The Hellenic Ministry of Health, following ECDC guidelines, identified 5 main objectives for testing in order to 1) control transmission, 2) reliably monitor SARS-CoV-2 transmission trends and severity over time, 3) mitigate the impact of COVID-19 in healthcare and social care settings 4) rapidly detect clusters or outbreaks in specific settings and 5) maintain sustained control of COVID-19 once achieved.
The testing strategy for SARS-CoV-2 followed can be analysed in three pillars:
1) Diagnostic testing: intended to identify occurrence at the individual level and is performed when there is a reason to suspect that an individual may be infected, such as having symptoms or suspected recent exposure, or to determine resolution of infection. It is performed in accordance to the COVID-19 ‘case definition’ provided by the National Public Health Organisation (NPHO) in/by:
a) COVID-19 Reference Hospitals: People with symptoms are urged to call the Hellenic NPHO on the dedicated number 1135 and report travel or contact history and any alarming symptoms (dry cough, fever, shortness of breath, arthralgia, myalgia, etc.) and receive instructions for referral to any of the 14 COVID-19 reference hospitals across the country for free medical evaluation and RT-PCR testing for SARS-CoV-2 in the case that the person is evaluated as a suspected case.
b) Primary Health Care settings: operational expansion of 185 Health Centres and 42 Regional Clinics, to include case management of citizens with coronavirus symptoms. The activation of Primary Health Care in the battle against the pandemic has decongested to a large extent Hospitals, especially the COVID-19 reference Hospitals (30.03% of COVID-19 tests performed are in PHC structures).
c) NPHO Mobile Health Units: Fixed examination points around the country are being set in areas with high epidemiological burden, where tests are performed with a SARS-CoV-2 rapid antigen detection test by NPHO Mobile Health Teams.
2) Screening testing: intended to identify occurrence at the individual level even if there is no reason to suspect infection - e.g., there is no known exposure. This includes, but is not limited to, screening of non-symptomatic individuals without known exposure with the intent of making decisions based on the test results. Screening tests are intended to identify infected individuals without, or prior to development of, symptoms who may be contagious so that measures can be taken to prevent further transmission. For this purpose, 500 mobile health units have been mobilised across the country in order to increase testing capacity, incorporating mainly RT-PCR, as well as rapid antigen testing. It includes all screening tests performed on air, land and sea entry points (33 in the country), to new conscripts on military service, to healthcare personnel, refugee camps, prisons and Elderly Care Units, and in the context of pre-operative hospital assessments.
3) Surveillance testing: includes ongoing systematic activities, including collection, analysis, and interpretation of health-related data that are essential to planning, implementing, and evaluating public health practice. Surveillance testing may sample a certain percentage of a specific population to monitor for increasing or decreasing prevalence and to determine the population effect from community interventions, such as social distancing. A network of45 Health Centres and Local Health Units(‘Sentinel’) from all geographical regions in the country, reports clinical cases based on the defined clinical definition and monitor the evolution of the disease.
Since March 2020, people with symptoms have been urged to call NPHO on the dedicated number 1135 and report travel or contact history and any alarming symptoms (dry cough, fever, shortness of breath, arthralgia, myalgia, etc.) and receive instructions for referral to any of the 13 COVID-19 reference hospitals across the country for free medical evaluation and smear test for SARS-CoV-2 in the case that the person is evaluated as a suspected case. The medical team may also test for Influenza Flu Viruses, so as to rule the possibility out.
Samples are sent to one of seven COVID-19 reference laboratories. The samples are processed to give the result as soon as possible, during which time people who underwent testing should self-isolate. In case of a positive result, the patient is transferred to a reference COVID-19 hospital in proximity and, depending on the severity of symptoms and underlying medical conditions doctors decide if the patient remains in hospital for treatment or home isolation. Those tested negative should remain in home isolation for at least 14 days.
Alternatively, private diagnostic laboratories and private hospitals carry out tests and medical examinations, with the cost being covered by the individual wishing to take the test (see section 4.2). When a case is confirmed, the NPHO is notified, and the patient, depending on severity, gets transferred to a COVID-19 reference hospital for assessment.
The Ministry of Health organised for antibody test to be performed on health professionals and all NHS workers, starting June 1. In addition to health professionals and permanent healthcare structures staff, staff of all kinds (seconded employees, contractors, cleaning crews, security services, subcontractors, etc.), were given the choice to test for a past infection.
Greece was one of the first European countries to obtain 1 million rapid antigen tests. 200.000 units were obtained beginning of September, to be used in mobile health units, the country's gateways, remote health units, closed settings such as refugee camps and penitentiary institutions, and in hospital emergency departments for triage purposes. Recurring orders of rapid antigen tests have been placed.
Moving into the second phase in May 2020 (see section 5), testing strategies were intensified, taking into account geographical and epidemiological data, with priority given to high-risk groups (people over 70 years of age or of any age with underlying serious chronic conditions, such as cardiovascular diseases, diabetes, respiratory diseases and people with immunosuppression).
Plans were accelerated in preparation for the progressive resumption of tourism services. Α strategy was formulated to ensure testing was readily available on all islands whereby samples were transported to designated laboratories for analysis and results.
The Greek government presented an elaborate plan on preparing for tourism from July 1st.The Passenger Locator Form (PLF) is a key element in the planning. All travellers must complete their PLF 24 hours before entering the country, providing detailed information on their point of departure, the duration of previous stays in other countries, and the address of their stay while in Greece. In case of multiple stays, they are required to provide the address for the first 24 hours at least. One PLF should be submitted per family.
A complex artificial intelligence algorithm with the code name EVA combines data from the tests performed at entry points in the country, as well as the data obtained from the Passenger Locator Form (PLF), creating a profile for each visitor, which health authorities can utilise so as to determine whom they will test, enhancing public health and safety. Since the gradual reopening of borders and ease of restrictions on travel (until October 30), 637,044 tests (RT-PCR) have been performed at air entry points, of which 5.842 were positive.
In the early stages of the pandemic, Greece had the ability to perform approximately 800 COVID-19 molecular diagnostic tests per day. By June, testing capacity had increased to 6,500 tests daily. Consistent efforts to increase this number even further have been ongoing amid the gradual easing of restrictions and the beginning of tourist season. By September, daily testing capacity further increased by 15 times (compared to March 2020) to accommodate for 14,000 samples (on average). By the end of November, 25,000 samples (on average) are being tested on a daily basis. In addition to this, sampling points have multiplied, the cost per sample analysis has been reduced by 80% and the availability and quality of reagents has been ensured. By February 2021, daily average COVID-19 testing further increased to 38,000, with a maximum of 50,000 tests.