2. Ensuring sufficient physical infrastructure and workforce capacity
ENSURING SUFFICIENT PHYSICAL INFRASTRUCTURE AND WORKFORCE CAPACITY is crucial for dealing with the COVID-19 outbreak, as there may be both a surge in demand and a decreased availability of health workers. The section considers the physical infrastructure available in a country and where there are shortages, it describes any measures being implemented or planned to address them. It also considers the health workforce, including what countries are doing to maintain or enhance capacity, the responsibilities and skill-mix of the workforce, and any initiatives to train or otherwise support health workers.
2.1 Physical infrastructure
It was initially estimated that 136 inpatient facilities providing intensive care had 2 080 lung ventilators and 4 481 ICU beds; with 37% of ICU beds and 61% of lung ventilators being unoccupied as of March 22, 2020 (1). In the end of April, the reported ICU bed capacity was 4 148 ICU beds (38.9 per 100 000 people) and 1 968 lung ventilators (18.5 per 100 000 people) with a free capacity of 41% and 66%, respectively (2). There were in total 75 ECMO-equipped beds with 86% free capacity rate. With an estimated 10% share of COVID-19 patients requiring intensive care, the MoH estimated that the system could handle up to 30 000 COVID-19 detected cases. Beyond that, a plan was prepared to transfer standard beds into ICU alongside a staff redeployment. Originally, the MoH ordered providers to delay all planned care and non-acute treatment to open capacity for expected COVID-19 patients (3); this measure was relaxed by the MoH recommendation issued on April 14 in the effort to bring care provision for non-COVID patients back to standard levels (4). As of May 3, there were 299 COVID-19 patients in hospitals, including 58 severe cases (5). The inpatient facilities are obliged to report any change in their ICU beds capacity and occupancy on a daily basis (6).
Meanwhile, a nationwide scientific team, led by the Czech Technical University, Faculty of Biomedical Engineering, developed a new type of emergency mechanical lung ventilator called CoroVent, which was specifically designed for patients with respiratory failure due to COVID-19. As of April 22, CoroVent has passed all necessary tests required by the EU for use in hospitals. The research and preparation for its mass production is the result of the public initiative COVID19CZ, which included crowdfunding to finance production of the first 250 ventilators and the capacity to kickstart mass production in the thousands once the licensing process is finished. The University made the underlying design open source, including the temporary licence for open use (7). In late August, the CoroVent ventilator finally received American FDA EUA (Emergency Use Authorisation) certification (www.micomedical.cz).
Following the outbreak of COVID- 19 (end of February), there was a shortage of various types of personal protective equipment (PPE), caused by increased demand, general shortage in the market and low stockpiles of the State Material Reserves. The MoH banned free sale and export of FFP3 respirators and started their own price regulation (8); the sales ban was revoked on April 6 (9). The MoH also banned export of disinfectants for hand washing; this was later revoked as well. Stricter prescription regulation has been issued to safeguard Plaquenil stocks. The licensing of new medical devices and aids (associated with treating COVID-19 infection), including their development, approval and permission to produce, has been accelerated. This includes approval of newly developed respirators and ventilators, as well as the permission to produce disinfectant solutions for distilleries, universities and others. Fast-track approval by the State Institute of Drug Control also was taken for Remdesivir allowing for its administration in the CZ. Temporary suspension of certain alcohol regulations by the state in the spring, which allowed for quick and necessary production of disinfectant solutions, expired in early September. Now, producers can continue to make disinfectants under their own brand names, but they have to abide by the full-scale alcohol-handling regulations of the state.
Since March 4, PPE was purchased centrally by the MoH and Ministry of Interior based on government resolutions. An airlift was established between CZ and China on March 20, arranging for more than 25 aircraft with PPE to arrive (as of April 14) (10). After the end of the State of Emergency, the Administration of State Material Reserves was supposed to manage the centralized PPE purchasing, including standard public procurement. The Government also signed purchase contracts with some domestic producers, including the Czech Technical University and the start-up company TRIX Connection to produce a new type of FFP3 respirator. These contracts are expected to lower CZ dependency on the import of respirators in the near future.
In the beginning of March, testing for COVID-19 was carried out only by the National Institute of Public Health. The number of certified labs has been gradually increasing, including private labs (by March 9). By the second week of March there were 13 facilities testing suspected cases (11). At that time there were several problems with testing capacity, lab capacity, as well as overloaded public health authorities (12, 13). As of April 27, there were 97 laboratories performing tests for COVID-19 with the current capacity for daily testing estimated to be close to 10 000 tests, above the number of tests on average performed on weekdays in early summer (range was between 6 500 and 8 800) (14). As of May 4, sample collecting points and laboratories declared enough capacity and mostly no waiting lines.
Most of the central purchasing of PPE was terminated with the end of the state of emergency. Since then, only the equipment for organizational bodies of the state has been provided centrally and the responsibility was moved from the Central Crisis Staff to the Administration of State Material Reserves (Správa státních hmotných rezerv). Furthermore, the Administration of State Material Reserves is now also responsible for increasing stocks of PPE in order to be better prepared for potential future crises.
In early September, with the surge of a second infection wave, the government provided five face masks and one FFP2 respirator per person to all aged 65+; the Czech Post Office (Česká pošta) was charged with the distribution.
As the need for testing decreased in early summer, collection points for testing samples were closed in May and June rather arbitrarily, similar to how they popped up at the beginning of the first outbreak. The National COVID-19 Testing Strategy, presented as draft for expert consultation in mid-August, aims to define a laboratory and sample collection points network to be accessible throughout the country, based on the current epidemic situation at any given time. The strategy is not yet finalized. Sample taking capacities started to increase again with the reinstallation of collection points in big hospitals in late July (Prague) and then early September (throughout the rest of the country in addition to Prague). On September 15, there were no reported shortages in laboratory capacities. There are two new tools in place that help the situation: first, the Covid Forms App that, among others, gathers data from laboratories, sample collection points and public health authorities. Second, CovIT, a laboratory information system provides electronic administration of samples, including digitally signed proofs of testing and the results.
On September 18, there were 126 sample collection points across the country, including 22 in Prague. People were queuing for up to a few hours at most places, with free registration slots available only 2 or more days in advance (for Prague). Opposition party MPs have proposed to include pharmacies as sample collection points to increase capacity. This would require changes in legislation that they call on the government to enforce quickly. If successful, pharmacies could also join as sample collection points by early October.
Some serious deficiencies in contact tracking capacities became obvious in early September. For details, see section 1.4 Monitoring and Surveillance.
(3) Ministry of Health Extraordinary Measures issued on March 16, 2020 (MZDR 12066/2020-1/MIN/KAN) and March 19, 2020 (MZDR 12312/2020-2/MIN/KAN)
(4) Ministry of Health recommendation for healthcare providers, issued on April 14, 2020 https://koronavirus.mzcr.cz/doporuceni-poskytovatelum-zdravotni-pece/
(5)https://onemocneni-aktualne.mzcr.cz/covid-19 . Accessed May 4, 2020.
(6) Ministry of Health Extraordinary Measure on intensive care capacity reporting, issued on April 8, 2020 (MZDR 15190/2020-6/MIN/KAN)