Policy responses for Netherlands - HSRM


Policy responses for Netherlands

1.5 Testing

Since 25 March 2020, the following testing protocol is used:

• Patients admitted into hospitals with (severe) acute respiratory infections are tested to ensure proper treatment and to protect hospital personnel and other patients.
• Patients presenting at GP practices and patients that receive home care are in principle not tested, with the exception of patients with intensive care demands, requiring many care related contact moments (potentially with different care professionals) per day. They can be tested when they present themselves with symptoms. GPs that would like to have a patient tested have to organize this themselves.
• Nursing homes and homes for disabled: one or two patients per department or location may be tested when they become symptomatic to assess a possible outbreak in order to protect those living and working in these facilities and to optimize individual patient care.
• Practices of the Nivel Primary Care Database: these are GP practices (40) where all patients with influenza-like illnesses and symptoms are tested for surveillance purposes. Since early February, the collected swabs are also tested for COVID-19.
• Healthcare personnel are not tested. Symptomatic personnel with a fever >38⁰C should stay at home until 24 hours symptom free. In all other cases, when there has been unprotected contact with a confirmed patient and the healthcare worker has symptoms, he/she should either stay at home up to 24 hours symptom free or be tested.

As of 11 May 2020, tests will also be available for primary school teachers, child day care workers, and those with professions that require physical contact. (https://www.rivm.nl/coronavirus-covid-19/testen). Testing will be done after triage by a physician.

As of 18 May 2020, tests will also be available for informal carers and paid carers that are hired by a patient living at home (https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/richtlijnen/2020/05/12/richtlijn-testbeleid-mantelzorgers-vrijwilligers-palliatieve-zorg-en-pgb-gefinancierde-zorgverleners/Richtijnen+mantelzorgers+PGB+en+vrijwilligers.pdf).

Testing is not available upon request for individual citizens, and is only done after triage by a physician up to 1 June 2020.

As of June, testing is available for all citizens that have symptoms. Following a positive test, the regional Public Health Services will perform a comprehensive contact tracing (https://www.rijksoverheid.nl/onderwerpen/coronavirus-covid-19/nederlandse-maatregelen-tegen-het-coronavirus). There is some discussion about whether the regional Public Health Services have sufficient capacity to perform such comprehensive contact tracing and a national protocol on how to do this is not (yet) available (https://nos.nl/nieuwsuur/artikel/2331268-grootschalig-contactonderzoek-nodig-maar-wie-moet-dat-gaan-doen.html). In some regions, citizens are asked to inform their contacts by themselves. In addition, informed contacts are asked to proactively report to the Public Health Service whether they have symptoms; the organisation will not perform active contact tracing (https://nos.nl/nieuwsuur/artikel/2333281-protocol-voor-contactonderzoek-kent-twee-grote-zwakke-plekken.html).

There are about 34 laboratories that can perform COVID-19 testing. Together they can handle about 10,000 tests per day. However, a problem for testing is the limited availability of supplies that are needed for these tests. Among these 34 labs, there are two reference labs (RIVM and Erasmus Medical Centre), and 13 are (relatively) large laboratories that have scaled up to be able to perform at least 100 tests per day, 24 hours per day. To confirm COVID-19, two tests are performed independently. (see https://lci.rivm.nl/covid-19/bijlage/aanvullend). It takes one to several hours before the test results are available.

As of 31 March 2020, the actual testing capacity is about 4000 tests per day. By the middle of April, this should increase to 17,500 per day and later on to 29,000 per day. As a result, from 6 April onwards, the testing protocol will be adjusted so that personnel in nursing homes, home care, youth care and mental care can also be tested for COVID-19 (https://nos.nl/l/2328996).

The Dutch government announced on 15 April 2020 that they had successfully purchased extra testing materials, so that an additional 14,000 tests are available per day (https://nos.nl/artikel/2330578-nederland-krijgt-toezegging-voor-2-7-miljoen-testen-maar-is-het-genoeg.html).

The Netherlands is still (summer 2020) facing an impending shortage of testing material, especially concerning cotton swabs and virus transport medium (https://lci.rivm.nl/covid-19/bijlage/aanvullend).

As of 1 June, all Dutch citizens that have COVID-19 related symptoms can be tested, and can make an appointment without seeing a physician using a dedicated phone number. However, people are asked to go only when they have symptoms.

The numbers of people who test themselves has fluctuated. At peak moments, the Public Health Services had to scale up testing facilities. The norm of getting tested within 24 hours and receiving the result within 48 hours was not always realized.

The capacity of the Public Health Service is a problem, particularly in big cities with high numbers of tests and positive cases. The Public Health Service of the cities of Amsterdam and Rotterdam have restricted the tracing of contacts of positive cases to high risk contacts due to lack of capacity. The government has suggested that the Public Health Service can use military personnel for tracing.

An evaluation by the Algemene Rekenkamer (National Auditing Agency), published in September 2020, of the testing policy of the Dutch government revealed that the government did not have a clear view on the testing capacity of the Dutch testing labs and the supplies necessary for testing. The landscape of labs is fragmented and labs use a multitude of testing systems which have varying and different problems with acquiring sufficient supplies. As a result, the number of performed tests has lagged behind the available capacity (https://www.rekenkamer.nl/publicaties/rapporten/2020/09/23/testen-op-corona).

At the end of September 2020, the testing capacity lagged by an average of 10,000 requests for tests per day (the total capacity is 28,000 tests per day). The reasons include lack of testing capacity at the labs and that persons without health complaints also requested tests (for instance, those coming back from holidays from areas with high infection rates). As a result, the government started buying test capacity in Germany and Abu Dhabi, although the Data Protection Authority (Autoriteit Persoonsgegevens) has objected against the latter, because data protection outside the EU should be studied carefully. (https://nos.nl/artikel/2349563-privacywaakhond-wil-uitleg-over-abu-dhabi-deal.html; https://nos.nl/artikel/2349521-lab-in-abu-dhabi-gaat-nederlandse-coronatests-analyseren.html)

Young children (primary school and younger) do not have to be tested when they have symptoms (since returning to school after the summer holidays).

To prevent schools from closing and healthcare providers from having insufficient staff due to the long waiting times for testing, as of 21 September, a temporary special phone number is available to request priority testing as long as testing capacity is insufficient.

To ensure sufficient testing capacity in the near future, expanded ‘XL’ test facilities are set up in all large cities and the national airport as of November 2020. Furthermore, the use of rapid tests will be introduced in the near future. These facilities are the result of a public-private partnership, where the commercial sector will be responsible for the infrastructure and part of the personnel.  XL test facilities will be able to perform 3,000 to 12,000 tests per day. In the beginning, the swabbing will initially be performed by 1,000 military personnel who will receive a one-day training to do so. After the start-up phase, the military will be replaced by personnel from the public health services and by personnel recruited by the commercial sector (https://www.rijksoverheid.nl/documenten/publicaties/2020/11/06/factsheet-xl-teststraten-en-snelteststraten).

As of 1 December 2020, people who have had a high risk contact as detected by the corona app or contact tracing can get a test after 5 days.  There is a dedicated phone number for requesting a test after being detected by the corona app or contact tracing (https://www.rijksoverheid.nl/actueel/nieuws/2020/11/26/testen-op-corona-vanaf-1-december-voor-bepaalde-groepen-ook-mogelijk-zonder-klachten).

The corona app operates with apps from other European countries as of 30 November 2020.

For rapid testing, currently (as of 1 December) the LAMP (Loop mediAted isotherMal amplification) test is recognized as a reliable test and can be used for testing people without symptoms. The antigen tests are still under consideration as this test is less reliable for people without symptoms. The antigen tests can be used for testing people with symptoms, but preferably only in the first week of illness (https://www.rijksoverheid.nl/onderwerpen/coronavirus-covid-19/testen/testbeleid/soorten-testen; https://www.nhg.org/sites/default/files/content/nhg_org/uploads/2.11.20_antigeensneltesten_covid-19.pdf).

As of 1 January 2021, children under the age of 12 years old should be tested for COVID-19 when having symptoms as well. This is to monitor the new mutations of the virus and to be able to evaluate the impact on children.

In the Netherlands in February 2021, the following tests are available: 1) the PCR test (considered to be the golden standard), 2) the LAMP test, 3) the antigen test, and 4) the breath test. Negative antigen tests and positive breath tests need to be confirmed with a PCR test. For this reason, the Public Health Services advise healthcare personnel in direct patient contact to get tested with a PCR test. The general public cannot choose which test will be done. People with severe symptoms and people who are vulnerable can be tested with a PCR test, LAMP test, or antigen test. All others can be tested by all four types of tests (https://www.rivm.nl/coronavirus-covid-19/testen/verschillende-type-testen). The breath test can be used as a pre-selection: for every person with a positive test, 70% have a clear outcome from the negative test and the other 30% require additional testing. Testing is mainly done at the central test locations of the Public Health Services. Under certain conditions, testing is conducted at the workplace or in nursing homes, provided that there is clear information for the tested person and that positive test results are communicated with the Public Health Services. The tests should be done by a trained person with sufficient PPE and under the medical responsibility of physician (https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/publicaties/2020/11/04/uitgangspunten-voor-inzet-testen-op-covid-19-waaronder-antigeensneltesten-buiten-de-ggd-testlocaties/20210210_Uitgangspunten+voor+inzet+testen+op+COVID_versie_5.pdf).

Genetic sequencing of SARS-CoV-2 in confirmed cases is done by means of sampling. To investigate the spread of new mutations, in some cases a whole community is tested (see also section 1.1)

As of 30 March 2021, self-tests are available for the general public in several pharmacies. This will be gradually extended to all pharmacies and supermarkets by the end of April 2021

For children, a new testing method was developed. Testing is now done by a swab that needs to go less deep into the nose. Several testing facilities have implemented the new testing method and it will be gradually extended to all testing facilities. Since a whole school class has to be tested when a pupil or teacher is infected, many children need to go for a test. Because it is considered an unpleasant experience for children the new method of taking the sample was developed. It is called a “picking your nose” swab.