Policy responses for Bulgaria - HSRM


Policy responses for Bulgaria

3.2 Managing cases

First points of contact for patients who experience COVID-19 symptoms are GPs, emergency care centres or the RHIs. Patients need to first call their GP or the respective RHI or, in case of emergency, to call 112. There is a national 24-hours telephone line for citizens and organization for information and consultations on COVID-19, announced on the MoH website.

An Order issued by the Minister of Health on March 16 regulates isolation and treatment at home and hospitalization and provides criteria for mild cases (including temperature <38 oC and without chronic diseases and immunocompromising conditions).

Asymptomatic patients and patients with mild symptoms without chronic conditions self-isolate and are treated at home. All patients aged 60+ regardless their condition, as well as chronic patients, patients with moderate and severe symptoms, and those who cannot be isolated at home are subject to compulsory hospitalization. Patients with 2 negative tests in 24 hours are considered recovered but still subject to quarantine at home for 28 days.

There are recommendations based on the WHO guidelines home treatment of COVID-19 patients and the protocol for treatment of the novel coronavirus pneumonia (NCP). The Medical Expert Council to the Council of Ministers, which was established on March 24 to prepare algorithms and guidelines for diagnostics and treatment of COVID-19 patients, presented a 400-pages report and medical guidelines on April 3rd. The report was intended for physicians only and it is not publicly available. This was criticized by medical specialists as well as the overall activity of the Council.
The National Centre of Infectious and Parasitic Diseases (NCIPD) issued a procedure for disinfection of public places such as bus stops on March 13.

On May 14, the Minister of Health issued an order authorizing hospital treatment of COVID-19 patients with Hydroxychloroquine Sulfate Tablets 100 mg and Azithromycin Dispersible Tablet 250 mg. The usage of these medicines should be based on guidelines with therapeutic algorithms, prepared by the Medical Council following the recommendations of the WHO and the European Medicines Agency.

As of May 14, one negative PCR-test is required for hospital discharge. After hospital discharge, patients are subject to compulsory 28-days home quarantine. The quarantine for both discharged from hospitals patients and for those treated at home can be terminated after one negative PCR-test.

At the end of April, new treatment of severe COVID-19 patients with blood plasma was initiated in the Military Medical Academy, which have shown positive results.

Since mid-October, patients aged 60+ (regardless their condition) as well as chronic patients, patients with moderate and severe symptoms and those who cannot be isolated at home are no longer subject to compulsory hospitalization. Hospital discharge requirements were changed as well. No negative PCR test is required and patients can be discharged based on the attending physician’s assessment on improvement in the patient’s condition. Patients who need follow-up medical care in a healthcare establishment or cannot be isolated at home from family members belonging to risk groups should be hospitalized at least ten days following the first COVID-19 symptoms and three days more without symptoms. The quarantine period after hospital discharge was reduced from 28 to 14 days. Patients treated at home are also subject to 14 days of quarantine. Quarantine is terminated with the end of this period and no negative PCR is required for this purpose. Contacted people are subject to 10-days quarantine, which is considered terminated if no symptoms appeared.

In November, triage centres to specialized outpatient clinics were established to serve suspected COVID-19 patients. This happened after an amendment to the National Framework Contract. Diagnostic-consultative centres currently receive additional fixed monthly payments from the NHIF for consulting and testing (with rapid antigen tests) patients with COVID-19 symptoms. The aim was to decrease pressure on GPs and to regulate patient flows. Patients with positive antigen test results are however not officially registered as COVID-19 patients. Due to the much lower price of antigen tests compared with PCR tests, their availability and the fact that patients with positive tests are not subject to compulsory 14-days isolation, citizens tend to use them broadly. Some data suggest that 20 to 40% of all antigen tests are positive, which suggests much higher prevalence of COVID-19 than the official statistics show.

Since the beginning of December, positive antigen tests can be a reason for issuing a referral for a PCR test covered by the NHIF. GPs are thus allowed to issue referrals for PCR tests if patients have at least two of 11 symptoms or a positive antigen test. A new system for electronic referrals was introduced for this purpose.

According to the Minister of Health, algorithms for treatment of patients with Remdesivir are provided to all physicians, however they are not compulsory. Announcements in the press disclosed that at national level, all necessary quantities of Remdesivir and low-molecular-weight Heparin, which is also used for treatment of COVID-19 patients, are available.

Sources and links:
Ministry of Health, COVID-19 Information for citizens and medical professionals;  http://www.mh.government.bg/bg/informaciya-za-grazhdani/informaciya-otnosno-noviya-koronavirus-2019-ncov/ 
bTV news; https://btvnovinite.bg/bulgaria/kompleksen-dokument-shte-pomaga-na-medicite-ni-v-borbata-s-covid-19.html