Policy responses for Lithuania - HSRM


Policy responses for Lithuania

1.5 Testing

From 13th of March the coronavirus hotline 1808 became operational. People in isolation who came from high level risk countries and showed symptoms (i.e., fever, caught and ect.) were asked to dial the number. Dialing 1808 gives access to Hotline Consultant who follows a set algorithm to approve the testing. Suspected cases (according to existing case definition) were initially tested in isolation rooms in emergency care and were observed in hospitals. Starting from 16th of March, the collection of swabs for COVID-19 was launched through mobile COVID-19 clinics .(1) By the 31st of March, there were 12 mobile clinics (3 of them in Vilnius). In addition, on the 25th of March it was announced that so-called fever clinics should be rolled out in Lithuanian municipalities,(2) where patients, referred by a GP, and with symptoms of upper respiratory tract infection will be examined for suspected COVID-19. As of 1st April, fever clinics were functioning in Vilnius, Kaunas, Vilkaviškys and Raseiniai municipalities. (3)

Possible case criteria

The case criteria for possible cases, requiring testing has changed throughout the course of the epidemic. In chronological order defined as:
(29-01-2020) - A. Person with severe acute respiratory infection (i.e., fever, cough, hospitalization required) and no other aetiology has been identified to meet at least one of the following criteria: former trip to or residence in Wuhan (Hubei Province, China) during the 14 days prior to the onset of symptoms of the disease, or the patient is a healthcare professional who worked in an environment that treated individuals with unspecified respiratory infections. B. Patients with acute respiratory tract infection and at least one of the following criteria: close association with confirmed or probable case 2019-nCoV for 14 days prior to onset of disease symptoms, or visiting or working at an animal market in Wuhan (Hubei Province, China) for 14 days prior to onset of disease symptoms, or person working or visiting a health facility for 14 days at the onset of symptoms of the disease in which 2019-nCoV hospitalizations were recorded.
(4-02-2020) - Person with acute respiratory infection (fever and one of the following: cough, sore throat, difficulty in breathing) who requires or does not need hospitalization and has responded to at least one of the following epidemiological criteria: close contact with a confirmed or probable case of 2019-nCoV or traveled in areas where 2019-nCoV is spreading to the public - China (mainland, all provinces) or worked in an environment where persons suffering from 2019-nCoV infection were treated.
(24-02-2020) - Person with acute respiratory infection (fever and one of the following: cough, sore throat, difficulty in breathing) who requires or does not need hospitalization and has responded to at least one of the following epidemiological - has been in close contact with the confirmed or probable case of COVID-19 or have travelled in areas where COVID-19 is spreading - China (all provinces), the region of Northern Italy (regions of Lombardy, Veneto, Piedmont and Emilia-Romagna), which treated individuals with COVID-19 infection.
(27-02-2020) - Person with acute respiratory infection (sudden onset of at least one of the following symptoms: cough, fever, difficulty breathing). Requiring or not requiring hospitalization and meeting at least one of the following epidemiological criteria during the 14 days prior to onset of symptoms - close contact with a confirmed or probable COVID-19 or traveling in areas where COVID-19 is spreading in the community or worked in environment where patients of COVID-19 were treated.
(28-03-2020)  1. Person with acute respiratory infection (displaying one of the following symptoms: fever, cough, breathing difficulties) and without an underlying cause that explains these symptoms, who within the past 14 days travelled from areas with COVID-19 spread. 2. Person with acute respiratory infection who has been in close contact with confirmed or suspected COVID-19 case. Furthermore, laboratory testing is implemented for the following groups: a) persons with severe respiratory infection who require hospitalization; b) health care professionals and other key workers.  
(01/06/2020)  1. A person with an acute respiratory infection (displaying one of the following symptoms: fever, cough, breathing difficulties) and who within the past 14 days travelled or lived in areas included in the list of countries affected by COVID-19 (coronavirus infection) approved by the Minister of Health of the Republic of Lithuania - Head of State Emergency Operations. 2. Person with symptoms of an acute respiratory infection who has been in close contact with confirmed or suspected COVID-19 case during the 14 days prior to the onset of symptoms. 3. Person with severe acute respiratory infection (fever and at least one symptom of respiratory disease - cough, difficulty breathing) AND requiring hospitalization AND has no other etiological cause has been identified to explain these symptoms.(33)

Testing capacity

Throughout March doctors and residents reported lack of testing for the virus.(4) COVID-19 laboratory testing capacity expanded gradually.(5) Initially, all tests were conducted in one National Public Health Laboratory in Vilnius (with testing capacity around 200 tests per day), afterwards other laboratories have joined in. From 18th of March four additional laboratories (6): Santara Clinic (Vilnius), Kaunas Clinic, Šiauliai Republic Hospital and Klaipėda University Hospital; and later VU Life Sciences Center (12) started to perform tests for the detection of the COVID-19 (with capacity of up to 1,500 tests). Private laboratories are also beginning to test for coronavirus infection as announced on 30th of March.(7)

On 26th of March, 100,000 reagents reached Lithuania from South Korea; in addition, 300,000 more reagents were received from China. By the end of March lab testing is functioning according to the criteria for testing. On 30 of March, the first batch of rapid tests (2,500 units) has arrived out of the total half a million units purchased by Lithuania.(11) 

Municipalities were obliged to set up mobile points for testing by 20th of March.(8) by 12th April, there are mobile testing units in 16 municipalities, and further 40 fever clinics across the country. As the number of tests carried out increased and outpaced laboratory capacity for processing, in early April the operational hours of some mobile points have temporarily been temporarily restricted.(10)

The capacity of the five laboratories allows the processing of more then 1500 samples (reached 28th March, increasing from 1170 previously. From 28th of March the COVID-19 testing capabilities are being expanded - the new testing system for one of the laboratories is purchased to carry out more tests from 8th April. By 15th April, 12 laboratories across the country perform testing, with testing capacity reaching 3,000 tests per day.(15) On 21st April, the daily number of samples tested has reached over 6,000 across all laboratories.(17)  

From 23rd of March eHealth portal allows residents to check their test results for  COVID-19 online.(9) The speed of getting the results varies, from 6-8 hours to, more recently, several days.

By November 2020 there were 20 public and private laboratories able to analyse COVID-19 testing samples, with daily capacity varying from dozens to about 1.5 thousand. Around mid- November, about 15,000 samples were tested daily, which is probably close to full capacity. The time taking to receive the result has increased to 48+ hours in November. ECDC data from 26th November shows that Lithuania remains among the EU countries with the highest number of tests per population. 

In early January 2021, the National Laboratory for Public Health has signed new contracts for the centralised procurement of equipment for COVID-19 testing. The contracts were awarded through public tender. (49)

Expansion of categories for preventive testing

On 11th of April it was decided that healthcare professionals should be screened for COVID-19 every seven days. Staff working in nursing and long-term care facilities, as well as ICU and ambulance services should be given priority. (14) From 16th of April social care and nursing staff will be tested in as a matter of priority every seven days. (16) In addition, MOH now urges physicians to intensify referral of patients after 14 days of isolation and no symptoms for testing (13).

From 27th April, a number of additional categories of key workers, such as customs officials, employees of energy companies and dispatch centres, as well as employees of emergency services, operational management teams and control centres, displaying at least one symptom of acute respiratory infection, are tested as priority.(19) Specialists of the Public Security Service, the National Centre for Public Health, The State Food and Veterinary Service, and the military are also getting tested, as well as new patients admitted to hospitals and patients transferred to nursing homes.(20)  

Over the long weekend of 1-3 May, nearly 9,000 asymptomatic people across Lithuania were handed in leaflets in retail outlets, markets and pharmacies to invite them to be tested for coronavirus infection. By 4th of May, about one third of those have been tested, with no new COVID-19 cases detected. Remaining people have signed up to be tested in mobile testing units nearest days. (21)

From 4th May, selected (e.g. based on age or risk) staff of shops and other outlets directly serving customers will be tested as a measure of prevention. (22) Staff should register using the COVID-19 hotline 1808 to be directed to a local mobile testing point. (23)

On the weekend 9-10th May, testing for COVID-19 was offered to public. During this time, 1,629 people requested a test, mostly in Vilnius and Kaunas. Among those, 1031 were the employees of pre-school settings. Other were: doctors - 221, pharmacists - 191, sales staff - 135, social workers - 49, officials - 2. (24) All samples tested negative. (25)

From 11th May not only a GP but also a specialist doctor can order a test for coronavirus infection  for a patient awaiting planned hospitalisation (see also Section 3.3). Previously, patients had to go back to a GP for referral for a test.(25)

Transition measures May-June

In mid-May, with relaxation of quarantine, people returning to work, and requirement for employers to ensure that only healthy employees are allowed to work, the number of people asking to be tested has risen markedly, putting the pressure on the 1808 COVID-19 phoneline to handle the calls, and on mobile testing units to carry out tests. People were then advised to only contact the helpline to get the referral for testing if they have symptoms (or fall into other categories for testing, e.g. need to be hospitalised for planned health care).(27)

From 25th of May, persons entering to Lithuania from abroad will not be routinely tested for COVID-19 at airports and other border crossings, but they will have to do the test within 48 hours by registering and attending local mobile testing points. (28)

As of 1st of June COVID-19 morbidity rate in Lithuania is 4.3 cases per 100 thousand populations. Under the new procedure, testing volumes will be increased for the first week of June in those municipalities where the incidence is higher than country average. This is currently the case in Vilnius region (37.9), Lazdijai (16.4), Vilnius city (10.9), Ignalina (6.9), Šalčininkai (6.6) and Skuodas (6.2) municipalities. (30) This selective additional testing will target all health care workers and staff of social care institutions (with exception of those for children); 5-10% of randomly selected hospital patients and residents of social care institutions; other selected categories (e.g. pharmacists, retail staff) randomly by registration via 1808 hotline.(30)

From June, five private laboratories can perform ensure the safety of both patients and staff are eligible to perform paid testing for coronavirus infection (COVID-19). The cost of the test is also set by the testing laboratories themselves, not by the state. (29)

On 3rd of June policy on rapid serological tests has been adopted. Serological tests will be used for several purposes: a) to check if a person has had COVID-19 b) as late diagnosis, at least 14 days after the onset of coronavirus-specific symptoms, c) to assess what proportion of the population has become ill. It is envisaged that rapid tests could also be performed in cases where a person experiences clear clinical signs of coronavirus infection, but repeat PCR tests are negative. (31)

From 10th of June, anyone returning from abroad will be able to register for a coronavirus infection test (COVID-19) at mobile points if they demand so. This means that there will be no obligation to examine all returnees, as in the past. Do be testes or not decides the person. (32)

From 17th of June, only symptomatic people who need to be admitted to hospitals for scheduled treatment as well as to social care facilities need to be tested. Until this date, testing had to be performed on anyone who needs to be admitted. (34)

From June 22. by June 28 population is tested more intensively for prevention in Širvintos, Vilnius district, Jonava, Vilnius, Šalčininkai, Radviliškis and Klaipėda district, the coronavirus infection (COVID-19) spread is higher than in other municipalities of the country.(35)

From June 29 by July 5 population will be tested more intensively in Vilnius and Vilnius district, Širvintos, Šalčininkai and Radviliškis district , the coronavirus infection (COVID-19) spread is higher than in other municipalities of the country. (36)

Residents and businesses wishing to carry out paid testing without intervention of state public health services can do so in five private laboratories. This information may be relevant to employers who hire workers from abroad. According to the current procedure, foreigners arriving to Lithuania from a third country must self-isolate for 14 days, and foreigners arriving from affected countries must both self-isolate and be tested. (37)

Testing from August 2020 (2nd wave)

From the end of August and in light of increase in the number of cases, testing will focus on case finding, while the scope of population testing is reduced. Population testing will continue in high-risk municipalities, the list of which is updated weekly. From 31 August, routine testing will not be carried out for social workers, employees of pre-school settings, employees of mobile testing points, and of those working at border checks. (38) Teachers and other staff of educational institutions will have access to rapid serological tests. Upon a positive result, they will have to undergo a PCR test that shows if a person is currently infected. (39)

On 28th of September preventive testing procedures have been updated. From now on, students doing internships in medical institutions will be tested, as well as selective testing in hospitals will be expanded (40). In high-risk municipalities, up to 50% of all health and social care workers working in inpatient settings and care homes will be tested, together with the same share of of hospitalised patients and care homes residents (compared to 15 to 20 percent tested previously (41). 

With increasing number of COVID-19 cases in September, the procedure for identifying high and low-risk municipalities has been updated. From 16 October, high-risk municipalities are those where covid-19 rate per 100 000 population is more than 50, more than 10 cases have been reported within 14 days and/or the weekly positive tests represent 4 % or more of all tests.(42) 

In the autumn 2020 there was an increasing volume of calls to the Hotline 1808, stretching its capacity. From 3rd of November in four major cities people can register for testing online on a designated 1808.lt website. (43) In December 2020, the dedicated 1808 service takes about 3,500- 4,500 registrations for testing a day on weekdays (and slightly less on weekends). Of these, about 1,000-1,200 are registered via online platform.(48)

From 16th November, all travellers arriving from Denmark, Spain, Italy, the United States, the Netherlands and Sweden should be tested, due to mutated type of COVID-19 detected on mink-growing farms in these countries (45).

On 9th December, MOH announced that a GP may diagnose COVID-19 disease without having a test result.  Diagnosis can be made when a person experiences symptoms characteristic of COVID-19 disease within 14 days of the last day of contact with a living family member or another person with coronavirus infection and for whom the diagnosis has been confirmed by a laboratory test by PCR. In this case, the family doctor records the diagnosis of U07.2 (COVID-19 disease, virus not detected) in the eHealth system, which in theory should inform the public health authorities responsible for daily counts of a new positive case. (47)

With growing outbreaks in LTC, in December 2020 MOH has adjusted the procedure for preventive testing health and social care facilities. Health and social care providers employing more than 10 staff who have contact with patients have to test between 10% and 20% of employees weekly.

From 8th February, the Ministry of Economy and Innovation plans to provide EUR 30 million for small and medium-sized businesses to test for coronavirus. Businesses will be partially reimbursed for the cost of rapid tests and tests carried out by staff in health care facilities. 8 Eur per rapid serological test for antibodies and 12 EUR for a rapid antigen test will be reimbursed. These funds are aimed to cover about 10,000 tests. (50)

Since 26 January until 20th February 2021, 8,000 teachers have been tested for antibodies as part of the voluntary testing and results showed that almost 18% of them had COVID-19 disease. This indicates that educational institutions are those public places where there is a relatively high risk of transmission or infection with coronavirus. For this reason, education staff continue to be one of the priority voluntary testing groups, especially as restrictions ease. (51)

From 26th of February, information on the results of coronavirus (COVID-19) disease tests will be sent to foreigners by short message. One of the functions of the Hotline of the Coronavirus Hotline 1808 is the doctor's consultation line. Foreigners arriving in Lithuania who register for the COVID-19 test at the mobile coronavirus checkpoint will receive information about the test results by a short message. It will provide information that the result of the test can be found by logging in to the provided password-protected link. (53)

From 1st March 2021 passengers leaving the country through Vilnius Airport can do COVID-19 test for a fee at a private lab site nearby and obtain the required certificate on the spot. (52)

From 10th March anyone arriving to Lithuania will be required to have negative COVID-19 test result done in the past 72 hours. (54)

Testing strategy March 2021 (see section 1.4 for genome sequencing)

Testing is performed according to MOH Order No. V-1336 on the organization of testing for coronavirus infection, issued by the MOH in May 2020 and regularly updated https://e-seimas.lrs.lt/portal/legalAct/lt/TAD/fa9c0ad0a1be11eaa51db668f0092944/asr ; in March 2021 it includes: 
- PCR test, rapid PCR test, pooled PCR test, rapid antigen test and laboratory antigen test for acute COVID-19 infection.
- Serological tests can be carried out to detect previous coronavirus infection.

Testing in Lithuania is divided into targeted testing and preventive testing. As preventive testing is divided into regular (e.g. employees of health care, social care institutions, law enforcement officers and others) and ad-hoc.

From 9th March preventative COVID-19 testing for various targeted population groups using rapid antigen tests gains ground (55) (56) (previously only PCR was used for large-scale testing). People from target groups are invited to register for study online or via 1808 hotline. From 29th March 2021 all small and medium-sized businesses, including the self-employed, can be compensated for testing kits.

According to the Government Resolution, representatives of certain professions that are restricted during quarantine and have constant direct contact with other persons have to be tested for COVID-19 before resuming face-to-face activities or periodically. Professions required to be tested once before resuming activities/services are those engaged in retail, catering, sports, art, leisure and entertainment services, and beauty industry. Professions tested on a regular basis (every 7-10 days) are health and social care workers, teachers and those engaged in educational activities, unless they have been fully vaccinated.
From mid-April, rapid antigen tests (LFD), meeting the EU minimum standards (80% sensitivity and 97% specificity) for self-monitoring should be more widely available for sale (57).

From mid-April, rapid antigen tests (LFD), meeting the EU minimum standards (80% sensitivity and 97% specificity) for self-monitoring should be more widely available for sale (57). The European Commission organised the delivery of rapid antigen tests for COVID-19 to the Member States of the European Union, using the Emergency Support Instrument. By 29th April Lithuania has received over 280,000 rapid antigen tests, and expects to receive the remaining 174,000 in the near future.