Policy responses for Croatia - HSRM


Policy responses for Croatia

1.5 Testing

On 24 July, the Croatian Institute of Public Health revised its recommendations on priorities for SARS-CoV-2 testing as well as the procedure regarding close contacts of patients with COVID-19.

1. Procedure with close contacts of a COVID-19 patient

In order to reduce the spread of infection, the aim is to place all close contacts of the patient under medical supervision in quarantine/self-isolation.

Beginning of 14-day quarantine and exceptions in testing:
Close contacts do not need to be tested either at the beginning or during quarantine/self-isolation, unless they develop symptoms of the disease. There is one exception: at the beginning of quarantine/self-isolation, if close contacts of COVID-19 patients have been identified as close contacts three or more days after exposure to the patient and have in the meantime made contact with vulnerable groups, then should be tested.

End of 14 days quarantine and testing:
Upon completion of the 14-day quarantine, if people have not developed symptoms testing is not required unless they are health care workers, staff in nursing homes or any other institution within social welfare system.

If a person in quarantine/self-isolation develops symptoms of a disease compatible with COVID-19, they should be tested for SARS-CoV-2 and, if positive, proceed as a newly infected person.

2. Priority groups for testing are:
a. Symptomatic people who, due primarily to their occupation, have a high potential for spreading the disease to vulnerable groups (healthcare professionals and hospitalized patients, residents and employees of nursing homes)
b. Symptomatic people who, due to their characteristics, have a high potential for infecting a large number of people with a risk of rapid spread of infection and cluster formation (prisoners and prison staff, refugees and asylum seekers, homeless people, members of ethnic/cultural groups)
c. Symptomatic people at increased risk of severe disease and complications: people aged 65 and over, people with chronic diseases
d. Symptomatic persons in cases where a grouping of respiratory diseases is noticed in a health institution, which cannot be interpreted by any other etiology.
e. Health and other professionals at increased risk of spreading the infection among vulnerable groups with confirmed COVID-19 disease for the purpose of confirming their cure and the possibility of returning to work.
f. People who report to the health care system with symptoms of a disease compatible with COVID-19, which cannot be explained by another etiology.

As of August 10, there were 22 test sites in the Republic of Croatia performing RT-PCR analysis of collected samples of COVID-19. All processed samples are entered into a national platform at the Croatian Health Insurance Fund, and this is available to all county public health institutes. County public health institutes submit data on positive cases, sources of infection and hotspots as part of their daily reports to the Croatian Public Health Institute. The Croatian Institute of Public Health also collects information on hotspots, hospital treatment of COVID-19, COVID-19 patients on respirators, and on deaths.

As of September 21, 22 test centers are available in the Republic of Croatia (more information can be found at the following link: https://www.koronavirus.hr/svi-testni-centri-u-republici-hrvatskoj/763) 

As of September 21, the Croatian Institute of Public Health had revised their COVID-19 recommendations on SARS-CoV-2 testing priorities, contact monitoring, the end of isolation and self-isolation process. The changes compared to earlier versions are as follows: 
• release from isolation is based primarily on the clinical picture and exceptionally on the basis of negative PCR findings;
• isolation of an asymptomatic PCR-positive patient is shortened from 14 to 10 days after taking a swab that is PCR-positive (except in immunocompromised individuals);
• isolation of a patient with a mild or moderate clinical picture is shortened from a minimum of 14 to a minimum of 10 days from the onset of the disease (except in immunocompromised individuals);
• Isolation of a patient with a severe clinical picture (treatment requiring intensive care) or an immunocompromised patient (e.g. patients with chemotherapy malignancies, people receiving high doses of corticosteroids / immunosuppressive drugs due to their underlying diagnosis) regardless of the severity of the clinical picture lasts at least 20 days
• at the end of isolation, health professionals no longer need to have a negative PCR result of a swab before returning to work (except in immunocompromised individuals);
• upon completion of the quarantine for health professionals and social service providers, it is no longer necessary to have a negative PCR result of a swab before returning to work (except for immunocompromised persons);
• if a person has had laboratory-confirmed COVID-19 disease in the last three months, she or he does not need to be tested for COVID 19 if there are no clear symptoms of the disease.
• all measures relating to health professionals and employees of social service providers, apply equally to students who practice in these institutions and to any parents who reside with their child in the hospital

As of September 28, 24 test centers were available in the Republic of Croatia, representing an increase of 2 centers from the previous week. More information on all national test centers can be found at: https://www.koronavirus.hr/svi-testni-centri-u-republici-hrvatskoj/763

Testing is performed in the following situations:
• Suspected COVID-19 infection: people with clinical and / or epidemiological indication (according to ECDC definition)
• In certain cases asymptomatic people (close contacts of COVID-19 patients)
• In certain cases, people at the end of self-isolation and isolation (treatment) - for example, healthcare professionals before returning to work (negative finding is a condition for returning to work)
• In certain cases, people in nursing homes (mostly healthcare professionals)

A suspected case of COVID-19 infection is considered to be when the following criteria are met:
o Acute respiratory infection symptoms that occur in patients who have visited countries 14 days prior to symptom development
o Respiratory infection symptoms in patients that were in close contact with a probable or confirmed case 14 days prior to the symptoms
o Severe acute respiratory infection requiring hospitalization
Testing can be performed at the request of elected primary care physicians, epidemiologists or hospital clinicians (in the case of hospitalized patients).

COVID-19 ambulances are set up throughout Croatia for taking patient samples. They are established in all counties in the Republic of Croatia. In Zagreb they operate within health centers (primary physicians work there in shifts. For the first 14 days these were available around the clock; now they operate every day from 6 am to 8 pm.

A new testing method introduced on 31 March 2020 is drive-in diagnostics. The Andrija Štampar Teaching Institute of Public Health was the first in Croatia to introduce this type of testing.  The aim of the new test method is to speed up diagnostics and increase the number of tests. This method of testing means that people do not need to get out of their vehicles, which increases the safety of both the person undergoing the test and the health professional. The test is ordered by primary care physicians (https://www.koronavirus.hr/nzzjz-dr-andrija-stampar-prvi-u-hrvatskoj-uveo-drive-in-dijagnostiku-koronavirusa/355). The General Hospital Pula, the General Hospital Karlovac, the Health Centre Split-Dalmatia County (branch office Makarska), the Health Centre Dubrovnik-Neretva County (branch office Metković), as well as several health centres in Zagreb have also introduced drive-in diagnostics.

Some hospitals have provided special ambulances to enable them to conduct more frequent testing of health professionals on COVID-19.

Croatia has thirteen laboratories to which samples are submitted for analysis:
• University Hospital for Infectious Diseases “Dr. Fran Mihaljevic” (they first started testing)
• Teaching Institute of Public Health “Dr. Andrija Štampar”
• Croatian Institute of Public Health (started with testing on 14 March)
• University Hospital Centre Zagreb
• Clinical Medical Centre Osijek (from 1 April 2020)
• Clinical Hospital Center Rijeka
• University Hospital Centre Split (from 26 March 2020)
• Institute of Public Health of Osijek-Baranja County
• Institute of Public Health of Varazdin County
• Teaching Institute of Public Health of Primorsko-Goranska County (from 24 March 2020)
• Institute of Public Health of the Zadar County
• Institute of Public Health of the Split-Dalmatia County
• Institute of Public Health of the Istrian County

The results of the tests are available within 24 hours.