Policy responses for Denmark - HSRM


Policy responses for Denmark

1.5 Testing

People with relevant severe symptoms are referred to testing. This ”conservative” testing strategy is gradually being replaced by a more “aggressive” strategy. As of March 2, the criteria for testing were changed to include the following (guidelines from the Danish Health Authority):
• Citizens in specific risk groups – elderly citizens and chronic care patients can be referred to testing when presenting mild symptoms.
• Pregnant women and infants with mild symptoms may also be tested
• Employees in health care, elderly care and social care can also be tested even with mild to moderate symptoms.

Further guidelines were issued on 24 March: testing can be requested/approved by the patient’s own doctor. Emergency services (by phone) can refer patients to hospitals and test. Hospital doctors can also refer admitted patients to test. COVID-19 testing occurs in specialist settings in tents outside hospitals and there are also some drive-through test facilities. The test is done using PCR machines. Laboratory capacity is sufficient, but there is a shortage of some of the supplies needed for the test machines (plastic trays, chemical substances, pipettes). The Danish strategy has therefore been relatively restrictive in terms of the number of tests performed.

A total of 912 persons were tested from 27 Jan to 7 March. Since 8 March, the daily number of people tested has been below 1,000 except for a peak of 1,800 on 19 March  and close to 1,200 on 18 and 19 March. From 30 March the aim is 5,000 tests per day (https://www.dr.dk/nyheder/indland/danske-virksomheder-har-tilbudt-corona-hjaelp-i-en-uge-nu-raekker-myndighederne). The Danish Health Authority has signaled that it expects the daily number of tests to increase to 5,000-10,000 with the recent strategy change, depending on the availability of test kits, etc.

New guidelines for COVID-19 testing are available since April 1 (https://www.sst.dk/da/Udgivelser/2020/Retningslinjer-for-haandtering-af-COVID-19). After critizism from experts and media for not providing a sufficient number of COVID-19 tests, health authorities have decided to increase the numbers dramatically by offering testing to a larger group of persons after referral from the general practitioners. The following groups with mild symptoms are now considered suitable for testing:
• persons who are in close contact with special riskgroups
• persons with chronic diseases
• persons who due to social or behavioural problems or their housing situation are not easily able to follow recommendations for isolation
• persons who have been in close contact with confirmed COVID-19 infected individuals
• persons with key functions in society.
Health professions and staff involved in social care for vulnerable groups may attend testing facilities directly without GP referral.

From April 20, testing is offered to anyone who has symptoms of COVID-19 (https://www.dr.dk/nyheder/indland/heunicke-med-ny-strategi-nu-skal-alle-med-symptomer-testes). This is initiated since Denmark has sufficient (and vacant) testing capacity, and since the Danish Health Authority has declared that testing is essential to stop the chains of infection.

On April 21, the Danish Health Authority published new guidelines for testing, in order to achieve a much better overview of the prevalence of COVID-19; from April 21, persons in these groups may be referred to test:
- Citizens with mild symptoms of COVID-19
- Citizens in close contact with a confirmed diagnosis of COVID-19
- Patients who presumably will be hospitalized for 24 hours or more
- Out-patients who presumably will undergo one or more procedures which constitute a serious risk of exposure to COVID-19
- Inhabitants and personnel in institutions where one or more inhabitants or employees have a conformed diagnosis of COVID-19

From May 4, guidelines for testing in hospitals, nursing homes and other assisted living facilities have been updated. Staff and citizens with a negative test are henceforth to be retested after 7 days (https://www.sst.dk/da/Nyheder/2020/Opdaterede-retningslinjer-for-sundhedsvaesenet

By September 22, 3,442,785 COVID-19 tests have been performed  (https://experience.arcgis.com/experience/aa41b29149f24e20a4007a0c4e13db1d).

The parliament’s agreement on April 17 on extending the previously announced Phase 1 of the re-opening of society (see Exit Strategy: Measures in other sectors) partly builds on an understanding that the Statens Serum Institut (SSI) will prepare an integrated test-strategy, including health care personnel and vulnerable groups to improve information on the incidence and prevalence of COVID-19.

April 22: The regions have established temporary test facilities away from hospitals (including in public parks), and the Danish Health Authority published new indications for testing:
Patients with symptoms (immediate implementation)
- Patients with mild respiratory symptoms will be referred directly to test for SARS-CoV-2 after evaluation by phone by the patient’s GP or acute out-of-hours-service
- Health care personnel (including long-term care and home care) with mild respiratory symptoms. Self-referral directly to test for SARS-CoV-2 after discussion with the employee’s manager
- Patients with moderate-serious respiratory symptoms for evaluation and test (after evaluation by phone by the patient’s GP or acute out-of-hours service)
Estimated test activity: Approx. 6,000 patients/weekday. Presumably a smaller test activity on weekends and on public holidays.*

Persons without symptoms to be tested to reduce the risk of further spread of the disease (fully implemented by April 27 2020)
- Asymptomatic inhabitants of nursing care homes (and other institutions) as well as front line nursing home personnel in case of infection among inhabitants or colleagues
- Patients expected to be hospitalized for 24 hours or more, independently of the patient’s condition (referral by the hospital)
- Patients – independently on the patient’s condition – who are going to attend certain procedures at a specialist, a dentist or an out-patient clinic at a hospital (referral by a specialist, a dentist or a hospital)
Estimated test activity: Approx. 6,000 patients/weekdays on weekdays. Presumably a smaller test activity on weekends and on public holidays*.

Asymptomatic persons tested to prevent further spread of the disease (to be implemented as soon as possible)
- Close contacts of a person with confirmed COVID-19 on day 4, 6 or 8 after contact
Estimated test activity: Approx. 15,000 patients/weekday. Presumably a smaller test activity on weekends and on public holidays.*

Possible new indications for test
- Systematic, standardized test of asymptomatic employees in the health care sector, including nursing homes, other social institutions, the probation services’ half way houses, etc., who work with people in increased risk, including patients in ongoing immunosuppressive treatment (cancer, chronic inflammatory diseases, organ transplantation, etc.), innate or acquired compromised immune system (premature newborns, certain hematological diseases, severely uncontrolled diabetes), immobile persons (secure institutions, people with handicaps, elderly people, etc.) and other certain groups in increased risk (especially elderly people > 80 years).
Estimated test activity: Approx. 15,000 patients/weekday (highly uncertain estimate)*.

*: Estimates in need of regular revision.

The Danish Health Authority has emphasized the need to prevent outbreaks of COVID-19 in nursing homes

April 28: The Danish Health Authority has published new guidelines for testing women giving birth in hospital. They will now all be tested independent of the duration of their hospital stay (https://www.sst.dk/da/Nyheder/2020/Retningslinje-for-graviditet-og-foedsel-er-revideret).

April 29: The Danish Health Minister has announced plans to be implemented over the next couple of weeks for a new strategy on testing in order to limit new infections. All individuals who are tested positive for COVID-19 infection will be asked to track down recent contacts with other persons that they may have infected and these will then be offered testing 4, 6 and 8 days after the day of the contact (https://www.dr.dk/nyheder/indland/coronasmittede-skal-selv-opspore-kontakter-vi-skal-undgaa-skjulte-smittekaeder).

May 12: The Danish Health Authority published an updated strategy for testing and contact tracing. In contrast to previous plans on this regard, it will now be the responsibility of public authorities to assist in tracking and contacting close contacts to persons tested positive for COVID-19. Close contacts will be offered to be tested on day 4 and day 6 of the initial contact. Close contacts will be urged to enter into self-isolation until they have received a negative result of the testing. The government will provide capacity for those that are unable to self-isolate at home, e.g. in hotels (https://www.sum.dk/Aktuelt/Nyheder/Coronavirus/2020/Maj/Offensiv-national-teststrategi-sikrer-trygt-genaabning-af-Danmark.aspx).

Besides, the government announced on May 12 a new agency for coordination of capacity in testing and provision of personal protective equipment. The agency will be operational from August.

The government published more details about the new test strategy. The strategy now contains two "tracks" for testing:
-Track 1 (“the health care track”): testing of referred citizens with COVID-19 symptoms, citizens in hospitals and health care personnel (this track is organized by the five regions)
-Track 2: ("the societal track"): testing of asymptomatic "close contacts", citizens selected for random sample testing, social care personnel, etc. This track is organized by national authorities and takes place in temporary COVID-19 test facilities in 16 locations throughout the country.

The "health care track" precedes “the societal track” in case of resource limitations.

May 15: A majority of the parliament agreed to develop an app in a public-private partnership. The app will track citizens who voluntarily decide to use the app, and if a citizen using the app is diagnosed with COVID-19, all citizens who have been close to the patient will be informed that they may have been exposed to COVID-19, but the identity of the patient will not be revealed to them. The app was implemented on June 18. (https://www.sum.dk/Aktuelt/Nyheder/Coronavirus/2020/Maj/Politisk-aftale-om-frivillig-smittesporingsapp-for-covid-19.aspx). By June 28, the app has been downloaded 563,000 times. In total, 85 persons have registered themselves as infected with COVID-19 using the app (https://www.dr.dk/nyheder/indland/85-personer-har-meldt-sig-smittet-i-corona-app-efter-godt-en-uge). By September 7, the app has been downloaded 1,241,488 times. In total, 904 persons have registered themselves as infected with COVID-19 using the app.

May 18: In order to increase testing of the population, all citizens may get tested (in “the societal track”) without a referral – a citizen who wants to get tested for COVID-19 may make a reservation on a website: https://www.coronaprover.dk/Account/NemIdLogin?RequestPath=%2F  
This has been fully implemented by May 25 based on a daily testing capacity up to 50,000 tests. Citizens with symptoms must still call their GP to be referred to a test at a hospital (“the health care track”) (http://sum.dk/Aktuelt/Nyheder/Coronavirus/2020/Maj/Alle-borgere-faar-mulighed-for-at-blive-testet-for-COVID-19.aspx).

May 20: The Danish Health Authority revised its guidelines on testing at nursing homes: more citizens who have been in close contact with infected persons at nursing homes must be tested, and if a test of a person is negative, the test must be repeated one week later to establish, whether the outbreak is under control.

May 26: Blood banks discontinue temporarily Covid-19 antibody testing among blood donors due to the low precision of the newly delivered test equipment
30 May:  If requested by the authorities, corona-infected citizens must declare with whom they have had contact in order to contribute to the containment of the infection. Resistance to do so will result in a fine. The rule applies to anyone who has been found infected from May 20. The rule is set to expire on October 31, 2020 (https://www.retsinformation.dk/eli/lta/2020/746).

June 10: A minor adjustment to the strategy for tracking COVID-19 infected persons was announced on June 10. - Henceforth the Danish Patient Safety Authority will contact all infected persons with an offer to assist in tracing and contacting close contacts. - https://stps.dk/da/nyheder/2020/nu-intensiveres-kontaktopsporingen-af-naere-kontakter-til-covid-19-positive/ - (This is an example of a behavioral public policy initiative whereby infected persons are "nudged" to engage in tracing and contacting through a change in the decision architecture).

June 16: The Danish Health Authority published revised guidelines on testing of close contacts (https://www.sst.dk/da/Nyheder/2020/Retningslinjen-for-smitteopsporing-af-naere-kontakter-er-opdaterede). 

June 17: The app agreed upon on May 15 (see above) was presented: “Smitte|stop” (Infection|stop’). If a citizen downloads the app on his/her mobile phone, the app registers which phones the citizen is in close contact with, and if the citizen is diagnosed with COVID-19 and registers this finding in the app, the other users of the app, who have been close to the citizen, will receive a warning that they may have been exposed to COVID-19 (specifically: if a device has been closer than one meter to the device belonging to the citizen diagnosed with COVID-19 for more than 15 minutes less than two weeks before the diagnosis, the owner of the device will receive a warning). The other citizens will not be informed which person was infected, and the information that a citizen was infected will be automatically validated by the national patient registry, before the other citizens receive the warning. Due to privacy and data protection concerns, there is no centralized storage of data from the app.

June 30: As part of the surveillance of the epidemic and the protection of the most vulnerable citizens at risk of being seriously ill from COVID-19, the government, the Danish Regions and Local Government Denmark (KL) have agreed on a systematic testing of nursing staff working at nursing homes and in home care) in all the municipalities. The frequency of the tests will be adjusted according to how widespread the infection is in each municipality. The new test system will be implemented in addition to the open test offer that nursing staff already have access to, and it will be done with a new setup, which will make it much easier to be tested at the workplace. In those municipalities that exceed a certain level of infected population, the testing program will be immediately implemented. For the other municipalities, the system will be ready by the end of August (https://sum.dk/Aktuelt/Nyheder/Coronavirus/2020/Juni/~/media/Filer%20-%20dokumenter/2020/Aftale-mellem-regeringen-KL-og-DR-om-model-for-test-af-personale-paa-plejehjem-og-i-hjemmeplejen.pdf).

On July 2, the Government decided to pause the representative study of the development of the coronary infection in the population (part of “the societal track”) since the purpose of the study was not achieved due to very low participation rates (https://files.ssi.dk/PCR-undersoegelsen_24_6_2020_2).

From August, it is planned that a representative sample of the population will be asked to be tested for both actual COVID-19 infection and COVID-19 antibodies (https://www.dr.dk/nyheder/politik/ny-model-coronatest-skal-fa-flere-borgere-til-melde-sig), on the assumption that it will be possible to achieve a higher participation rate.

On July 9 the Danish Health Authority published three revised leaflets to citizens with symptoms of COVID-19, citizens who had tested positive, and close contacts

July 30: The Ministry of Health reported that the app Smitte|stop has been downloaded 824,000 times, and that 209 citizens have registered in the app that they are infected with COVID-19 virus (whereupon the app notified other users of the app who have been in close contact with the infected users). According to a survey by the SSI of citizens who booked a test for COVID-19 from July 7 to July 28 (response rate: 56%), at least fourty-eight citizens booked a test because they had been notified by the app that they had been in close contact with a person who had tested positive for COVID-19. Fourty-six of the 48 citizens had not been in touch with the Danish Patient Safety Authority’s contact tracing unit –indicating that the app identifies citizens in increased risk of COVID 19-infection, who would not have been identified as early by other means

August 25: The health authorities have updated their guidelines for testing and sending home teachers and pupils in in case of infections in schools. The recommendations suggest different measures according to the physical distancing in the actual school (more or less than one meter). In the first case, close contacts should be identified, sent home and tested according to the general rules for close contacts and the whole class/group just tested once, whereas in the latter case, all pupils and staff in the class/group are considered close contacts and should be tested and sent home according to the general rules for close contacts to infected persons

By August 26, a new technical solution made it possible for parents to access their children’s test results electronically through sundhed.dk without calling their GP
By September 9, in order to be tested at the Copenhagen Airport test center, which is one of the few places where you can be tested without having booked an appointment in advance, because it is designed so travelers can be tested directly on arrival in Denmark, persons will have to show airline tickets. This is a consequence of a survey among 1,500 persons showing that two-thirds of those who have been tested at the airport have not been travelers (https://www.dr.dk/nyheder/indland/slut-med-springe-testkoeen-over-nu-skal-der-vises-flybilletter-blive-testet-i).

September 9, The Minister of Health has proclaimed an increase of test facilities: the test capacity at Copenhagen Airport will be increased, and new test centers will be set up around Copenhagen this weekend as a results of long waiting times for corona tests (https://www.dr.dk/nyheder/indland/lang-koe-til-coronatest-der-er-ikke-kapacitet-til-alle-lader-sig-teste-foer-hver).

On September 17, The Health Authorities have published a slightly revised version of the guidelines for handling cases of infections in schools and other educational institutions. The publication now more clearly emphasizes that in a situation with just one case in a class, it is not required to send the whole class home, but only those who have been in close contact with the case. The same rule should be followed when one member of the staff is infected (https://www.sst.dk/da/Nyheder/2020/Opdaterede-retningslinjer-tydeliggoer-hvad-man-goer-ved-enkelttilfaelde-af-smitte-hos-boern-og-elever).