Policy responses for Estonia - HSRM

Estonia


Policy responses for Estonia

3. Providing health services effectively

The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.

3.1 Planning services

Health care providers started to increase their preparedness after the health system preparedness level was raised to level 2 (of 3 levels) on 13 March.

Ambulance care providers have activated additional teams to only interact with COVID-19 patients. The functions of these teams includes taking tests, as well as providing transport for patients referred from local level hospitals to higher levels. Ambulance care providers prioritize urgent patients with life-threatening conditions, and refer other patients to primary health care (PHC).

Hospitals have been increasing their capacity by repurposing wards to accommodate COVID-19 patients and expanding intensive care units by reassigning staff and opening additional beds.

Elective inpatient and outpatient care was stopped on 17 March until 30 April 2020 and only continues for those patients whose health situation does not allow for postponement of the treatment. The decision about continuation of the treatment is made by the treating doctor. As of 26 March, dental care and private clinics can only provide emergency services.

PHC providers have postponed elective care to increase capacity for urgent patients. PHC and outpatient specialist care providers have increased consultations via telephone, email or alternative digital channels and Estonian Health Insurance Fund have introduced online-consultations as a new service. Also, sick leave notices are possible to open at PHC digitally.

All health care providers are ready to relocate and start to operate in another location.

Despite the emergency situation and regulation to postpone elective and non-emergency care, the North Estonian Medical Center, one of the two biggest hospitals in Estonia, has continued to provide some elective and non-COVID-19 services. The hospital reports that due to the rapid response to COVID-19 at the beginning of the emergency, the hospital was able to collaborate well with patients and partly rearrange their service provision to remote appointments. This has ensured a similar level of service provision in March 2020 as compared to earlier years. The East-Tallinn Central Hospital has announced that  more outpatient (virtual) appointments in urology will be available. There may be other similar experiences from other service providers, but these have not been reported.
Source: https://www.koroonakriis.ee/regionaalhaigla-jatkas-martsis-aktiivselt-plaanilist-ravi

COVID-19 vaccines

On 15 December 2020, the Government approved the COVID-19 vaccination plan, which was renewed on 19 January 2021.

Vaccination in Estonia will be voluntary. The main objectives of procuring the COVID-19 vaccine and enabling the Estonian population to be vaccinated are: 1) to protect the most vulnerable groups of people, ie risk groups, who are more likely to be infected or for whom the disease may be particularly dangerous; 2) to protect essential workers in order to ensure the normal functioning of society; 3) to reduce and prevent deaths caused by COVID-19 and 4) to provide the opportunity to vaccinate also those Estonian residents who do not belong to the vaccination target group, but who want to be vaccinated.

The European Union's common vaccine portfolio includes vaccines from a total of eight vaccine manufacturers (Pfizer / BioNTech, Moderna, AstraZeneca, Janssen Pharmaceutica NV and CureVac, Sanofi, Novavax, Valneva).

So far, Estonia has joined the EU COVID-19 vaccine joint procurement with five pre-purchase agreements: Pfizer / BioNTech, Moderna, AstraZeneca, Janssen Pharmaceutica NV and CureVac, and has made a decision in principle to join the agreements of the vaccine manufacturers Novavax and Valneva. Estonia can purchase a total of 4,558,810 doses of vaccine for 2,429,405 people.

The first COVID-19 vaccine (Pfizer and BioNTech vaccine Comirnaty) received EU marketing authorization on 21.12.2020. The first doses of Comirnaty vaccine arrived in Estonia on 26.12.2020. The first vaccinations were performed 27.12.2020 in hospitals, ambulances and family medicine centers.

The vaccine manufacturer Moderna was the second to receive an EU marketing authorization on 6.01.2021. The first doses of vaccine arrived in Estonia on 13.01.2021.

The vaccine manufacturer AstraZeneca and Oxford received EU marketing authorization on 29.01.2021 and the first doses of AstraZeneca vaccine arrived in Estonia on 07.02.2021.

The following quantities are planned for Estonia:
• 1,330,000 doses from the AstraZeneca pre-purchase agreement; As of 20.02.2021 Estonia has received 33,600 doses and expects to receive a total of 59,470 in February and 119,762 in March.
• 300,000 vaccine courses from Jannsen Pharmaceutica NV's pre-purchase agreement;
• 603 876 doses + 350 000 additional doses (additional dose negotiations are ongoing) from the Pfizer / BioNTech pre-purchase agreement; As of 20.02.2021 Estonia has received 83,070 doses and expects to receive a total of 47,970 doses in February and 70,200 in March
• 234,467 doses from Moderna's pre-purchase agreement; As of 20.02.2021 Estonia has received 4,800 doses and expects to receive a total of 8,400 doses in February and 19,200 in March.
• 659,383 doses from the Curevac pre-purchase agreement.

Vaccine manufacturers have agreed to deliver the vaccines to the central office of the Health Board, which will ensure the necessary conditions for storage (incl. particularly low temperatures and compliance with cold chain requirements). The Central warehouse provides the necessary conditions for storage of vaccines (-90C to +8 ͦC). Vaccines are stored in and distributed from the central warehouse of the Health Board according to the vaccine distribution plan and vaccine orders.

Vaccination providers do not need to create special conditions or acquire additional resources for the storage of vaccines. Even the most demanding COVID-19 vaccines can be stored for up to five days under normal storage conditions (+2 ͦC to +8 ͦC).

A package with important information for the vaccine will be distributed to the vaccination providers from the central warehouse with leaflets in both Estonian and, if necessary, Russian. If needed, syringes, needles and solvents for administering the vaccine are also provided.

Intra-Estonian transport to vaccination sites takes place according to the orders of the vaccinators and at the temperature prescribed by the vaccine manufacturer (generally between +2 ͦC and +8 ͦC, but also -25 C to -15 ͦC can also be provided). Transport is organized by the Health Board. If there is availability at the vaccination site to store vaccines at low temperatures, it is possible to arrange transportation to the vaccination site also at -90 C to -60 ͦC.

The vaccinator specifies the number of people to be vaccinated and agrees on vaccination times for the coming week and submits an order to the Health Board. The order must be submitted at least three working days in advance of the planned start of vaccination and the minimum order size will be specified according to the vaccine.

The initial vaccination plan stated that Estonia will start by vaccinating  health and care workers, people working in healthcare institutions, residents of care institutions (around 55,000 people), the elderly (older than 70 years) and people with certain chronic diseases (around 260,000). There are slightly more than 300,000 people in the COVID-19 risk group in Estonia. After that, it was planned to make vaccination available to areas that are critical for the functioning of the society, including people who have higher risk due to their work or who are essential workers (at least 35,000 people). The third stage is to open the vaccination to all Estonian residents who wish to vaccinate.

The initial target groups were changed in a renewed vaccination plan in 19.01.2021. Estonia's objectives for COVID-19 vaccination coverage are:
• to vaccinate all healthcare workers by the end of February; and employees and residents of welfare institutions by the end of March; By 20.02.2021 all healthcare workers who work in hospitals, primary healthcare centers, ambulatory healthcare, and most of the workers in dental care and pharmacies, who wanted to get the vaccine when they were asked in the first round have received them (77% of physicians, 80% of GPs, 60% of nurses and 61% of midwives have received at least one dose by 22nd of February). The first round (all who wanted to be vaccinated when asked) of vaccinations in welfare institutions is almost finished.
• to vaccinate all people at risk by the end of April; All GPs should receive the vaccine to vaccinate risk groups in the middle of March. By the 22nd of February 9.5% of people at risk had received at least the 1st dose of vaccine.
• to make vaccination available to all from May;
• to achieve at least 50% of adult coverage by the end of October.

Priority target groups for COVID-19 vaccination have been defined for the Ministry of Social Affairs Advisory Committee on Immunoprophylaxis.

In the first instance, vaccination is provided to healthcare workers and welfare services providers and people with high risk. These are:
• health care workers and people working in health care institutions - about 30,000 people;
• employees and residents of welfare institutions - approx. 25,000 people;
• all people over the age of 70 and / or people with certain diagnoses - about 360,000 people.

The National Expert Committee on Immunoprophylaxis has identified the diseases and conditions that cause the person to be at risk. Preliminary list of diseases and conditions were specified in early 2021 in collaboration with GPs. As a result, the initial target audience changed the number of people covered.

The Immunoprophylaxis Commission approved the principles compiled by the Estonian Society of General Practitioners for the risk groups and the order in which persons belonging to risk groups are invited to be vaccinated. This depends mainly on age and a defined set of conditions. For example the priority according to age groups is as follows:
• all people aged ≥80 years;
• people ≥70 years of age who have diseases and conditions that have a very high or high risk based on their previous medical conditions;
• all people ≥70 years of age, regardless of comorbidities, and 16-69 years of age people with diseases and conditions that put them at a risk or very high risk;
• people ≥60 years of age who have diseases and conditions that have a very high or high risk based on their previous medical conditions;
• people between the ages of 50 and 59 who have the diseases and conditions that make them high risk;
• people aged ≥16-49 years who have the diseases and conditions that make them high risk.

The government decided on 04.02.21 that the AstraZeneca coronavirus vaccine will only be administered to people aged 70 and lower. On 7 February, the first shipment of the AstraZeneca COVID-19 vaccine arrived in Estonia, consisting of 7,200 doses.

In the week of 15 February, vaccination centres commenced the vaccination of the employees of educational institutions with the AstraZeneca vaccine.

On 16 February, vaccination commenced for frontline workers who are responsible for ensuring internal security (such as employees of the Rescue Board and the Police and Border Guard Board, plus volunteer rescuers and assistant police officers) with the AstraZeneca vaccine. In March the vaccination of social welfare workers in local governments is planned to take place.

If, in the opinion of the family doctor, there are people on his / her list who do not have the diseases described defined to cause high risk, but definitely need to be vaccinated due to their medical condition (eg rare disease patient or for any other justified reason), the GP may also vaccinate them as a matter of priority.

Once a critical part of the previous target groups have been given the opportunity to be vaccinated, it will be permitted to vaccinate also for the most important areas for the functioning of society. These are:
• High-risk frontline workers - to be specified by mid-February 2021 in cooperation with ministries, local governments and other parties;
• providers of vital services (within the meaning of the Emergency Act) - approximately 35,000 people.

The Estonian Health Insurance Fund has said that vaccines will be available to all people who have health insurance and also to those who do not have it including non-Estonians who have lived in Estonia for a longer time. People who do not have health insurance but do have a GP will be contacted by their GP when the time comes. People who do not have a GP can contact their closest GP or primary healthcare center to ask for a vaccine when they belong to the group who is being vaccinated.

Since the vaccination lists are based on Estonian Insurance Fund medical records data, it may underestimate the number of high risk patients who have received care outside of Estonia or whose care has not previously been covered by the insurance fund.

The primary vaccination sites will be hospitals, primary care providers, elderly care homes, workplaces, and infectious disease clinics or vaccination locations. Vaccination sites for specific groups include:
• Healthcare professionals and people working in healthcare facilities: generally vaccinated in hospitals, GP centers and ambulances.
• Welfare institution staff and residents: usually vaccinated by a nursing service provider or family doctor in institutions on site.
• At-risk groups: generally allowed in family doctor centers, but if any person at risk due to his or her state of health is hospitalized, he or she may be offered vaccination in a hospital.
• Critical service providers, frontline workers and other workplace-based target groups: the vaccination is conducted in the workplace, if conducted by health care providers who have passed specific training and other health care providers including private health care providers are used;
• General population: Vaccination will be carried out in family doctor centers, infectious disease clinics, vaccination rooms and, if necessary, additional vaccination sites. Vaccination will also be provided in mobile vaccination centers provided by the private sector, which will likely open in May.

In addition to stationary vaccination places there are also 4 mobile units (3 in public and 1 in private sector).

Vaccination can be done by doctors, nurses and midwives who have undergone immunization basic and further training during the last five years. Online free basic training for immunizers has started and training opportunities were open until the end of January. COVID-19 vaccine-specific training was provided immediately after obtaining an EU marketing authorization for the respective vaccine. The vaccine-specific training of Pfizer and BioNTech in the Comirnaty vaccine took place on 29.12.2020, there were about 2,000 participants in the training. Moderna vaccine specific training took place on 14.01.2021, which was attended by about 1,200 vaccinators.

Vaccine providers are required to:
• draw up a target vaccination plan;
• assess the need for COVID-19 vaccine on a weekly basis according to the plan;
• order the required amount of vaccine from the Health Board;
• invite target group representatives to be vaccinated;
• Identify temporary and permanent immunizations before starting vaccination contraindications, explains the need for vaccination, informs patients on side effects that may occur and what to do if they occur;
• tell the person about the need to inform their doctor of any possible  post-immunization side effects;
• book a time for the second dose and inform the person to be vaccinated;
• after vaccination, send a notification of immunization to the health information system;
• inform the State Agency of Medicines about side effects caused by immunization.

The person to be vaccinated receives a notification from his or her family doctor and through eesti.ee that he or she belongs to the target group of vaccination and has the opportunity to be vaccinated.  Specific information about vaccinations are available on the Health Board's website www.vaktsineeri.ee. Vaccination against COVID-19 disease will be free of charge in 2021.

The Immunoprophylaxis Commission decided to abolish the age cap on AstraZeneca vaccines. Instead, the Commission will more closely monitor the risk of thrombosis for the patient and if risk is foreseen, the vaccination will be postponed.

In addition, the Commission recommended extending the time between the first and second doses of AstraZeneca vaccine from 8 weeks to 12 weeks and the time between Pfizer / BioNTech vaccines to six weeks, in order to increase the number of people receiving the first dose in the coming months.

Source:
https://www.sm.ee/et/uudised/immunoprofulaktika-ekspertkomisjon-uuendas-covid-19-vaktsiinide-kasutamise-soovitusi

A voluntary pilot was launched for the people older than 65 to register themselves for vaccination through the digital registration database. The vaccinations were provided in larger regions by various medical institutions across Estonia. Vaccination of at-risk people continues in parallel. The current priority is to vaccinate  educators and social workers. During March, vaccination will be provided to persons working in strategically important positions to resolve the COVID-19 crisis, including members of the Riigikogu and the government, in addition to other frontline employees.

Estonia is additionally requesting more than 660,000 doses of the Pfizer / BioNTech vaccine in the framework of an EU joint procurement in case the vaccines are delivered in the second quarter of 2021.

Source: https://www.sm.ee/sites/default/files/news-related-files/covid-19_vaktsineerimise_plaan_14.12.2020.pdf

Starting from the first week of April 2021, the EHIF is using the vaccine distribution ITC solution it developed for primary healthcare centres. The aim of the solution is to distribute the vaccines more effectively to primary healthcare centres. The solution creates automatic recommendations to more than 700 family doctors taking into account the number of vaccines that have arrived in Estonia and the number of risk group patients in the family doctors’ patient lists. Family physicians can specify the order and approve it after which the Health Board starts to fill the orders. The solution also gives family physicians a clear overview of the upcoming deliveries (the time when they arrive). It also makes it easier to follow the 1st and second dose.

More than 670,000 leaflets were posted to the general population to encourage vaccination (in EST and RUS with information where to find out more also in ENG).

A new agreement was made at the EU level that will provide Estonia more than 62,000 additional doses of Pfizer/BioNTech vaccine in the next 3 months (starting from April).

Sources:
https://www.postimees.ee/7216153/perearstidel-on-uus-vaktsiinirakendus-ei-pea-enam-laupaeviti-aktiivselt-kirja-ootama-ja-tellima 
Eesti saab teises kvartalis lisaks üle 62 000 vaktsiinidoosi | Eesti | ERR

A total of 670,000 homes will receive leaflets which cover vaccination against COVID-19 | Government installation profile (terviseamet.ee)

During the second wave, some COVID-19 patients treated in hospitals have reported reduced elective care provision since late November 2020. Recently further cuts were notified, for instance the Tartu University Hospital has already reported to cut the elective care by 50% (excluding elective day surgery) and in light of increasing infection numbers, the North Estonian Medical Center was informed to prepare for reallocating the beds for COVID-19 patients and reducing the elective care provision. East-Tallinn Central Hospital will open its third COVID-19 ward for 26 beds on 1 March. In total, the hospital has capacity for 114 patients making it the largest COVID-19 treating hospital in Estonia. For the opening of the third ward the elective care in surgery and internal medicine was reduced.

Sources:
https://tervise.geenius.ee/rubriik/uudis/ida-tallinna-keskhaigla-avab-kolmanda-covid-osakonna-plaanilist-ravi-on-vahendatud/
https://www.regionaalhaigla.ee/et/kasvava-nakkusfooni-taustal-oht-plaanilise-ravi-piirdumisele
https://www.err.ee/1173889/tallinna-haiglad-tombavad-ravitegevust-koroona-tottu-koomale
https://www.delfi.ee/news/paevauudised/eesti/tartu-ulikooli-kliinikum-valmistub-senisest-suuremaks-plaanilise-ravi-piiramiseks?id=92671133 

The Government Emergency Committee supported the proposal of health authorities to start gradually reopening elective care. As long as the transmission does not escalate over the weekend of 18 April, the Health Board will make the decision the following week about which elective specialist care, primary care, dental care and services provided by private providers for non-urgent care can be reopened. The prerequisite for expanding the treatment volumes will be to reduce risks for infection transmission to a minimum. The Health Board will provide the conditions in the guidance, which is currently in development.

In view of the current trend in the number of people diagnosed with COVID-19 and receiving inpatient care in Estonia, as well as the availability of personal protective equipment (PPE), the restrictions on scheduled treatment due to the emergency situation will be gradually abolished starting from 21 April. The restrictions for private providers and dental care will be lifted from 26 April. The Health Board has provided instructions and minimum requirements for health care providers for restarting the provision of elective care under COVID-19 circumstances. These instructions were developed by the emergency medical directors and the Estonian Society of Infectious Diseases and consulted with all parties.

The instructions set the basic requirements among others: (i) availability of infection prevention and control guidelines (hand hygiene, use of PPE, cleaning and disinfection of the facilities, waste management); (ii) employees must be trained in the above guidelines; (iii) adequate supply of infection control equipment; (iv) ability to treat COVID-19 positive patients, including conducting COVID-19 testing.

Due to low demand, the University Clinic of Tartu reinstated its emergency medical department for COVID-19 patients on 8 May, as it was temporarily used for day care of hematology-oncology patients. Although all patients needing emergency care will use the same entrance, the COVID-19 patients will be separated from the rest. Specifically, emergency departments will conduct two levels of triage: first for COVID-19 and then for emergency care.

Source: https://www.kliinikum.ee/kliinikum-uhendab-erakorralise-meditsiini-osakonnad/ 

The opening of elective care continues in hospitals and starting from 18 May, the most affected hospital in the epicenter of Estonia’s COVID-19 outbreak – Kuressaare hospital – will also begin providing elective care.