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
Measures due to rising numbers of patients in summer and autumn 2020
Since the beginning of July, Luxembourg saw an increased number of people infected with the coronavirus. The upsurge of cases must certainly also be seen in conjunction with Luxembourg's ambitious testing strategy, composed of PCR diagnostic testing for those showing symptoms as well as large-scale testing aimed at identifying asymptomatic persons (see Section 1.5). As response to the rising numbers, an emergency overflow ward for non-intensive corona patients to receive care that was previously disassembled due to low numbers of infections has been rebuilt as new cases continue to rise. 28 beds will be put back in the cafeteria of the „Centre hospitalier Emile Mayrisch“ (CHEM) in Escher as a preventative measure.
On October, 27, hospitals across Luxembourg entered into stage 3 of virus alert preparedness due to rising numbers of people infected with COVID-19. The move, undertaken by Luxembourg’s chief medical officer, means that hospitals can begin to reschedule procedures not related to COVID-19. In stage 4 (the final phase), hospital beds must be apportioned so that 264 beds are available for regular patients and a maximum of 100 beds for patients in intensive care. As of 27 October, 114 patients were being treated for COVID-19 in a hospital, including 16 in intensive care.
On 26 October, Luxembourg opened its “Covid Consultation Centre”. This has been set up to specifically relieve general practitioners from an increased influx of COVID-19 patients, and people with Covid-19 symptoms can use the services free of charge. Furthermore, new testing stations began opening on October 20 in response to increased demand and prolonged waiting periods.
With the aim of improving the management of COVID-19 patients, a second COVID Consultation Centre (CCC) opened on November 18 in Esch-sur-Alzette. The consultation is open to everyone with symptoms of COVID-19 infection or already diagnosed with COVID-19, regardless of whether or not they have social health insurance coverage. There is no charge for the consultation.
Vaccine services and delivery
The first COVID-19 vaccines for Luxembourg are scheduled to arrive on December 26 and medical and care staff working in hospitals and residential facilities for the elderly are among those most exposed to COVID-19 will are immunized starting on December 28 (first phase). Vaccination centers in Luxembourg were operational late December and the first phase of vaccinations is expected to require 35,000 doses. 9,700 doses of the Pfizer-BionTech vaccine were initially delivered to a central storing space on December 26 and distributed to hospitals shortly thereafter. 12,000 individuals are set to be fully vaccinated by the end of January 2021.The second phase of the vaccination campaign on the basis of the opinion of the National Ethics Commission was decided on January 21. In the second phase, people aged 75 and over, both healthy and vulnerable, are vaccinated, starting with the oldest. At the same time, highly vulnerable resident adults due to a pre-existing health condition, with no age limit, are also eligible to get vaccinated. This includes people with the following conditions : trisomy 21, solid organ transplants (including people on a waiting list who have undergone a hematopoietic stem cell transplant within the first 6 months or under immunosuppressive treatment), cancer or malignant hemopathy undergoing treatment (chemotherapy, radiotherapy, immunotherapy) and congenital immunodeficiencies. The degree of vulnerability is ascertained by the attending doctor, who will issue a medical certificate on the basis of certain criteria. The Superior Council of Infectious Diseases (Conseil supérieur des maladies infectieuses - CSMI) has provided a definition of persons considered vulnerable.
In phase 3, the following groups of people will be vaccinated: (1) People between 70 and 74 years old, starting with the oldest and (2) People who are significantly vulnerable due to a pre-existing health condition, which includes:
• People suffering from acquired immunodeficiency: immunosuppressive medication, biotherapy and/or long-term corticosteroid therapy at immunosuppressive doses
• People with one of the following factors: HIV infection with CD4 <200/mm3; asplenia, functional or not; severe chronic respiratory disease; severe chronic obstructive pulmonary disease (COPD), GOLD stages 3 and 4, group D; Cystic fibrosis; severe chronic pulmonary fibrosis; severe restrictive extrapulmonary disease, with or without ventilation support; severe uncontrolled asthma (level 5 according to GINA) corticosteroid-dependent (under oral corticosteroid therapy
• Severe cardiovascular disease (cardiac insufficiency NYHA stage III or IV; unstable coronary heart disease; cardiomyopathy)
• Major neurocognitive deficiency (MMSE score < 20)
• Chronic renal failure on dialysis
• Stage B or C cirrhosis in the Child-Pugh score
• Morbid obesity (body mass index > 40 kg/m2)
In phase 4, people aged 65 to 69 and people who are moderately vulnerable due to pre-existing health conditions (diabetes with or without insulin, with cardio-neurovascular complications; complicated arterial hypertension with sequelae resulting from a stroke or associated heart disease; neuromuscular disease with clinical repercussions) are to be vaccinated.
In phase 5, people aged 55 to 64 and people who have a health condition that may expose them to increased risk (controlled diabetes, without complications; uncomplicated arterial hypertension; obesity (body mass index 30-40 kg/m2).
In phase 5, specific categories of the population (people living in precarious conditions, in communities, and who have not previously been vaccinated because of their vulnerability; people who are particularly exposed to contracting an infection as a result of their occupation) and general resident population between 16 and 54 years of age are vaccinated.
In Luxembourg, vaccinations are carried out in vaccination centres (for general population) and in hospitals and in old people's homes and nursing homes with the help of mobile teams.
Persons identified on the basis of the order of priority to which they are assigned are invited by mail to be vaccinated. Each invitation includes a personalised access code that allows the beneficiary to make an appointment online. Citizens can choose their vaccination centre and preferred time slot (subject to availability of appointments) online. When making an appointment, the citizen must provide some information about his or her state of health. In addition, people will be able to contact a Health Helpline to get assistance in the process of making an appointment.
On the day of the vaccination, the patient reports to the reception desk of the vaccination centre with their confirmation letter, an identification document and their social security card. The reception desk checks the information and completes it if necessary. The patient then has a consultation with a physician, who discusses the patient's information with the patient. The physician completes the second part of the vaccination questionnaire, chooses the most suitable vaccine and prints the vaccination certificate. If, following the vaccination, the patient experiences any adverse effects in the rest area, he or she will be cared for by staff at the centre and his or her effects of the vaccination will be documented. Appointments for people with medical vulnerabilities are arranged in consultation with the person's GP.
Following a new assessment from the European Medicines Agency from April 7, 2021, Luxembourg announced it would continue to administer the vaccine from AstraZeneca without any specific recommendation regarding the age or sex of the recipient. On April 21, 2021, it was announced that people aged 30 to 54 will be able to volunteer themselves to receive the AstraZeneca vaccine through an online system. The registration system went live on April 21, 2021.
Following advice from the Conseil supérieur des maladies infectious (CSMI), the infectious diseases high council, issued on 16 February, Luxembourg’s vaccine programme will now include an interval of between 8 and 12 weeks when administering the two doses of the AstraZeneca covid-19 vaccine. Previously the health authority had been using an interval of four weeks.
Phase 2 of Luxembourg’s vaccination campaign began on February 23, 2021. Residents over 75 years of age are eligible and receive an invitation from the Ministry of Health in the mail. Phase 2 also covers those classified as having vulnerable health status and are registered by their attending physicians/specialists. The first invitations to people covered by phase 3 of the vaccination campaign are send out by the end of calendar week 11.
Phase 4 of the vaccination campaign (those 65-69 years of age and people will pre-existing conditions) has begun, with the first invitations for this group being sent out during week 13. Phase 5 of the vaccination campaign (those 55-64 years of age and people will pre-existing conditions) has begun, with the first invitations for this group being sent out during calendar week 14. The government confirmed that the final stage in the vaccination campaign would be launched end of April/early May 2021 (17th calendar week), meaning that all 16-54 years-old are to receive invitations for vaccination appointments. This final group consists of nearly 360,000 people, just more than half of the Grand Duchy's total population.
In addition, a waiting list was set up on April 30, 2021, in order to benefit from the remaining doses of coronavirus vaccine. People who are on the list must be able to get to one of the six vaccination centres within 20 minutes.
Luxembourg paused the administration of its AstraZeneca doses on March 11 pending further judgement and review of its recipients being at risk for blod clots. The administration of the AZ vaccines was resumed on March 19, following the green light from the European Medicines Agency (EMA).
On May 18, Luxembourg's main hospital, Centre Hospitalier de Luxembourg (CHL), stated that it has its intensive care unit dedicated to coronavirus patients as the number of cases is declining after two months of lockdown measures. The hospital had separated its intensive care unit into two zones, one for patients suffering from the deadly coronavirus and the other for non-corona patients. However, if the number of patients seriously ill with Covid-19 rose it would have to split the unit into two again.
From June 8, the Advanced care centres (Centres de soins avancés, CSA) at LuxExpo and the Rockhal will close their doors permanently. Patients with COVID-19 symptoms can contact their general practitioner or, in case of emergency, the hospital emergency departments.
On March 15, the Government Council adopted measures for the reconfiguration of hospitals services. Hospitals will deploy their staff and services mainly to urgent and acute activities that cannot be re-scheduled. Medical, surgical and care activities which are not short-term or indispensable are cancelled.
On March 18, the Government has decided to designate the ‘Maisons médicales’ (GP out-of-hour offices) as advanced care centres (Centres de soins avancés - CSA) with the purpose of channeling patients with symptoms of a severe respiratory infection. The objective is to concentrate these patients outside of emergency departments and general practices, so as to contain the spread of the epidemic, and to provide on-site access to collection capacity for diagnosis of infections by staff with the required protections. These facilities are designed to operate through two strictly separate lines of consultation - the first is designed to accommodate patients with signs of COVID-19 infection, the second is designed to accommodate patients who come to the centre with no signs of COVID-19 infection. In order to limit waiting times as much as possible, each channel provides healthcare to several patients in parallel.
As of March 20, a patient reception structure next to the Centre Hospitalier de Luxembourg (CHL, the main hospital in Luxembourg City) was set up with the support of the NSPA (NATO Support and Procurement Agency) and allows to house up to 100 patients. This new centre is designated for suspected and confirmed cases and allows triage of patients.