have them.
Home isolation may require social support measures for the proper conduct of the quarantine. It must be carried out through the
collaboration of the territorially competent public health services, the social services of the municipal administrations, the voluntary
associations of the territory. Some functions must be guaranteed, such as support for the needs of daily life for people who live alone and
123
without caregivers (support of the family and neighborhood network) and psychological support. Where the appropriate conditions for
quarantine / isolation cannot be guaranteed at home, it is recommended to propose the transfer to specifically dedicated residential
structures with adequate medical support for monitoring and assistance.
At the end of the surveillance period, the Prevention Department communicates to the contacts the outcome of the surveillance.
5.7 Early case detection methods
5.7.1 Surveillance based indicators used to detect early cases
Date report(ed) and reference
Statement / definition
30 April 2020
The legal decree to contain the second Phase of the epidemic, based on the integrated COVID-19 surveillance, will monitor the daily and
http://www.trovanorme.salute.gov.i
weekly number of tests and the number of SARS-CoV-2 cases. Information on the date of disease diagnosis and the symptoms onset
t/norme/renderNormsanPdf?anno
will be collected.
=2020&codLeg=73981&parte=1%
Evaluation of the number of cases will also be done for the last 7 or 14 days in order to monitor the trend of the infection over time.
20&serie=null
5.7.2 Identification of clusters
Date report(ed) and reference
Statement / definition
30 April 2020
In the integrated COVID-19 surveillance system, together with the number of new cases, also their geographical distribution will be
http://www.trovanorme.salute.gov.i
monitored. Investigations about the possible geographical and/epidemiological epi-link of cases will take place in order to establish if
t/norme/renderNormsanPdf?anno
there is a possible outbreak ongoing.
=2020&codLeg=73981&parte=1%
A cluster is defined as 2 or more epidemiologically linked cases or an unexpected increase in the number of cases in a defined time and
20&serie=null
place.
5.7.3 In hospitals
Date report(ed) and reference
Statement / definition
30 April 2020
The integrated COVID-19 surveillance system will contain information regarding the number of accesses to the emergency unit with ICD-
http://www.trovanorme.salute.gov.i
9 classification compatible with syndromic panels attributable to COVID-19 to monitor its evolution and early detect an increase in the
t/norme/renderNormsanPdf?anno
incidence.
=2020&codLeg=73981&parte=1%
In case of outbreaks in hospitals, long-term residential facilities and other residential facilities for old people, all related patients and health
20&serie=null
staff are tested.
29 May 2020
124
http://www.trovanorme.salute.gov.i
t/norme/renderNormsanPdf?anno
=2020&codLeg=74178&parte=1%
20&serie=null
5.7.4 In nursing homes and other collective facilities
Date report(ed) and reference
Statement / definition
24 March 2020
A national survey was conducted by the National Institute of Health (ISS) on the nursing homes, in order to report the characteristics of
https://www.epicentro.iss.it/corona
the structure, the number of staff, residents, capacity, number or cases, deaths and several indicators. The survey was completed and
virus/sars-cov-2-survey-rsa
the last report refers to May 5, 2020.
Within the national monitoring system, two indicators are dedicated to long-term residential facilities:
30 April 2020
Number of checklists administered weekly to residential social-health facilities (optional).
http://www.trovanorme.salute.gov.i
Number of residential social-health structures responding to the checklist weekly with at least one problem encountered (optional).
t/norme/renderNormsanPdf?anno=
For the first indicator, results should have a positive trend for at least 50% of facilities in each Region; for the second indicator, the value
2020&codLeg=73981&parte=1%2
should be <30% with a positive trend.
0&serie=null
In case of outbreaks in hospitals, long-term residential facilities and other residential facilities for old people, all related patients and health
staff are tested.
29 May 2020
http://www.trovanorme.salute.gov.i
t/norme/renderNormsanPdf?anno=
2020&codLeg=74178&parte=1%2
0&serie=null
5.7.5 In schools
Date report(ed) and reference
Statement / definition
Schools are still closed and will reopen in September.
5.7.6 Precarious population
Date report(ed) and reference
Statement / definition
No specific information found
125
5.8 Coordination and responsibility of testing and tracing
Date report(ed) and reference
Statement / definition
26 June 2020
The testing and tracing are conducted a local level by the local public health authorities which do it with teams on the field.
http://www.salute.gov.it/portale/
The data is collected in different formats and is used at a local level to manage the situation and shared with national coordinating bodies.
nuovocoronavirus/dettaglioCon
The flow of aggregate data sent by the Regions is coordinated by the Ministry of Health with the support of National Health Institute
tenutiNuovoCoronavirus.jsp?ar
(Istituto superiore di Sanita’), to collect timely information on the total number of positive tests, deaths, hospitalisations in hospital and
ea=nuovoCoronavirus&id=535
ICU admissions in every Province of Italy.
1&lingua=italiano&menu=vuoto The flow of individual data sent by the Regions through the Integrated surveillance Covid-19 goes directly to the National Health Institute,
and it includes demographic data, comorbidities, clinical status and its evolution over time, for a more accurate analysis.
126
6 RESULTS FOR SPAIN
6.1 Existence of a plan to prevent the second wave
Date
report(ed)
and
Statement / definition
reference
General
page
for
Important factors of the strategy are:
professionals
is
●
Early detection of all COVID-19 compatible cases: one of the key points (above others) in controlling transmission.
https://www.mscbs.gob.es/pr
o
By strengthening the teams of
primary care professionals,
guaranteeing diagnostic and case management capacity from this
ofesionales/saludPublica/cca
level, ensuring the
availability of the necessary material for this purpose and the availability of
personal protection equipment.
yes/alertasActual/nCov-
The Autonomous Regions must guarantee this diagnosis and strengthen health centres for the management and monitoring of cases.
China/home.htm
o
PCR testing should be aimed primarily at the
early detection of cases with transmission capacity, prioritising this use over other
strategies.
July
9th
2020.
●
Monitoring the epidemic requires
https://www.mscbs.gob.es/en
o
epidemiological information systems that provide daily information for decision making.
/profesionales/saludPublica/c
o
adaptations must be made to the health information and
epidemiological surveillance systems to enable the
National Network
cayes/alertasActual/nCov-
for Epidemiological Surveillance (RENAVE) coordinated by the Ministry of Health which needs the
necessary information to
China/documentos/COVID19
react timely.
_Estrategia_vigilancia_y_con
o
each component of RENAVE, both at the
Autonomous Communities as well as at the National level (both the Ministry of Health
trol_e_indicadores.pdf
and the National Centre of Epidemiology) should have sufficient human resources especially in the epidemiological surveillance units,
and the technological and computer developments necessary to obtain and analyse cases continuously and to manage contacts
properly.
Monitoring the transmission requires: information from different levels, including public and private health and social care centres, and
occupational risk prevention services.
A new information system has been developed to get information directly from laboratories.
Information is requested from the Central level in terms of
the number of PCR tests developed and the number of positive cases. To
this end, the Autonomous Regions' Health Services and both the public and private health care services will adapt their computer systems
to enable the minimum required information to be obtained in the time and manner indicated in the corresponding established computer
applications.
The main goals of this strategy are:
1. Early detection of cases with active SARS-CoV-2 infection.
2. The early establishment of the necessary control measures to prevent new infections
3. The availability of the information necessary for epidemiological surveillance, with an appropriate level of disaggregation and detail
The results of laboratory testing, mainly in the context of screening, can also detect cases of resolved infection, but the search for such cases
is not the aim of the strategy. In the content of
screening also asymptomatic active cases can be detected.
127
6.2 Testing strategy
6.2.1 Indications for PCR testing
Date report(ed) and reference
Statement / definition
July
9th
2020.
Detection of COVID-19 cases:
https://www.mscbs.gob.es/en/profesionales/s
Any person with suspected and probable SARS-COV-2 will be tested (PCR). A prescription is required:
aludPublica/ccayes/alertasActual/nCov-
China/documentos/COVID19_Estrategia_vigi
Any person with
suspected SARS-CoV-2 infection should have a PCR (or other appropriate molecular diagnostic
lancia_y_control_e_indicadores.pdf
technique) performed within the first 24 hours.
○ Suspected case:
▪
any person with a clinical picture of acute respiratory infection of sudden onset of any severity, including fever,
cough or shortness of breath.
▪
any person with symptoms such as odynophagia, anosmia, ageusia, muscle aches, diarrhea, chest pain or
headaches.
Any person with
probably SARS-CoV-2 infection: a PCR that is negative and high clinical suspicion of COVID-19
o
PCR repeated after
48 hours with a new sample from the respiratory tract.
o
If the PCR remains negative and several days have passed since the onset of symptoms,
IgM detection could be
considered using a serological ELISA2 type test or other high throughput immunoassay techniques.
▪
Probable case:
o
suspected case with inconclusive PCR;
o
a person with severe acute respiratory infection with clinical and radiological picture compatible with
COVID-19 and negative PCR results
▪
In close contacts, PCR is only needed when these close contacts are suspected cases (so only when
they are symptomatic)
6.2.2 PCR testing conditions: how and by whom?
Date report(ed) and reference
Statement / definition
July
9th
2020.
1. PCR testing available upon physician’s prescription.
https://www.mscbs.gob.es/en/profesionales/s
2. PCR testing conducted in Health Care Centres.
aludPublica/ccayes/alertasActual/nCov-
3. The samples recommended for the diagnosis of SARS-CoV-2 by PCR are from the respiratory tract:
China/documentos/COVID19_Estrategia_vigil
Upper, preferably nasopharyngeal and oropharyngeal exudate or nasopharyngeal exudate
ancia_y_control_e_indicadores.pdf
Lower, preferably bronchoalveolar lavage, bronchoaspirate, sputum (if possible) and/or endotracheal aspirate, especially
May 26th 2020.
in patients with severe respiratory disease
128
https://www.eldigitaldealbacete.com/2020/05/
26/coronavirus-test-pcr-sin-bajar-del-coche-
en-albacete/
6.2.3 Indications and conditions for serological testing
Date report(ed) and reference
Statement / definition
July
9th
2020.
Rapid antigen or antibody detection techniques are not considered suitable for the diagnosis of acute infection. Nor are
https://www.mscbs.gob.es/en/profesionales/sal
ELISA-type serology or other high-performance immunoassay techniques alone indicated for diagnosis in the acute phase
udPublica/ccayes/alertasActual/nCov-
of the disease. This follows WHO guidance.
China/documentos/COVID19_Estrategia_vigila
Serology can be used in the definition of confirmed cases in the following situations:
ncia_y_control_e_indicadores.pdf
1. Confirmed case with active infection:
○ Person meeting clinical criteria for a suspected case, PCR negative and IgM positive by high throughput serology
(not by rapid test).
○ Asymptomatic person with PCR positive with IgG negative or not performed.
○ (Person meeting clinical criteria and positive PCR)
2. Confirmed case with resolved infection:
○ Asymptomatic person with positive IgG serology regardless of the PCR result (positive PCR, negative PCR or not
performed).
Serology is used in the definition of discarded cases in the following situations:
○ suspected case with negative PCR and IgM also negative, if this test has been performed, in which there is no high
clinical suspicion.
July
9th
2020.
The recommended samples for serological testing are blood obtained by peripheral venous sampling or finger stab,
https://www.mscbs.gob.es/en/profesionales/sal
depending on the type of test.
udPublica/ccayes/alertasActual/nCov-
Screening studies are those conducted on asymptomatic people. It is not recommended to set up screening studies with
China/documentos/COVID19_Estrategia_vigila
either PCR or serological techniques, because of the difficulties of interpretation the results in asymptomatic and low-risk
ncia_y_control_e_indicadores.pdf
people. It could only be considered in certain situations when persons are continuously exposed to the virus and always on
the recommendation of the public health authorities.
Screening with serological tests (if health authorities consider it): the aim is to improve the quality of life of vulnerable
populations or those with greater exposure, such as health and social care personnel or residents of retirement homes
or other social centres.
129
Screening with PCR: at this moment it should only be used for the detection of early cases between contacts, in vulnerable
populations in the context of outbreaks or in a prior to some welfare actions. Asymptomatic people who have had a
positive PCR test that was negated (due to lack of evidence at the time of transmissiblity from patients who are PCR
positive again)
130
.
6.2.4 Laboratory capacity
Date report(ed) and reference
Statement / definition
July
2nd
In total 3,644,458 PCR tests (77,38 tests per 1,000 inhabitants) and 1,993,931 rapid antibody tests (42,33 per 1,000
(https://www.mscbs.gob.es/profesionales/salud
inhabitants) are conducted across Spain.
Publica/ccayes/alertasActual/nCov-
In the week of June 26 to July 2nd 228,650 PCR and 107,743 rapid antibody tests were conducted.
China/documentos/COVID-
19_pruebas_diagnosticas_02_07_2020.pdf)
131
July 13th, Personal communication
There are currently
176 public laboratories that can process PCR samples. There are university labs, in hospital
microbiological labs, research centres, both military and veterinary labs.
During the ‘state of alarm’ the Ministry of Science and ISCIII validated the diagnostic support capacity of the National
Centre for Microbiology (carrying out thousands of diagnostic PCRs) which was done due to circumstances and currently
they provide support in necessary cases.
6.2.5 Communication of test results to the patient
Date report(ed) and reference
Statement / definition
July
9th
2020.
The general practitioners or treating doctor communicates the result to the patient by phone and provides general
https://www.mscbs.gob.es/en/profesionales/salu
information on the virus to the patient, the hygiene measures and isolation or quarantine measures for close contacts.
dPublica/ccayes/alertasActual/nCov-
China/documentos/COVID19_Estrategia_vigilan
cia_y_control_e_indicadores.pdf
6.2.6 Recording and surveillance of test results
Date report(ed) and reference
Statement / definition
July
9th
2020.
The Public Health epidemiological surveillance services of the Autonomous Regions must obtain information on
https://www.mscbs.gob.es/en/profesionales/
suspected and confirmed cases,
saludPublica/ccayes/alertasActual/nCov-
both in primary care and in hospitals
China/documentos/COVID19_Estrategia_vi
gilancia_y_control_e_indicadores.pdf
from the public and private systems,
as well as from prevention services.
Confirmed cases (except those of infection resolved or with negative or indeterminate PCR result) are of
obligatory urgent
declaration.
July
9th
2020.
The Autonomous Regions have to notify the state level (by using the national COVID-19 confirmed case notification survey)
https://www.mscbs.gob.es/en/profesionales/
through the
SiViEs surveillance tool managed by the National Epidemiology Centre each day before 12:00 all information
saludPublica/ccayes/alertasActual/nCov-
accumulated and updated up to 24:00 the previous day will be incorporated. This surveillance has been in place since 12 May.
China/documentos/COVID19_Estrategia_vi
Suspected cases are reported to the CCAES as follows:
gilancia_y_control_e_indicadores.pdf
Number of suspected cases in primary care. This information shall be reported in aggregate to the CCAES at established
intervals. If aggregated information is available from other sources of information on compatible cases (Apps, phone lines,
etc.) they shall also be reported, if possible differentiating it from the previous ones.
Number of suspected cases attended in hospitals (do not include persons indicated as having PCR for screening
purposes). This information shall be reported in aggregate to the CCAES at intervals to be established.
132
Percentage of suspected cases of COVID-19 in primary care where a PCR has been performed. This information shall
be reported to the CCAES on a weekly basis. It shall be reported on Wednesdays before 12:00 noon with the data from the
previous week, from Monday to Sunday.
Percentage of suspected cases in hospital care where a PCR has been performed (not including PCRs resulting from
screening tests). This information shall be reported in aggregate on a weekly basis to the CCAES. It shall be reported on
Wednesdays before 12:00 noon with the data from the previous week, from Monday to Sunday.
Number of close contacts confirmed as cases: This information shall be reported in aggregated form on a weekly basis
to the CCAES from the monitoring systems when established. Calculated as contacts that are confirmed as case that
week/contacts in follow-up that week x 100. It shall be reported on Wednesdays before 12:00 noon with the data from the
previous week, from Monday to Sunday.
Number of professionals in the epidemiological surveillance services (public health technicians epidemiologists, public
health nurses, other technical staff) dedicated to the response of COVID-19 in relation to the number of daily cases detected
and the reference population. Indicating the initial personnel and the new backup personnel incorporated. It shall be reported
on Wednesdays before 12:00 noon with the data from the previous week, from Monday to Sunday.
Information on detected outbreaks should be sent to the CCAES
(xxxxxxxxxxxx@xxxxx.xx) and to CNE
(xxxxxxxxx.xxx@xxxxxx.xx)
following a standard table (see 1.4.2).
6.2.7 How is testing reimbursed?
Date report(ed) and reference
Statement / definition
July
9th
2020.
Accessing COVID-19 tests requires a physician’s prescription.
https://www.mscbs.gob.es/en/profesionales/
saludPublica/ccayes/alertasActual/nCov-
China/documentos/COVID19_Estrategia_vig
ilancia_y_control_e_indicadores.pdf
June
6th
2020.
In the Spanish health system, insurance is mandatory and coverage is virtually universal; provision of services is free of charge
https://www.covid19healthsystem.org/countri
at the point of delivery, with the exception of pharmaceuticals and some ancillary goods. Everyone with legal residency status
es/spain/livinghit.aspx?Section=4.2%20Entit
is entitled to receive full coverage for COVID-19 treatments, at any point of care. For non-residents, emergency care and
lement%20and%20coverage&Type=Section
subsequent treatment are also fully covered.
133
6.3 Isolation strategies and monitoring of confirmed cases
6.3.1 Suspected cases (having symptoms)
Date report(ed) and reference
Statement / definition
July
9th
2020.
Managing cases with active infection:
https://www.mscbs.gob.es/en/profesionales/
All suspected cases will be kept in isolation pending the outcome of the PCR
saludPublica/ccayes/alertasActual/nCov-
The search for their close contacts (such as co-habitants and co-workers) will be initiated
China/documentos/COVID19_Estrategia_vig
ilancia_y_control_e_indicadores.pdf
In case of negative PCR, and if there is no high clinical suspicion, the case is discarded and the isolation is terminated.
Management if the test is positive; see management of confirmed case 1.1.2
6.3.2 Confirmed cases
Date report(ed) and reference
Statement / definition
July
9th
2020.
a. Primary care setting
https://www.mscbs.gob.es/en/profesionales/
home isolation will be provided in case effective isolation can be guaranteed.
saludPublica/ccayes/alertasActual/nCov-
When this cannot be guaranteed, isolation in hotels or other facilities fitted for such use shall be indicated.
China/documentos/COVID19_Estrategia_vig
ilancia_y_control_e_indicadores.pdf
Symptomatic: up to three days after resolution of fever and clinical presentation with a minimum of 10 days from onset of
symptoms.
Asymptomatic: until 10 days from the date of diagnosis.
Follow-up will be supervised until epidemiological discharge in the manner established in each autonomous community.
b. Hospital environment
isolated during their stay in the hospital following standard precautions, contact and air-droplet transmission precautions
and will be managed according to the protocols of each centre.
discharge from hospital, if clinical conditions allow it, even though the PCR remains positive, but home isolation must be
maintained with monitoring of the clinical situation for at least 14 days from the date of discharge from hospital. After these
14 days, and provided that three days have passed since the resolution of the fever and the clinical picture, the isolation
may be terminated. In any case, if a PCR is performed and a negative result is obtained (before these 14 days of home
isolation from hospital discharge have elapsed) patient’s home isolation may be terminated.
If the last negative PCR is performed at the time of hospital discharge and there are no respiratory symptoms in the three
days prior, the infection is considered to have been resolved and the patient may be discharged without the need for home
isolation. In any case, the provisions of each Autonomous Region will be followed.
c. Nursing homes and other social health care centres
In confirmed cases that are residents in centres for the elderly or in other social health centres
134
isolation in the centres where they reside (if clinical condition allows it).
isolation shall be maintained up to three days after the resolution of the fever and the clinical picture, with a minimum of 10
days from the start of the symptoms.
The follow-up and discharge will be supervised by the doctor who has done the follow-up in his centre or in the way that is
established in each autonomous community.
If the effective isolation of mild cases cannot be guaranteed, isolation in hotels or other facilities fitted for such use will be
indicated if this possibility exists.
Due to the vulnerability of social health centres, the detection of a single case in these institutions will be considered an outbreak
for the purposes of implementing action measures. In addition to general actions, PCR will be carried out on close contacts or,
depending on the circumstances, on all residents and workers of the centre, in the manner established by each Autonomous
Region.
d. Prisons and other closed institutions
isolation shall be indicated in the facilities where they are confined.
Isolation shall be maintained until three days after the resolution of the fever and the clinical picture with a minimum of 10
days from the onset of symptoms.
Follow-up and discharge will be supervised by the doctor who has carried out the follow-up in his centre or in the manner
established in each Autonomous Region.
e. Work environment
Health and social-health personnel who are confirmed cases
Home isolation as in a)
resolution of symptoms at least 3 days before, and with a minimum of 10 days from the start of the symptoms.
PCR before return to work,
In the event of a negative result, return to work.
If the PCR remains positive no return to work and repeat PCR.
Health and social care personnel who have required hospital admission
discharge from hospital if their clinical situation allows it, even if their PCR remains positive,
kept in home isolation with monitoring of their clinical situation for at least 14 days from the date of discharge from hospital.
resolution of symptoms at least 3 days before, and with a minimum of 14 days from the start of the symptoms.
PCR before return to work,
In the event of a negative result, return to work.
If the PCR remains positive no return to work and repeat PCR.
Non-healthcare workers who are confirmed cases will be managed as in a)
Monitoring will be supervised by the personal primary care physician, or work physician, in a manner established in each
Autonomous Region.
135
6.4 Contact tracing strategy
6.4.1 Contact definition
Date report(ed) and reference
Statement / definition
July
9th
2020.
A close contact (within 2 days before the onset of symptoms of the case until the time when the case is isolated and in
https://www.mscbs.gob.es/en/profesionales/
asymptomatic cases confirmed by PCR, contacts should be sought from 2 days before the date of diagnosis) is defined as
saludPublica/ccayes/alertasActual/nCov-
follows:
China/documentos/COVID19_Estrategia_vig
Any person who has provided care to a case: health or social-health personnel who have not used the appropriate protective
ilancia_y_control_e_indicadores.pdf
measures, family members or persons who have other similar physical contact.
Any person who has been in the same place as a case, at a distance of less than 2 metres (e.g. housemates, visitors) and
for more than 15 minutes.
Close contact in an aircraft, train or other long-distance transport (and where possible access to passenger identification)
is considered when within two seats of a case and the crew or equivalent personnel who have had contact with that case
(see flight schematic). All persons within the 5x5 seatings including path way indicated in the red squares are close contacts
on the schematics
136
6.4.2 Organisational process of contact tracing
Date report(ed) and reference
Statement / definition
https://coronavirus.sergas.es/Contidos/CS
1. Each Autonomous Region organizes contact tracing.
C-Central-de-seguemento-de-
For instance in Galicia, when PCR is positive, the lab will inform the physician (to inform the patient) and a sort of call centre
contactos?idioma=es
‘Central de Seguimientos de Contactos’ will start the process of contact tracing.
2. According to the strategy,
performance of PCR is recommended in every close contact at the time of identification as
contact, and also a second PCR on day 10 will be conducted. If the latter turns out to be negative, contact’s quarantine
measures may be lifted.
3. The Autonomous Regions have to
notify the state level (by using the national COVID-19 confirmed case notification survey)
through the
SiViEs surveillance tool managed by the National Epidemiology Centre each day before 12:00 all information
accumulated and updated up to 24:00 the previous day will be incorporated. This surveillance has been in place since 12
May.
6.4.3 Testing of contacts
Date report(ed) and reference
Statement / definition
July
9th
2020.
In the event of contacts of a suspicious case:
https://www.mscbs.gob.es/en/profesionales/
Identify and controlling contact, and recommend house-members to avoid leaving home immediately
saludPublica/ccayes/alertasActual/nCov-
China/documentos/COVID19_Estrategia_vig
When the PCR result can be guaranteed within 24-48 hours (depends on corresponding Autonomous Community): wait for
PCR confirmation.
ilancia_y_control_e_indicadores.pdf
○ confirmed case with active infection: identification and control of the other close contacts (non-cohabitants)
○ PCR negative, the quarantine of contacts will be suspended.
6.4.4 Contact tracing apps
Date report(ed) and reference
Statement / definition
On 27th of March, the Secretary of Digitalisation and Artificial Intelligence (a body of the Ministry of Economic Affairs) was ordered
to develop an app to support the management of the COVID-19 crisis. Using this app
(Asistencia-Covid19), citizens are able
to self-assess their health status and how likely it is for them to suffer from a COVID-19 infection, as well as receive advice and
recommendations about how to proceed depending on the results of this assessment (Order SND/297/2020
https://www.boe.es/buscar/doc.php?id=BOE-A-2020-4162). Since April 7th, the app is available and covers the population living
in those Autonomous Communities that have not developed their own information and monitoring applications (that is, Cantabria,
Canarias, Castilla-La Mancha, Extremadura and the Balearic Islands). Similar web or mobile apps are available for the population
137
in
other
Autonomous
Communities,
such
as
Andalucía,
Madrid,
Aragón,
Cataluña
or
País
Vasco
(https://www.boe.es/buscar/doc.php?id=BOE-A-2020-4829).
The same Order regulates the use of anonymised and aggregated data provided by mobile operators in order to analyse the
population movements prior and during the lockdown, with a view to identify hotspots and improve the management and
coordination of health care resources (Order SND/297/2020 https://www.boe.es/buscar/doc.php?id=BOE-A-2020-4162). On
April 20, the National Institute of Statistics published the main results of the data analysis on population movements at
https://www.ine.es/covid/covid_movilidad.htm.
The app is also useful for close contacts to monitor their symptoms.
June 23 2020.
Spain plans to launch a
COVID-19 tracing app through a pilot project in the Canary Islands on June 24th 2020 (Canary Islands
are chosen because of the tourism). The technology of Apple and Google will be used. It was difficult to implement apps earlier
https://www.elperiodico.com/es/economia/2
in respect of the rights of individuals and the protection of privacy and personal data. If the pilot phase is successful, it will be
0200623/espana-lanzara-su-app-de-
applicable nationally with the aim of being interoperable between countries. In the event this app becomes available national ly,
rastreo-del-coronavirus-en-junio-en-
would complement the Asistencia-Covid19 app, launched a few months ago to support those users who present symptoms
canarias-7969239
of the virus.
138
6.5 Quarantine strategies and monitoring of contacts
Date report(ed) and reference
Statement / definition
July
9th
2020.
Contact management:
https://www.mscbs.gob.es/en/profesional
In the event of a
suspicious case
es/saludPublica/ccayes/alertasActual/nCo
v-
Identify and recommend house-members to avoid leaving home immediately
China/documentos/COVID19_Estrategia_
When the PCR result can be guaranteed within 24-48 hours (depends on corresponding Autonomous Community): wait for
vigilancia_y_control_e_indicadores.pdf
PCR confirmation.
○ confirmed case with active infection: identification and control of the remaining close contacts (non-cohabitants): see
1.3.2
○ PCR negative, the quarantine of contacts will be suspended.
Close contact must be
informed and active or passive surveillance will be initiated (following the protocols established in each Autonomous
Community)
Basic epidemiological data and identification and contact details collected (following the protocols established in each
Autonomous Community)
All contacts will be provided with the necessary information about the COVID-19, the alarm symptoms and the procedures to
be followed during the follow-up:
○ Because the possible period of transmissibility begins 48 hours before the onset of symptoms you have been classified
as a risk contact. You will be actively monitored throughout the maximum incubation period of the disease, which is 14
days, but may be shortened to 10 days depending on whether or not a diagnostic test is performed.
○ During this period you should watch for any symptoms of illness (particularly fever, coughing or shortness of breath) so
that you can act as early as possible, especially to prevent transmission to others. In addition, you should remain at home
in quarantine for 10 to 14 days. The goal of these measures is to prevent that in case you acquired the infection, you
may in turn transmit it to other persons. Moreover, the transmission begins within 48 hours before the onset of the
symptoms, if they develop.
○ You should perform a temperature control twice a day, between the following times: - From 08:00 to 10:00 hours - From
20:00 to 22:00 hours
○ The person responsible for your follow-up will contact you to know about the temperature measurements and if you have
had any suspicious symptoms, following the protocols established in your Autonomous Region. In addition, you should
follow the following recommendations:
Stay at home until 10 or 14 days after the last exposure to risk, i.e. the day you last came into contact with the case
Stay in a single room most of the time and preferably with the door closed (and try to do activities that will entertain
you such as reading, drawing, listening to the radio, listening to music, watching television, surfing the internet, etc).
If possible, use your own bathroom, i.e. do not share it with any of your housemates.
139
Wash your hands often with soap and water, especially after coughing or sneezing or handling tissues you have
used to cover yourself. You can also use hydro-alcoholic solutions.
Restrict exits from the room or house to the absolute minimum and, when necessary, always wear a surgical mask.
Limit as much as possible the contact with co-habitants.
○ In case you have a fever (take into account if you are taking antipyretics in order to assess the fever) or develop any
symptoms such as cough or breathing difficulty, you should contact immediately (XXX local responsible person telephone
number). If this person is not available, call 112/061 and report your symptoms and that you are being followed as a
contact for possible exposure to the new coronavirus (SARS-CoV-2).
Action on close contacts shall be as follows:
Monitoring and quarantine shall be indicated for 14 days after the last contact with a confirmed case. If close contact quarantine
cannot be guaranteed, it is recommended that it will be carried out in community facilities prepared for this purpose.
PCR test is recommended for close contacts with the main objective of early detection of new positive cases. The most
effective strategy would be to perform PCR at the time of contact identification, regardless of the time since the last contact
with the case. Priority may be given in testing (people who care for) vulnerable people, co-habitants, or (social)-health staff of
(social)-health centres or other very important people or people who the Autonomous Region considers in its strategy. In case
PCR is negative, quarantine should be conducted for at least 14 days. In addition, to reduce the duration of quarantine, a PCR
could be repeated 10 days after the last case-contact, and quarantine can be lifted if PCR is negative.
If co-inhabitants cannot be isolated from the case under optimal conditions, the quarantine can be prolonged with 14 days
from the end of the case isolation.
The contact will be instructed to remain at home during the quarantine, preferably in a separate room, and to stay as much as
possible in the room. If exiting the room is needed, it should be done with a surgical mask. Contact with co-habitants should
be restricted as much as possible. Contact should be organized in a way that no exit of the house is needed during the period
of quarantine unless in exceptional circumstances.
washing hands frequently (with soap and water or hydro-alcoholic gel) especially after coughing, sneezing, and touching or
handling tissues or other potentially contaminated surfaces.
They need to be able to be contacted during follow-up periods.
All contacts should avoid taking antipyretics without medical supervision during
surveillance period to avoid masking and delaying the detection of the fever.
If the contact, at the time of identification, presents any symptoms related to suspicious cases, it will be handled in the manner
established for suspicious cases. Also if during the follow up the contact develops symptoms, it will be considered a suspected
case. The contact should be immediately isolated at the place of stay and immediately contact the monitoring person in charge
or contact 112/061 indicating that it is a contact from a case of SARS-COV-2.
If any contact PCR is positive, the contact will be considered confirmed by immediate self-isolation at the place of stay or
where the health authorities establish residence. On its turn, close contacts will be identified.
If the contact remains asymptomatic at the end of the quarantine period, return to normal routine is allowed. However, if it is
impossible to continue with the work activities due to the follow up measures, it must be communicated to the company or the
company’s prevention service, in accordance with the imposed procedure.
140
6.6 Early case detection methods
6.6.1 Surveillance based indicators used to detect early cases
Date report(ed) and reference
Statement / definition
July
9th
2020.
Number of suspected cases in primary care
https://www.mscbs.gob.es/en/profesi
Number of suspected cases attended in hospitals
onales/saludPublica/ccayes/alertasA
Percentage of suspected cases of COVID-19 in primary care where a PCR has been performed.
ctual/nCov-
China/documentos/COVID19_Estrate
Percentage of suspected cases in hospital care where a PCR has been performed (not including PCRs resulting from screening
gia_vigilancia_y_control_e_indicador
tests).
es.pdf
Number of close contacts confirmed as cases.
6.6.2 Identification of clusters
Date report(ed) and reference
Statement / definition
July
9th
2020.
The information on the detected outbreaks (any cluster of 3 or more confirmed or probable cases with active infection in which an
https://www.mscbs.gob.es/en/profesi
epidemiological link has been established) is sent at start and weekly to
onales/saludPublica/ccayes/alertasA
CC
AES (xxxxxxxxxxxx@xxxxx.xx),
ctual/nCov-
China/documentos/COVID19_Estrate
NEC (xxxxxxxxxx.xxx@xxxxxx.xx)
gia_vigilancia_y_control_e_indicador
according to the table below
es.pdf
Not for
household outbreaks unless they have special characteristics. For the purposes of this notification,
141
Identification number of the outbreak and date of communication to central level.
Place (Autonomous Community, Province, Municipal)
Date of symptoms of first case
Number of cases (number of hospitalisation & deaths)
Number of contacts
Name or place (institution, school, restaurant, building, etc.) of outbreak
Came the first case from outside the country? Which country?
Other information that could be relevant
142
6.6.3 In hospitals
Date
report(ed)
and
Statement / definition
reference
July
9th
2020.
Confirmed cases will be :
https://www.mscbs.gob.es/en
isolated during their stay in the hospital following standard precautions, contact and air-droplet transmission precautions and will be
/profesionales/saludPublica/c
managed according to the protocols of each centre.
cayes/alertasActual/nCov-
discharge from hospital, if clinical conditions allow it, even though the PCR remains positive, but home isolation must be maintained with
China/documentos/COVID19
monitoring of the clinical situation for at least 14 days from the date of discharge from hospital. After these 14 days, and provided that three
_Estrategia_vigilancia_y_con
days have passed since the resolution of the fever and the clinical picture, the isolation may be terminated. In any case, if a PCR is
trol_e_indicadores.pdf
performed and a negative result is obtained (before these 14 days of home isolation from hospital discharge have elapsed) the patient may
be discharged.
If the last negative PCR is performed at the time of hospital discharge and there are no respiratory symptoms in the three days prior, the
infection is considered to have been resolved and the patient may be discharged without the need for home isolation. In any case, the
provisions of each Autonomous Region will be followed.
Information on detected outbreaks should be sent to the CCAES
(xxxxxxxxxxxx@xxxxx.xx) and to CNE
(xxxxxxxxx.xxx@xxxxxx.xx) following a
standard table. The table (see 1.4.2) needs to be sent at the time of the detection of the outbreak and shall be updated at least weekly with
the relevant information for their follow-up. Information on household outbreaks is not necessary unless there are special features. For this
table an outbreak is considered when 3 or more confirmed or probable cases with active infection in which an epidemiological link is
established.
6.6.4 In nursing homes and other collective facilities
Date
report(ed)
and
Statement / definition
reference
July
9th
2020.
In
confirmed cases that are residents in centres for the elderly or in other social health centres :
https://www.mscbs.gob.es/en
isolation in the centres (if clinical condition allows it).
/profesionales/saludPublica/c
isolation shall be maintained until three days after the resolution of the fever and the clinical picture, with a minimum of 10 days from the
cayes/alertasActual/nCov-
start of the symptoms.
China/documentos/COVID19
_Estrategia_vigilancia_y_con
The follow-up and discharge will be supervised by the doctor who has done the follow-up in his centre or in the way that is established in
trol_e_indicadores.pdf
each autonomous community.
If the effective isolation of mild cases cannot be guaranteed, isolation in hotels or other facilities fitted for such use will be indicated if this
possibility exists.
Due to the vulnerability of social health centres, the detection of a
single case in these institutions will be considered
an outbreak for the
purposes of implementing action measures. In addition to general actions, PCR will be carried out on close contacts or, depending on the
circumstances, on all residents and workers of the centre, in the manner established by each Autonomous Region.
An outbreak is considered when 3 or more confirmed or probable cases with active infection in which an epidemiological link is established.
143
6.6.5 In schools
Date
report(ed)
and
Statement / definition
reference
June 22, 2020
Schools will open in September 2020
http://www.educacionyfp.gob
Main components:
Attendance of all students guaranteed. If necessary, prioritization, or lower level of attendance.
.es/dam/jcr:7e90bfc0-502b-
It is recommended that in each educational centre there be a responsible person who can refer to aspects related to COVID-19. It may also
4f18-b206-
be useful for schools to create a COVID-19 team trained by the school management, secretariat, one or more members of the teaching staff,
f414ea3cdb5c/medidas-
a member of the cleaning service and representation of families and students, which guarantees the the basic principles and that the entire
centros-educativos-curso-20-
educational community is informed of their implementation.
21.pdf
There is a
guide for Prevention and Control of Infection at schools with the following objectives:
1. Create healthy and safe school environments through prevention, hygiene and health promotion adapted to each educational stage. The
basic principles are:
a.
Limiting the contacts:
i.
>1.5m distance between people in the school (or measures allowing social distancing e.g. panels, partitions, separation, etc.
ii.
And/or creation of coexistence groups (of 15 to 20 students and a tutor) which can interact with each other on <1.5m distance
from each other (this measure facilitates contact tracing).
iii.
Communication with families by phone, email, messages, or mail.
iv.
Encouraging walking and cycling (active transportation), to limit contacts.
b.
Personal prevention measures: hand and respiratory hygiene (common strategy).
i.
Masks for students: not compulsory in infant education. In primary and secondary education only compulsory outside
coexistence groups when social distancing cannot be held. A mask is not necessary when they are sitting at their desks at least
1,5m apart.
ii.
Masks for tutors: In infant and primary education, voluntary wearing masks in the coexistence group and mandatory use outside
this group when social distance cannot be maintained. In secondary education, mandatory when social distancing cannot be
maintained.
iii.
Compulsory in collective school transport from the age of 6.
iv.
Use of masks contraindicated: behavioural disorders, impossible to use masks, children under 2y, people with breathing
difficulties, etc.
v.
Objects for share need extreme cleaning between manipulations.
vi.
Use of
gloves not generally recommended except for cleaning.
c.
Cleaning and ventilation: i.
Specific cleaning and disinfection
protocol in place with measures such as disinfection at least once a day, special attention
to areas/surfaces of common use and private areas, which products to use, etc.
ii.
Frequent ventilation with measures such as time (5-10 min), weather conditions, etc.
iii.
Rooms used by multiple people will be ventilated and disinfected during switch.
iv.
Waste management with measures on masks, drying hands, buckets, etc.
d.
Case management: early management of detected cases (protocol)
144
i.
Person that starts to develop symptoms will be taken to separate space for individual use, a surgical mask will be fitted (both
persons), the family will be contacted as well as the Primary Care referral centre. In case of severe symptoms call 112. Worker
should leave his job until his medical situation is assessed.
ii.
study and follow up of contacts (easier when stable groups), Public Health should monitor contacts in accordance with the
surveillance and control protocol in force in the corresponding Autonomous Community. Autonomous Community should assess
the actions to be taken in the event of an outbreak.
iii.
Protocol of action created by Public Health in the event of outbreak (e.g. temporary closure of classrooms, or schools)
iv.
Confirmed case should stay at home in isolation (cfr. strategy)
Transversal actions (specific measures reported in document on 4 major topics):
Reorganisation of the school:
○ Management of the centre’s human resources: verify who is in home isolation or especially at risk, training/informing workers, risk
assessment for teachers (similar to community risks - risk 1, but in case of possible infection - risk 2 and surgical mask is indicated)
○ Reorganisation of spaces: social distancing in spaces used by multiple people, outdoor activities encouraged, fixed groups (15-20
students), public spaces will be used in case not sufficient space, classrooms may be used for eating, etc.
145
○ Flexible hours will be implemented to minimize the presence of people simultaneously and the use of spaces.
○ Equipment for prevention and hygiene measures will be provided.
Coordination and participation
○ Coordination: Local communication should be improved from the school / institute towards the primary care, with Public Health, with
Social Services, with local entities.
○ Participation with families and students (information, education on preventive measures and hygiene, etc.)
Communication and health education
○ Communication: management team must ensure that information on action protocols and prevention, hygiene and health promotion
measures are understood by the entire educational community.
○ Health education including the reason why, what, when, support materials, etc.
Equity: attention to the needs of certain groups such as social vulnerability, special need situations, parents working outside or teleworking
not possible, etc. Monitoring of absenteeism of tutors, schools must provide supportive, respectful environment, etc.
2. To enable early detection of cases and appropriate management of them through clear action protocols and coordination of the agents
involved.
There are specific protocols and measures for ‘special education’ and ‘early childhood education’ (0-3y) e.g. disinfection diaper changing area
every time, beds 2m apart, etc.
An outbreak is considered when
3 or more confirmed or probable cases with active infection in which an epidemiological link is established.
This document aims to provide a common framework that can be adapted at the level of each Autonomous Region and implemented according
to
the
reality
of
each
educational
centre
and
its
local
context
e.g.
Galicia
(
https://coronavirus.sergas.gal/Contidos/Documents/412/Plan_reactivacion_ambito_infantoxuvenil.pdf)
6.6.6 Precarious population
Date
report(ed)
and Statement / definition
reference
July
9th
2020.
Prisons and other closed institutions:
https://www.mscbs.gob.es/en
In
confirmed cases of inmates in prisons or other closed institutions that do not meet hospitalisation criteria and are managed in their own
/profesionales/saludPublica/c
facilities,
cayes/alertasActual/nCov-
China/documentos/COVID19
isolation shall be indicated in the facilities where they are confined.
_Estrategia_vigilancia_y_con
Isolation shall be maintained until three days after the resolution of the fever and the clinical picture with a minimum of 10 days from the
trol_e_indicadores.pdf
onset of symptoms.
Follow-up and discharge will be supervised by the doctor who has carried out the follow-up in his centre or in the manner established in
each autonomous community.
An outbreak is considered when
3 or more confirmed or probable cases with active infection in which an epidemiological link is established.
146
6.7 Coordination and responsibility of testing and tracing
Date
report(ed)
and
Statement / definition
reference
https://boe.es/boe/dias/2020/
Protocols agreed in the Interterritorial Council are mandatory all over the territory (Royal Decree 21/2020). Regional health authorities are
06/10/pdfs/BOE-A-2020-
responsible for deployment.
5895.pdf
The purpose of this
Royal Decree Law is to establish the urgent prevention, containment and coordination measures needed to deal with the
health crisis caused by COVID-19, and to prevent possible outbreaks, with a view to certain provinces, islands and territorial units exceeding
Phase III of the Plan for Transition to a New Normalcy and possibly expiring the validity of the state of alarm declared by Royal Decree
463/2020 of 14 March, declaring a state of alert for the management of a health crisis situation caused by COVID-19, and its extensions.
In Decree 2210/1995 of 28 December 1995: The
National Epidemiological Surveillance Network (la Red nacional de vigilancia
epidemiológica)
(https://www.boe.es/buscar/pdf/1996/BOE-A-1996-1502-consolidado.pdf) is established to enable the collection and analysis
of epidemiological information in order to be able to detect problems, assess changes in time and space, contribute to the implementation of
control measures individual and collective of problems that pose a health risk of incidence and national or international interest and disseminate
information at their operational levels competent. The National Epidemiological Surveillance Network is at the service of the National Health
Service.
Towards COVID-19 the National Epidemiological Surveillance Network are given a series of obligations for the collection, processing and
transmission of information, of the relevant epidemiological and health-related data, always safeguarding the protection rights of personal
data, as well as the system established with the laboratories for the collection and referral of information with the result of diagnostic tests by
PCR in Spain as a complement to the surveillance system of COVID-19 cases.
In case that Spain is in a ‘state of alarm’ (declared by the Ministery) the Government may agree jointly with each Autonomous Region, the
modification, extension or restriction of the units of action and the limitations on the freedom of movement of persons, on measures of restraint
and those of insurance of goods, services, transport and supplies, in order to better adapt them to the evolution of the health emergency in
each autonomous community".
https://www.consalud.es/paci
The health services of the Autonomous Regions are the ones that have to confirm the need for the diagnostic support that the research centres
entes/centros-investigacion-
and qualified universities can provide to the microbiological laboratories of the hospitals, in addition to developing a protocol for sending
validados-pruebas-pcr-
samples and collecting results that ensures the traceability and anonymity of the tests that have legal validity.
It is therefore the Autonomous
diagnostico-covid-
Regions that manage the request for support, in coordination with the central government and according to the needs detected,
19_77602_102.html
while the ISCIII is responsible for evaluating the capacities and resources of the proposing centres. The Autonomous Regions are
also responsible for policies, protocols and measures taken when no ‘state of alarm’ is implemented by the National Government.
147
7 RESULTS FOR THE NETHERLANDS
7.1 Existence of a plan to prevent the second wave
Date
report(ed)
and
Statement / definition
reference
https://lci.rivm.nl/draaiboeken
There is a
national pandemic response plan (which was already implemented before COVID-19 outbreak) describing the general actions
/generiek-draaiboek
in case of an infectious disease crisis and is directed towards the Public Health Services. It describes which measures should be taken in
which phase of the crisis and who is responsible and how the organisation of the Public Health Service should be modified to deal with the
crisis.
The phases are the following:
(1) after reporting the first case: direct measures including treatment of the patient, testing, contact tracing, and lab diagnostics;
(2) scaling up: including cooperation with other parties, information provision, type of measures for scaling up, ensuring continuation of usual
care; further measures including social distancing, refining contact tracing and diagnostics, hygiene measures, medical supervision, isolation
and quarantine, vaccination and prophylaxis;
(3) downscaling: including cancelling the crisis organisation, after care, evaluation, reporting.
7.2 Testing strategy
7.2.1 Indications for PCR testing
Date report(ed) and reference
Statement / definition
June 11th
From June 1st 2020,
everyone with symptoms of COVID-19 infection:
https://lci.rivm.nl/richtlijnen/covid-
must stay at home,
19#besmettelijke-periode
can have themselves tested.
GGD’s use PCR tests in persons who present symptoms of COVID-19 and in tracing of their contacts if symptoms are
presented.
It is particularly important that people who care for vulnerable people are tested immediately in the event of symptoms.
Vulnerable people or people with serious complaints should be tested by their GP and/or referred to the hospital if needed.
148
7.2.2 PCR testing conditions: how and by whom?
Date report(ed) and reference
Statement / definition
https://www.rijksoverheid.nl/onderwerpen/coro
For who?
navirus-covid-19/testen/soorten-testen
Initially, due to the limited testing capacity and the lack of a central overview on the existing testing capacity,
only hospital
staff and sick patients could be tested.
In the months of April and May,
more professions and high risk populations presenting symptoms were tested, in
correspondence with the
unlocking strategy e.g. health care professionals, teachers, childcare employees, police, supervision
and enforcement employees, informal care, contact professions, employees in public transport, etc.
The ultimate goal was to be able to
test everyone with symptoms. This goal was achieved on
the first of June.
https://www.rijksoverheid.nl/onderwerpen/coro
For who?
navirus-covid-19/testen/afspraak-maken
As of June 1st, testing will be available for all citizens presenting symptoms of COVID-19 infection (see section 1.3.1)
June 2nd
How?
https://www.youtube.com/watch?v=ZxZOLFd4
The person with COVID-19 symptoms should call a telephone number (0800-1202) and stay at home (except for the test).
ZJk&feature=youtu%2Ebe
During the cal the person should indicate his/her ‘citizen service number’ (I.D. or passport or driver license).
June 11th
An appointment will be made and confirmed by email and SMS.
https://www.youtube.com/watch?v=ArqP15ZiV
Testing is free of charge for the patient.
2g&feature=youtu.be
The person has to drive to the test location* (location nearby a GGD, or drive-in / drive-through location (person stays
https://ggdghor.nl/thema/testen-covid-19/
inside of the car for testing)) at the scheduled time and takes his/her ID and confirmation of appointment (email/SMS).
PCR test is conducted in the nose and throat by a staff member of the testing facility.
After the test, the person tested should return immediately to home and stay home until the result of the test is known.
The result will be telephoned to the person as soon as possible.
By Whom?
*The
GGD is responsible for testing and tracing. Since the 6th of April, 25 GGD’s have together more than 80 testing facilities
in the Netherlands.
In case of high-risk population or severe illness (e.g. high fever) the general physician, treating physician or general
practitioner's office should be called.
The testing policy for COVID-19 is constructed by the
‘Outbreak Management Team’ (OMT). They decide who can be tested.
After every meeting of the OMT, the National Institute for Public Health and the Environment (RIVM) writes an advice for the
ministry of Public Health, Wellbeing, and Sports (VWS). That advice is discussed in several boards and with the ministers.
Ultimately the cabinet decides what happens with the advice and which groups of people receive which test.
149
7.2.3 Indications and conditions for serological testing
Date report(ed) and reference
Statement / definition
June 23th
Blood is taken from the patient, currently only in selected labs, and only for research purposes. These tests are especially
https://www.rivm.nl/coronavirus-covid-
used to see if there is immunization among the population and for other research purposes.
19/testen
Rapid serological tests (sold on the market) are NOT reliable and should not be used at home (cfr. WHO).
7.2.4 Laboratory capacity
Date report(ed) and reference
Statement / definition
June
4th
https://lci.rivm.nl/covid-
Since February 26th:
2 reference labs (Erasmus MC & RIVM-IDS), and
13 regional labs.
19/bijlage/aanvullend
Since the beginning of March:
Other medical microbiological labs can be validated if they comply to the following:
proficiency panel testing with good results (validation analytical specificity and correct detection SARS-CoV-2);
run control SARS-CoV-1 and SARS-CoV-2 dilution series with good result (validation of analytical specificity);
confirmation of 5 positive samples and 10 negative samples at one of the expert laboratories (RIVM-IDS or Erasmus
MC) with good results (limited clinical validation).
Since April 1st: Also
bioveterinary labs and
HPV-screening labs can be validated to perform SARS-COV-2 analyses.
Since June 6th: Next to the 2 reference labs and 13 initial labs, 49 extra labs were validated. The criteria indicate that they
should be able to assess at least 100 tests a day.
150
7.2.5 Communication of test results to the patient
Date report(ed) and reference
Statement / definition
June 4th
Results of the test are available between
24-48h, but the norm is to provide them as soon as possible.
https://lci.rivm.nl/covid-19/bijlage/aanvullend
Results of diagnostics from Erasmus MC and RIVM-IDS:
To the hospitals: As soon as possible through telephone and via secure email (‘caremail’ or ‘zorgmail’) if available. It is
important to mention a direct 24/7 telephone number of the physician-microbiologist, who should receive the test result,
July 1st
on the request form.
https://lci.rivm.nl/leefregels
To the GGD: As soon as possible via secure email (zorgmail), until midnight. Positive as well as negative results. Later,
a definitive report will be sent through secured email or by mail. The GGD will NOT be called by phone. For questions
on the results, the GGD can contact a virologist of the reference centres by telephone.
Result of diagnostics from GGD to the patient:
151
In case of a positive test:
○ Patient is told to stay at home
○ Information* is given to patient and housemates
○ GGD investigates contacts and calls them: contact tracing is initiated.
*There are numerous information leaflets available to inform the patient and their contacts.
Videos:
○
https://www.youtube.com/watch?v=ZxZOLFd4ZJk&feature=youtu%2Ebe, ○
https://www.youtube.com/watch?v=ArqP15ZiV2g&feature=youtu.be
Standard information letters
(https://lci.rivm.nl/leefregels).
○ Someone with (possible) symptoms of SARS-COV-2 infection
○ Confirmed SARS-COV-2 infection:
Confirmed patient (& easy language version)
Positive test but no symptoms (yet)
○ Housemates
Of a confirmed patient (& easy language version)
Positive test but no symptoms (yet)
○ Close contacts
Of a confirmed patient (& easy language version)
Positive test but no symptoms (yet)
○ Other contacts
Of a confirmed patient (& easy language version)
Of a confirmed patient at primary school or childcare
These letters are all translated and available in Arabic, German, English, Polish, Romanian and Turkish.
7.2.6 Recording and surveillance of test results
Date report(ed) and reference
Statement / definition
June 25th
Recording of cases
https://www.covid19healthsystem.org/c
Since January 28th, it is mandatory for health professionals to report COVID-19 cases and suspected cases to the Public
ountries/netherlands/livinghit.aspx?Sect
Health Services.
ion=1.4%20Monitoring%20and%20surv
COVID-19 is considered an A-disease, which enables the government to take far-reaching measures to prevent the spread of
eillance&Type=Section
the disease, such as isolation, mandatory quarantine, mandatory treatment or prohibition of professional practice. Other A-
diseases are for instance MERS, SARS, smallpox and polio. However, because of the relatively mild symptoms for the majority
of cases and the limited testing capacity, not all suspected cases can be tested.
152
Since March 12th, only confirmed (tested) cases have to be reported to the Public Health Services.
https://lci.rivm.nl/richtlijnen/covid-19
Monitoring of source and contact tracing (see section 1.5)
Immunization across the population:
https://www.nivel.nl/nl/publicatie/weekcijfers
Forty GP practices of the Nivel Primary Care Database regularly take sample swabs from people with influenza-like symptoms.
-covid-19-patienten-de-huisartsenpraktijk-
Since 7 February, these swabs have also been tested for COVID-19. The aim is to provide a good overview of how the virus is
week-10-29-2-maart-19-juli-2020
spread over the Netherlands. For example, in week 12, 11% of the swabs contained the coronavirus. The positive swabs were
mainly coming from patients living in the highly affected areas.
7.2.7 How is testing reimbursed?
Date report(ed) and reference
Statement / definition
June
2nd Testing conducted by the GGD (testing, lab process and communication of the results to the general practitioner) is free of
https://www.youtube.com/watch?v=ZxZOLF
charge for the patient and is paid by the Public Health Care budget (OGZ-budget).
d4ZJk&feature=youtu%2Ebe
In principle, medically necessary care is available for all persons who need this in the Netherlands. COVID-19 services are
https://ggdghor.nl/thema/testen-covid-19/
covered by the Health Insurance Act, although patients have to pay the mandatory deductible (as in normal medical specialist
https://www.covid19healthsystem.org/countr
care) when admitted to the hospital. No other out-of-pocket expenditure is applicable.
ies/netherlands/livinghit.aspx?Section=4.2%
20Entitlement%20and%20coverage&Type=
Section
7.3 Isolation strategies and monitoring of confirmed cases
7.3.1 Suspected cases (having symptoms)
Date report(ed) and reference
Statement / definition
June 22
Suspicion of COVID-19 infection:
https://lci.rivm.nl/informatiebrief-niet-
In case of symptoms of COVID-19 infection such as coughing, cold, increased temperature or fever (>38°C), or losing taste
bevestigde-patient
and/or smell:
Case should stay at home
In case of fever or dyspnea, housemates should also stay home
In case of becoming more sick or in case of high risk population or vulnerable people, the general practitioner or hospital
should be called
Conduct PCR test (process PCR testing in section 1.2.2)
153
Before and after the PCR test awaiting the results,
following measures should be taken by the suspected case:
Stay at home, only exit the house for the PCR test.
Housemates have to stay home in case you have fever/dyspnea.
You can go in the garden or balcony, in case no other people are there.
You cannot receive visitors, except for the general practitioner and GGD
Only people who live with you, can be at your home
Also housemates cannot receive visitors
Stay as much as possible in your own room. Sleep alone.
Housemates should not access that room.
Limit contact with housemates and keep 1.5m distance (no kissing, no hugging, no sex)
Use your own service (plates, cups, fork, knife, spoon, etc.) Wash separately preferably in a dishwasher.
Throw your waste in a separate bag.
Use your own towels and toothbrush
Use a separate toilet and bathroom if possible. In case you have to share, clean the bathroom and toilet every day and
ventilate by putting a window open during 30 min.
Stay in a separate room and ventilate by opening windows. Clean regularly, also tap, switches, handles, etc. Use first
regular soap for cleaning and clean frequently used surfaces. Take a new bucket with 5l water, add 125ml bleach (a cup
of coffee). Throw a towel in the laundry. Wash your hands with water and soap afterwards.
Use a paper napkin, cuff in the elbow, use a paper napkin only 1 time and throw it after usage in a plastic bag. Wash your
hands.
Wash hands regularly with water and soap (definitely after coughing, sneezing, toilet, eating, etc.)
Limit the spread of faeces, urine, sweat, mucus, etc.
Throw your laundry in a separate bucket and wash at min 40°C with a full washing program and normal soap.
Write down with whom you had contact the last few days.
Of note, similar measures are also available to
inform housemates of a confirmed case and a confirmed case see
https://lci.rivm.nl/informatiebriefhuisgenootthuis
If test is negative:
Housemates can exit house, unless they evolve symptoms themselves
Index patients can exit the house, but if symptoms get worse a second test should be conducted.
If test is positive:
Source and contact tracing by GGD (see section 1.4)
Index patient and housemates stay home (see confirmed case 1.3.2)
Stick to the basic measures, even if you are not infected with SARS-COV-2.
154
7.3.2 Confirmed cases
Date report(ed) and reference
Statement / definition
May 28
Confirmed case - asymptomatic infection:
https://lci.rivm.nl/informatiepatientthuis
Index case: isolation during 72h after testing
Housemates and close contacts: quarantine
June 23
○ If the index case does not develop symptoms within 72h, exit isolation
https://lci.rivm.nl/COVID-19-bco
○ If the index case develops symptoms within 72h, the test is conducted in the pre-symptomatic phase. The policy on
symptomatic infections should be followed.
Confirmed case - symptomatic infection:
Index case: isolation at home 14 days
Housemates: quarantine at home 14 days
○ Exit isolation when 24h symptom free AND 48h fever free AND at least 7 days after becoming symptomatic.
○ In case of decreased resistance, exit isolation when 24h symptom free AND 48h fever free AND at least 14 days after
becoming symptomatic.
In case of severe sickness or increased symptom severity call the general practitioner.
7.4 Contact tracing strategy
7.4.1 Contact definition
Date report(ed) and reference
Statement / definition
June 23th
Contacts are categorized into:
https://lci.rivm.nl/COVID-19-bco
Housemates (Category 1): Living in the same place for a long-time at <1.5m distance from the patient.
Other close contacts (Category 2):
○ Persons > 15 min at < 1.5m distance with the patient during the infectious period*. Health care professionals who wore
protection materials following the guidelines are NOT considered as close contact.
○ When exposure < 15 min but there was a high risk of infection e.g. cuffing in face, direct physical contact, kissing, etc.
Other contacts (Category 3): Persons > 15 min at >1.5m distance of the patient during the infectious period e.g. office,
class, meetings, etc. The contact tracing of these contacts can be later supplemented with anonymous track-and-trace
apps, specifically for contacts who cannot be approached by the index patient.
*infectious period: starts 2 days before the clinical signs and ends if the patient is 24h free of clinical signs (48h fever free) and
minimum 7 days (14 days in case of immunocompromised patients) after the start of the symptoms.
155
In asymptomatic infections, look back at contacts 2 days before the test.
7.4.2 Organisational process of contact tracing
Date report(ed) and reference
Statement / definition
April
21st Discussions on capacity
(https://nos.nl/nieuwsuur/artikel/2331268-
National protocol not (yet) available
grootschalig-contactonderzoek-nodig-
Since the first confirmed case, contact tracing was in place for confirmed cases. Since 12 March, contact tracing has focussed
maar-wie-moet-dat-gaan-doen.html).
on groups of vulnerable patients. Contract tracing is done to inform contacts of confirmed cases, especially those in high-risk
groups, and highlight the importance of maintaining high hygiene standards and staying at home when symptomatic.
(see:
https://lci.rivm.nl/richtlijnen/covid-19)
May
8th Citizens are asked to inform their contacts by themselves.
(https://nos.nl/nieuwsuur/artikel/2333281-
Informed contacts are asked to proactively report to the public health organization whether they have symptoms.
protocol-voor-contactonderzoek-kent-twee-
grote-zwakke-plekken.html).
June 23th
As of June 1st, contact tracing will be conducted in case of a positive test.
https://lci.rivm.nl/COVID-19-bco
The goal of source- and contact tracing?
to identify the possible source
to identify contacts
to inform and guide them on the risk of COVID-19 infection
to point out the measures that need to be taken to prevent further dissemination
Special attention should be given to contact tracing of vulnerable contacts and contacts who work with vulnerable persons, such
as health care professionals. The role of source and contact tracing differs from phase of the pandemics. In an exit or transition
phase (current phase), all contacts should be traced to curb the epidemics. Contact tracing shortens the duration between the
clinical signs and the start of isolation measures, and reduces therefore the transmission.
Protocol available?
Ministry of Wellbeing, environment and sports guideline protocol for source and contact tracing:
Protocol is based on ECDC protocol.
Execution is the responsibility of the local health authority (the ‘GGD’ or ‘Gemeentelijke Gezondheidsdienst’).
Different protocols are available for testing, source and contact tracing and in case of outbreaks.
How?
In a confirmed case, the GGD (‘Gemeentelijke gezondheidsdienst’, local health authorities) starts source- and contact tracing. If
the capacity for the GGD is not sufficient, the GGD can scale up nationally. This allows complex source and contact tracing to
be carried out in the region.
156
Source tracing:
The patient is asked where/how (s)he might got infected
Watch out for local, regional or national clusters of confirmed cases. Conduct more investigation and take if necessary
supplementary measures.
Contact tracing:
GGD initiates contact tracing asap and within 24h, after receiving notification of a confirmed case.*
Rapid notification by treating physicians and lab are essential including patients’ contact details.
*Source and contact investigation conducted by GGD:
Discuss who could have infected you (source)
Discuss which people you met during last days (contact)
○ The GGD informs them (by phone) that they were in contact with an infected person and could possibly be infected
also.
○ The GGD provides information on what they should do.
○ The GGD calls the housemates and close contacts a few times (at least on day 1, 7, and 14) to verify (possible)
symptoms and measures.
○ Contacts that present symptoms that could be related to COVID-19 should call the GGD for rapid testing.
Each contact tracing procedure is custom work and is concentrated on the 3 categories of contacts (see section 1.5).
7.4.3 Testing of contacts
Date report(ed) and reference
Statement / definition
https://lci.rivm.nl/COVID-19-bco
Contacts are
only tested in case they present symptoms such as:
One or more of the following symptoms:
colds such as rhinitis, nose cold, sneezing, sore throat;
(minor) coughing;
sudden loss of smell and/or taste (without nasal congestion);
shortness of breath;
increase or fever > 38°C
And other symptoms that may fit COVID-19 infection, sometimes in combination with the above stated symptoms:
general malaise;
headaches;
muscle pain;
pain behind the eyes;
157
fatigue and anorexia
Less common symptoms:
chills;
general pain;
breathing pain;
dizziness;
hoarse voice;
irritability/confusion/delirium;
abdominal pain;
diarrhea;
nausea/vomiting;
conjunctivitis;
various skin abnormalities
Since the current policy is based on intensive source and contact research, a contact of a COVID-19 patient will be
easily tested if there are indications of one of the complaints from the entire broad palette of COVID-19 complaints.
7.4.4 Contact tracing Apps
Date report(ed) and reference
Statement / definition
June 25th
The OMT suggested that intensified contact tracing should be one of the conditions for relaxing COVID-19 restrictions (current
https://www.covid19healthsystem.org/count
phase). The Public Health Organisations (GGD’s) are responsible for contact tracing, but they might lack the capacity. Fol owing
ries/netherlands/livinghit.aspx?Section=5.1
this recommendation, the government studied the idea of a COVID-19 app for mobile phones.
%20Governance&Type=Section
A tender was issued and
7 apps were evaluated, but after an initial assessment
none of these appeared to meet the privacy
(https://nos.nl/artikel/2330914-overheid-
criteria.
presenteert-zeven-corona-apps-maar-nog-
At present, the
government itself is developing such an app with a group of experts and with the prerequisite that the app
veel-zorgen.html
;
has to be open source in order to show the population that their privacy will be protected.
https://www.nrc.nl/nieuws/2020/04/21/kabin
et-houdt-vast-aan-app-in-strijd-tegen-covid-
19-a3997460)
June 25th
At the beginning of July, users will be able to test a
corona-notification-app in the region of Twente. It is a
pilot to see if the
https://www.rijksoverheid.nl/onderwerp
app is in congruence with privacy, user friendliness and safety. The app will be used supplementary to the regular source and
contact tracing of the GGD. The app remembers e.g. train contacts, street contacts etc. It works through Bluetooth technology.
en/coronavirus-
It is aimed that the cabinet can decide mid-July on the use of the app.
app/nieuws/2020/06/24/coronavirus-
app-test-in-twente
158
7.5 Quarantine strategies and monitoring of contacts
Date report(ed) and reference
Statement / definition
June 2
3 https://lci.rivm.nl/COVID-19-bco
Quarantine strategies for 3 categories of contacts:
1.
Housemates (Category 1): The GGD informs all housemates (also children) orally and written with the following advice:
June 1,
Quarantine at home during 14 days after the last contact with the confirmed patient i.e. telework, no public transportation,
no visitors - especially not with a high risk to be infected.
https://lci.rivm.nl/lci.rivm.nl/covid-
19/bijlage/zorgmedewerkersinzetentestb
Taking care of cough- and hand hygiene.
eleid
To be alert, during 14 days, for clinical signs and symptoms of COVID-19 (coughing and/or nose cold and/or fever) and (i)
in case of suspected fever (≥38°C) measuring temperature (rectal or via the ear), (ii) cal GGD immediately for appraisal
and diagnostics.
GGD should be able to contact you during the period of quarantine.
In case the housemates show clinical signs/symptoms of SARS-COV-2 infection, the GGD is responsible for testing them
asap.
Exit quarantine for housemates:
14 days after the last moment of contact with the confirmed case, or 14 days counting from the day the confirmed case is
symptom free AND at least 7 days after the start of the symptoms (14 days in immunocompromised patients)
And the housemate is symptom free during this period.
Telephone call from the Municipal Health Service (GGD) to housemate at the beginning of the contact tracing, around day 7
(half-way) and day 14 (end) of the monitoring period, to follow up quarantine measures and discuss symptoms. Transmission
within members of the same family can lead to prolongation of the monitoring period. The moments to call are adjusted.
People working in the vital sector / crucial professions stay at home in quarantine. There are exceptions in consultation with
GGD and the company physician, and only when they are asymptomatic.
2.
Other close contacts (Category 2): The GGD informs other close contacts orally and written with the following advice:
Quarantine at home during 14 days after the last contact with the confirmed patient i.e. telework, no public transportation,
no visitors - especially not with a high risk to be infected.
Children ≤ 12y can go to school and play sports.
Keep at least 1.5m distance from other persons if you come out of home.
Taking care of cough- and hand hygiene
To be alert, during 14 days, for clinical signs and symptoms of COVID-19 (coughing and/or nose cold and/or fever) and (i)
in case of suspected fever (≥38°C) measuring temperature (rectal or via the ear), (ii) cal GGD immediately for appraisal
and diagnostics
159
The GGD should test ‘other close contacts’ asap if they present symptoms of SARS-COV-2 infection. Pending test results,
they stay strictly at home and make an overview of their own contacts from 2 days prior to the symptoms.
Telephone call from the GGD around day 7 (half-way) and day 14 (end) of the monitoring period, to follow up measures and
discuss symptoms.
People working in the vital sector / crucial professions also stay at home. An exception can be made for these groups in
consultation with the GGD and the company physician and only if they are asymptomatic. For care workers outside the
hospital: see Testing policy and deployment of care workers.
If a contact 14 days after the last moment of contact with a COVID-19 patient has remained complaint-free, no infection has
occurred and the contacts can rejoin society just like other citizens.
3.
Other contacts (category 3): The GGD ensures that contacts are informed about the determination of COVID-19 in a
person in their environment.
The contacts are advised:
good cough and hand hygiene;
take general measures to prevent COVID-19 (social distancing);
be alert during the 14 days after the last contact for symptoms of infection, and
in case of suspected fever (≥ 38.0ºC), measure the temperature (rectal or through the ear)
call the GGD directly for assessment and use diagnostics;
to stay at home at the moment of symptoms.
The GGD ensures that contacts are tested for SARS-CoV-2 as soon as possible if symptoms fit COVID-19.
In anticipation of the test results, they stay strictly at home and make an overview of their own contacts from 2 days prior to
the symptoms.
Quarantine strategies for contacts of specific groups:
1.
For contacts in child care and primary education:
If an adult or pupil in primary education or child care is diagnosed with COVID-19, colleagues and peers are informed in
accordance with policy category 3 (other (not close) contacts), and are tested in case of symptoms.
Exceptions are intensive contacts between children and adults, such as during the care of very young children at a
children's centre or lowest groups in primary education. In these cases, the child and the adult are considered to be
category 2 contacts (other close contacts).
Adult category 2 contacts in childcare and primary education are in principle not allowed to work.
Children designated as category 2 contacts in childcare and primary education are in principle allowed to go to a childcare
centre or primary school, provided they have no complaints
2.
Health care practitioners outside hospitals (different sectors)
Suspected health care practitioner with symptoms:
Everyone should stay home when having symptoms of COVID
Health care practitioners and housemates should let them test immediately when having symptoms
160
The symptomatic person stays home until the test results are available. If the person has fever / dyspnea, the housemates
should stay also home until the results are known.
Test negative: health care practitioner with mild symptoms and NO fever can work again.
Test positive: source and contact tracing GGD. Index and housemates stay home until 2 weeks after last contact at home.
Index stays at home at least 7 days after the start of the symptoms (or test) AND 48h fever free (<38°C without t° control
medication) AND 24h symptom free.
Asymptomatic health care practitioner (different scenarios):
Housemate COVID 19 positive: stay home until 14 days after last contact (exceptionally the health care practitioner may
work in communication with the GGD or company doctor, with the use of type II mask and gloves.
Close contact COVID 19 positive: health care practitioner may work (till 14 days after last contact, the health care
practitioner should use mask of type II and gloves)
Housemate with respiratory complaints and fever / dyspnea: health care practitioner may work (till test result is known, the
health care practitioner should use mask of type II and gloves)
3. Foreign travellers in the Netherlands
If foreign travellers staying in the Netherlands test positive for COVID-19, the Dutch guidelines are used.
The GGD of the region where the traveller is staying carries out the contact test in the Netherlands.
If the index was also abroad during the infectious period, the GGD informs the Centre of Infectious Diseases (LCI)
(https://cib.healthandsafety.nl/).
Foreign travellers in home isolation or quarantine are not allowed to travel, not even to their country of origin. If this is
nevertheless necessary, the Centre of Infectious Diseases will be consulted. If a tourist leaves the Netherlands without
permission, the GGD will inform the LCI.(more info
https://cib.healthandsafety.nl/)
4. Aircraft Contact Policy
Contact research of aircraft contacts is started:
1) if the index has been on board of an aircraft during the infectious period
The following aircraft contacts are defined as 'other close contact' (category 2):
○ Passengers seated within 2 seats away from the front, back and side of the index (max 24 contacts), where the aisle
is considered as a row of seats and aircraft compartments/sections as a boundary. (see also
www.seatguru.com)
○ Crew members who have had intensive contact with the index (e.g. because extra care has been provided).
If the index is a passenger, the data of the index will be transmitted to the GGD of the airport of arrival via secure mail
connection.
2) If a crew member was contagious:
The following aircraft contacts are defined as 'other close contact' (category 2):
○ passengers with whom this crew member had intensive contact (e.g. because extra care was provided)
○ directly cooperating colleagues who had > 15 min of continuous contact at a distance < 1.5 m. In practice, these will
often be the crew members who worked in the same compartment or section.
161
○ Other crew members are considered to have had other non-high level contact if they have had non-intensive contact
with the index (category 3)
If the index is a crew member who has flown during the contagious period, the contact tracing shall be coordinated with the
arrival airport GGD. (more info
https://cib.healthandsafety.nl/)
Monitoring of source and contact tracing:
To monitor the effects of source and contact tracing the transfer of daily information from the electronic patient file (checkbox)
to the National Institute of Public Health and the Environment is done and used already at the beginning of the pandemics. In
the electronic patient file the following data is reported:
personality characteristics (gender, year of birth, postal code);
link to index (Osiris number) or situation;
contact category;
first and last day of exposure;
monitoring period;
call contacts during monitoring period;
occurrence of complaints including first day of illness and type of complaints;
collected diagnostics;
GGD region.
Regular evaluation will take place to adjust policy where necessary and possible.
162
7.6 Early case detection methods
7.6.1 Surveillance based indicators used to detect early cases
Date report(ed) and reference
Statement / definition
June 2
3 https://lci.rivm.nl/covid-19-
Currently, the GGD and institutions should pay attention to clustering of confirmed cases.
testbeleid%20personen%20zond
er%20klachten
Testing of asymptomatic persons?
Here
you
may
find
a
policy
on
testing
asymptomatic
persons
https://lci.rivm.nl/covid-19-
testbeleid%20personen%20zonder%20klachten. Asymptomatic persons could be tested to prevent outbreaks.
It is still unknown to which extent asymptomatic people contribute to infections (subject of current research).
Several studies have shown that testing people without symptoms can help to map out the extent of distribution.
Testing people without complaints also has disadvantages, because results are difficult to interpret and have a
limited negative
predictive value.
In this phase of the pandemic, testing policy is used to monitor virus circulation as closely as possible, as part of the policy to limit the
spread of the virus as much as possible and thus prevent and significantly dampen a second wave. On the basis of current knowledge,
it is unclear whether differences in testing policies where people are tested without symptoms actually contributed to containment.
Asymptomatic testing has added value in well-defined groups, where there is an outbreak (suspicion of an outbreak) (where the
expected pre-test probability is higher than the percentage of positives in the general population), and the findings have
consequences for the policy to be followed to prevent the spread of SARS-CoV-2.
Indication for asymptomatic testing can take place in consultation with the GGD, LCI and/or in consultation with the infection
prevention department of the hospital in the context of a hospital outbreak.
Asymptomatic testing may also be useful in case of admittance in elderly care or in case of source and contact tracing in
combinations with a potential app.
In the examples mentioned, asymptomatic testing helps to map the extent of spread and is therefore currently being researched.
163
7.6.2 Identification of clusters
Date report(ed) and reference
Statement / definition
June 23th
In a confirmed case,
the GGD starts source- and contact tracing and should therefore pay attention to local, regional or national
clusters of confirmed cases. They should conduct more investigation and take if necessary supplementary measures.
https://lci.rivm.nl/COVID-19-bco
In
institutions, staff should pay attention at confirmation of several infected cases.
The advice is not to make a distinction in the type of sector in which the outbreak takes place.
Asymptomatic testing of patients/residents and/or healthcare personnel can also play a role in outbreaks within healthcare institutions.
Specific regulations on outbreak for primary schools and childcare (see under)
7.6.3 In hospitals
Date report(ed) and reference
Statement / definition
June 2
4 https://lci.rivm.nl/covid-19-
Only patients with
symptoms (at triage, at gate) are tested on COVID-19, thus not all patients who enter the hospital.
testbeleid%20personen%20zond
er%20klachten
7.6.4 In nursing homes and other collective facilities
Date report(ed) and reference
Statement / definition
June 2
4 https://lci.rivm.nl/covid-19-
Only patients with
symptoms are tested.
testbeleid%20personen%20zond
Asymptomatic testing could be of added value in elderly people in care institutions, for example at the time of admission to a care
er%20klachten
institution, as it has been shown that the clinical presentation of COVID-19 in this group can be very variable, and there is an increased
risk of serious course. Currently, the role of SARS-CoV-2 spread by atypical or asymptomatic infections in nursing homes is being
investigated. Based on the results of this research, a specific advice can be drawn up.
7.6.5 In schools
Date report(ed) and reference
Statement / definition
June 23th
So far there have been no outbreaks among children in schools or children's centres in the Netherlands. When asked about all
25 GGDs, there appears to
have been no report of possible COVID-19-clusters related to (emergency care for)
school or child
https://lci.rivm.nl/handreiking-
care before school closure from 16 March to 11 May. In this period the schools were closed and there was only child care for
uitbraakonderzoek-covid-19-op-
parents in crucial/vital professions. After the reopening of primary education and childcare, some infections were reported among staff
kindercentra-en-basisscholen
164
members at schools. As far as is known, there are no staff members who have been infected by children. The international literature
also supports the conclusion that children and schools do not seem to play an important role in the transmission of SARS-CoV-2.
1. In general:
○ Anyone with symptoms of COVID-19 stays at home and can be tested.
○ If the person presents symptoms, all housemates should stay at home until after the test result.
Negative test: children present mild symptoms, they are allowed to go to school or children's centre and do not have to stay at home.
Positive test:
○ source and contact tracing by the GGD
○ housemates stay at home until 2 weeks after the last contact.
○ a positive tested case remains at home at least 7 days after the start of symptoms and 48 hours fever free and at least 24
hours symptom free.
2. For children applies:
If the child's symptoms are recognizably unrelated to a pre-existing disorder (such as hay fever or asthma), the child may attend school
or children's centre.
If the pattern of symptoms changes or if new symptoms arise in addition to the known pattern of symptoms, the child remains at home
until these new symptoms have passed or the known pattern of symptoms has returned.
Any child with newly developed rhinitis symptoms or a change in the pattern of symptoms can be
tested at the request of the parents.
It is
especially important to test the child if it is a contact of a proven COVID-19 patient or if the parents have complaints that
may fit COVID-19.
If in a group of a primary school
3 or more children have complaints that fit COVID-19, it is advised to test these children.
In case of mild symptoms with children, they are allowed to go to school or children's centre and do not have to stay at home.
3. First study among 54 families by RIVM shows this:
○ no evidence that children are a major source of infection in the spread of the new coronavirus;
○ spread of SARS-CoV-2 among children or from children to adults is less common than among adults or from adults to children;
○ most of the spread occurs among adults and from adult relatives to children.
4. Adults in childcare and primary education should be kept as far away as possible from other adults and children as much as
possible. This condition includes all contacts of positive adults in a children's centre or at a primary school in category 3 (other (not
close) contacts). In practice, however, maintaining a 1.5-metre distance between adults and children, especially in childcare and in
the lower groups of primary education, will not always succeed.
5. Children from 0 to 12 years of age do not keep a distance from each other, but they do keep as much as possible 1.5
metres distance from adults. This condition includes all contacts of positive children in a children's centre or at a primary school in
category 3 (other (not close) contacts)). In practice, however, maintaining a 1.5-metre distance between adults and children, especially
in childcare and in the lower groups of primary education, will not always succeed.
6. Specific advice for contacts in childcare and primary education:
165
In principle, if COVID-19 is established in the case of an adult or pupil in primary education or child care, colleagues and peers are
informed in accordance with policy category 3 (other (not close) contacts) and are tested in case of complaints.
Exceptions are intensive contacts between children and adults, such as during the care of very young children at a children's
centre. In these cases, the child and the adult are regarded as category 2 contacts (other close contacts)(see protocol contact).
Adult category 2 contacts in childcare and primary education are in principle not allowed to work.
Children who have been designated as a category 2 contact in childcare and primary education are in principle allowed to go to a
childcare centre or primary school, provided they have no complaints.
Testing policy, contact tracing and measures taken for 6 possible scenario’s in adults working with children in children’s
centre or primary education.
1. An employee reports sick and has a suspicion of COVID-19
○ does not go to work
○ gets tested on COVID-19
○ stays at home in isolation awaiting the test result
2. An employee is reported to the GGD as confirmed COVID-19
○ does not go to work
○ stays at home in isolation
In cooperation with the school management and the youth doctor, the GGD conducts source and contact research around the
employee.
The same applies to the employee's contacts within the children's centre or primary school:
○ adults and children who had prolonged contact (> 15 minutes) at a distance of > 1.5 metres with the staff member, in the
same room, for example in the classroom or during meetings, are regarded as a category 3 contact (other (not close) contacts)
and are allowed to go to school or continue working;
○ adults and children who had prolonged contact (> 15 minutes) at a distance of < 1.5 metres with the employee, or who had
a high-risk exposure of < 15 minutes, are considered as a category 2 contact (other close contacts); adults are in principle
not allowed to work, children are allowed to go to a children's centre or primary school, provided they have no complaints;
○ persons without contact with the employee are excluded from contact examination.
3. A child reports sick and has a suspicion of COVID-19
○ does not go to school,
○ gets tested on COVID-19**
○ stays at home in isolation awaiting the test result
4. A child is reported to the GGD as a confirmed case of COVID-19
○ home isolation
In cooperation with the management of the children's centre or primary school and the youth doctor, the GGD conducts source and
contact research on the child. This applies to the contacts of the child within the children's centre or primary school (staff and children):
166
○ an employee who has had more than 15 minutes of intensive contact with a tested positive child (feeding, changing,
comforting) is considered a category 2 contact (other close contacts) and in principle is not allowed to work;
○ the other adults and group and classmates are in principle all considered as a category 3 contact (other (not close) contacts)
and are allowed to go to school or children's centre;
○ persons without contact with the child are excluded from contact examination.
5. ≥ 3 children from a group/class or several staff members report sick and have a suspicion of COVID-19
The school/children's centre notifies the IZB (‘infectieziekteverspreiding’ doctor) physician (and the youth physician) of the GGD in
question on the basis of art. 26 of the Public Health Act.
If necessary, in consultation with the GGD, the school informs the parents that the GGD will contact them.
The GGD advises to:
○ test the sick children/employees for COVID-19
○ stay at home in isolation awaiting the test result
Test result:
○ negative: the persons are allowed to go to school provided they are not ill.
○ In case of 1 positive test: apply scenario 2 or 4.
○ In case of multiple positive tests in the group, class or school:
cluster/breakout apply scenario 6
.
6. Cluster/outbreak-out scenario: multiple staff and/or children tested positive or reported to the GGD with suspicion COVID-
19
○ The GGD in cooperation with the management of the children's centre / elementary school, carries out source and contact
research on the positive staff members and/or children.
○ Under the guidance of the IZB-doctor, the GGD in question starts an outbreak investigation to map out the situation at school.
○ The GGD advises the school on the provision of information to the parents.
○ Other staff members and children are registered whether they have complaints and whether they have been or can be tested.
Depending on the context, only the group/class or several groups/classes are questioned.
○ In case of an outbreak with > 3 confirmed children/adults, consider further outbreak diagnostics (and/or also whole genome
sequencing (WGS)).
○ Policy for children's centres/schools can be tailored to the results of the outbreak investigation.
Outbreak investigation and WGS:
○ Consider also testing asymptomatic children and staff in case of a large outbreak. GGD's can consult with the LCI to make a
choice.
○ Consider also to have WGS performed on all positive samples.
6th May 2020 HSRM
As of 6 May, tests will also be available for primary school teachers, child day care workers, and those with professions that require
https://www.rivm.nl/coronavirus-
physical contact.). Testing will be done after triage by a physician.
covid-19/testen
167
7.6.6 Precarious population
Date report(ed) and reference
Statement / definition
18th May 2020
As of 18 May, tests will also be available for informal carers and paid carers that are hired by a patient living at home
HSRM
(https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/richtlijnen/20 20/05/12/richtlijn-testbeleid-mantelzorgers-vrijwilligers-
palliatieve-zorg-en-pgb-gefinancierde-zorgverleners/Richtijnen+mantelzorgers+PGB+en+vrijwilligers.pdf). Testing is not available
upon request for individual citizens, and is only done after triage by a physician.
As of June 1st, all patients presenting
symptoms of COVID-19 can be tested.
7.7 Coordination and responsibility of testing and tracing
Date report(ed) and reference
Statement / definition
To monitor the effects of source and contact tracing the transfer of daily information from the electronic patient file (checkbox) to the
National Institute of Public Health and the Environment (Art 26 of the Public Health Act) is done and used already at the beginning
of the pandemics. In the electronic patient file the following data is reported (see section 1.5)
Since June 2020, according to the protocol,
Regional Health Services i.e. GGDs will perform
source and contact investigations
on all reported persons.
168
Colophon
Title:
INTERNATIONAL COMPARISON OF COVID-19 TESTING AND CONTACT TRACING
STRATEGIES
Authors:
Vicky Jespers (KCE), Ana Hoxha (Sciensano), Justien Cornelis (KCE), Lieven De Raedt
(FPS), Chris De Laet (KCE), Dominique Roberfroid (KCE), Sophie Gerkens (KCE)
Reviewers:
Nancy Thiry (KCE)
Validator for each country Tinne Lernout (Belgium), Sofieke Klamer (Belgium), Ilse Peeters (Belgium), Sara
document:
Dequeker (Belgium); Natalia Bustos Sierra (Belgium); Dan Brun Petersen (Denmark),
Bolette Søborg (Denmark), Francesco Maraglino (Italy), Patrizia Parodi (Italy), Oscar
Pérez Olaso (Spain), Berta Suarez Rodríguez (Spain), Fernanco Simón Soria (Spain),
Silvia Herrera Leon (Spain), Eline van Daalen (Netherlands), Anne-Ruthi Knevel
(Netherlands), Jerom Geffen (Netherlands), Ingrid Van Hattem (Netherlands).
No validation received from France nor Germany by July 16th 2020
Project coordinator KCE:
Nathalie Swartenbroekx (KCE)
At the request of:
Belgian Risk Management Group and Crisis cell FPS Public Health Belgium
Disclaimer:
This document is a rapid review of scientific literature retrieved from several publicly
funded COVID-19 resource collections. The literature included in these repositories is
not always peer-reviewed or externally validated. KCE synthesised the evidence in a
short time frame to respond to urgent questions and could therefore not follow its regular
methodological procedures. This work is used to inform guidance of other governmental
agencies (like Sciensano, CSS/HGR, AFMPS/FAGG and SPF/FOD).
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