Policy responses for North Macedonia - HSRM

North Macedonia

Policy responses for North Macedonia

1.4 Monitoring and surveillance

The Institute of Public Health is responsible at the national level for epidemiological and laboratory surveillance and the response to all threats from communicable disease and to managing the implementation of the International Health Regulations (IHRs). All available surveillance systems for communicable disease are being used for detecting possible COVID-19 cases The Institute exercises its surveillance functions through: a) a syndromic surveillance and early warning system for outbreak identification or ALERT (EWARN) which it upgraded with WHO support to a real-time digitalized system (http://www.alert.mk); b) case-based surveillance of communicable disease as per the classic notification system of suspected and confirmed cases; c) Sentinel Surveillance of Influenza like illnesses (ILI), and Serious Acute Respiratory Infections (SARI). The Institute of Public Health prepares weekly and annual reports that are published on the Institute’s website (www.iph.mk). All confirmed COVID-19 cases and deaths are reported within 24 hours to WHO through IHR channels, according to the guidance provided by IHR procedures.
The regional surveillance network for communicable disease is composed of 10 Regional Centres for Public Health and 21 local Units of the Regional Public Health Centres, which are responsible for surveillance of communicable diseases, detection of clusters/outbreaks and response in their corresponding territory.
The country uses the WHO case definition of COVID-19.

Close contacts are defined as:
- Direct contact face-to-face, lasting more than 15 minutes in any environment with a confirmed case within a 24h period, or
- Sharing a confined space with a confirmed case over a prolonged period of time (e.g. longer than 2 hours), 24 hours prior to the onset of the symptoms in the confirmed case.
All contacts of confirmed COVID-19 cases are traced and interviewed by trained epidemiologists. 

WHO is supporting North Macedonia for Sero-epidemiological studies investigating the extent of infection in the general population, as determined by seropositivity. A standardized WHO master protocol is available that is being now tailored to country needs in terms of public health, laboratory and clinical systems, capacity, availability of resources and cultural appropriateness. Using this standardized protocol allows for comparability of data across different countries and helps to determine important epidemiological parameters (e.g. the proportion of the population that remains susceptible to infection, proportion of asymptomatic infections etc.) which inform public health action.

WHO is also supporting the country in assessing the situation in view of eventual relaxation of restrictive public health measures. WHO emphasizes that there should be gradual alleviation, close monitoring and constant calibration of measures. As measures are loosened, surveillance should be tightened. Different surveillance approaches (identification, confirmation, isolation, and contact identification and quarantine, event-based surveillance, sentinel ILI/SARI surveillance etc.) should be applied.

As the number of tests performed is decreasing and the laboratories have freed up their capacities, the Centre for Public Health and the Institute of Public Health are developing a plan for screening people considered to be at high-risk (health professionals, employees in kindergartens and care homes, members of the police, public transport drivers, employees in public services and patients prior to hospitalization). The screening is to be done with PCR tests.

As part of the screening in Debar, about 2,300 tests are performed – antibodies were detected in 35 individuals, of which some were infected and the rest were randomly chosen as of 5 May 2020.

The Institute of Public Health and the Centre of Public Health in Skopje completed a plan for COVID-19 screening to start as of the week of 11 May for about 400-500 people of vulnerable groups, including health workers, kindergarten staff, and nursing / elderly homes in the first phase, and in a later phase members of the police, drivers, employees in public service, patients before hospitalization, and patients needing biological therapy. These are categories where it is essential to assess the risk and identify asymptomatic carriers.  Screening will be done by PCR tests and with the help of primary care dentists and supported by the president of the Dental Association . 

55,000 people have downloaded the application “StopKorona”. The aim of the app is to facilitate contact tracing by epidemiologists.

On 13 May 2020, screening of people at high risk has begun, which will cover 2 000 employees in kindergartens, following the final phase of protocols for operation of kindergartens.

On 18 May 2020, a WHO Laboratory Workshop has started, which will be a weekly online meeting to discuss open questions and concerns around COVID-19 virus testing. The workshop is intended for health professionals working in a laboratory involved in COVID-19 virus testing/diagnostic. This week’s topic is “Saliva as a sample for testing” and North Macedonia is participating as well.

National Behavioral Insight Study in COVID-19
The Institute of Public Health is conducting a survey on behaviour related to COVID-19-in order to improve actions taken in response to the coronavirus pandemic. Answers will be used exclusively for scientific purposes, to improve the national response to the virus. Data will be stored at the Institute and can be used for research and lectures in the future. This is a non-commercial study and is supported by the World Health Organization.

As of 18 May 2020, 581 employees in kindergartens were tested for SARS-CoV-2 over the previous three-days as part of the targeted screening following the registration of one COVID-19 case in Bitola.

Between 14 and 19 May 2020, 908 screening tests were undertaken among employees in kindergartens in Bitola, Skopje and Veles and only one case has been detected.

On 27 May 2020, a joint Zoom meeting on sero-epidemiological studies was organized to discuss operational procedures in support of early epidemiological results in North Macedonia.

Scaling up COVID-19 testing is conducted and targeted to specific groups: residents of care homes for older people, health care workers and employees of kindergarten. More than 1,340 teachers and employees have been tested to determine when kindergartens can open, in order to allow parents to also go back to work.  One teacher in Skopje and one in Bitola were found positive as of 23 May 2020, and the testing will continue until the targeted 2,000 employees are all tested.  Kindergartens have been closed since 10 March. As of 30 May 2020, two cases in kindergartens in Skopje and Kumanovo and one case in a patient in a home for older people in Skopje were registered.

Five coronavirus cases had been discovered in retirement homes in Skopje as of 3 June 2020. So far North Macedonia has been spared major outbreaks in these facilities which have claimed many lives in other countries. The cases were identified in privately owned homes managed by the same company in the north and the east of Skopje. In one case two female residents tested positive, and in the other, three employees.

Representatives of the Football Federation of North Macedonia and members of the Commission for Infectious Diseases have decided to test all athletes and all persons involved in training sessions ahead of the season restart. The Public Health Institute will do the required testing. Individual sports such as tennis have already restarted.

A weekly Laboratory Workshop was held on 1 June on the topic “Sequencing”, presented by Vitor Borges, National Institute of Health, Lisbon, Portugal.

As of 3 June 2020, 7 factories in Shtip have been closed after employees tested COVID-19 positive. So far around 300 citizens in Shtip and the surrounding area have been put into isolation after it was concluded they had been in contact with COVID-19 patients. Three teams of epidemiologists are carrying out mass testing, a process which will cover 500 workers and is due to be completed by June 6.

All 60 police officers of the international contingent are to be tested after one Hungarian police officer deployed at the southern border tested positive for COVID-19 upon return to his homeland on May 26.

As of 12 June 2020, 15 people employed at the "8 September" city hospital in Skopje had been confirmed to be infected with coronavirus. Among the infected people were two doctors, with the remainder being nurses and technical staff. Three of them were hospitalized. Two health workers in Shtip tested positive and 6 were isolated. Employees working in a building that is part of the Skopje city hall complex were put in isolation after one of their colleagues was diagnosed with the coronavirus.

The Minister of Health urged infected citizens to cooperate fully with doctors when being asked about their contacts. It has been reported that many diagnosed patients refuse to cooperate with the mandatory surveys which prevents the full mapping of the new clusters.

The Weekly Laboratory Workshop was held on 8 June. Dr. Shantal Reusken, from the Netherlands Institute of Public Health, shared his experiences and the experiences in the Netherlands regarding immunodiagnostic testing (ELISA).

As of 16 June 2020, the situation in Shtip and Tetovo is stabilizing, while in Chair, where most cases are registered, the epidemiologists are still facing challenges in contact tracing.

As of 16 June 2020, in the 7 textile factories in Shtip, 778 samples were collected, and 126 cases were confirmed, of which 24 people were hospitalized.

The second conference for laboratory support in training: sampling and testing principles for the health professionals from laboratories in the Balkans was held on 11 June 2020.

The weekly Laboratory Workshop was held on 15 June at 12:00 to discuss questions related to the COVID-19 virus laboratory work and to exchange information. The focus this week was Pooling of samples - the Frankfurt Adjusted COVID-19 Test Method presented by prof. Dr. Michael Schmidt, German Red Cross Blood Donation Service Institute Frankfurt, Germany.

WHO and MOH are preparing a virtual review of the COVID-19 response in the country that will include areas of case management, public health measures, tracing and testing, mass gatherings, essential health services and risk communication. The meetings are planned for 18 and 19 June 2020.

123 tests were done on 14 June 2020 as part of the targeted screening of employees in kindergartens and 4 positive cases were registered in kindergartens in Shtip and Ohrid.

The Minister declared that over 40 large clusters were registered in the past period on the entire territory of the country related to various family events where 50-150 people and in some cases 200 people were present.

COVID-19 cases were confirmed in an additional textile factory in Shtip (by 23 June 2020, cases were confirmed in eight textile factories in Shtip) and the factory was closed for a period of seven days. As of 23 June 2020, there were 450 people in isolation in Shtip.

As of 23 June 2020, 41 employees in the Ministry of Interior were  infected and 180 were in self-isolation.

As of 23 June 2020, over 60 000 citizens had downloaded the StopKorona app.

One health worker at the Clinical Hospital in Shtip is  urrently infected with SARS-CoV-2 as of 24 June 2020. Four other health workers working the Department of neonatology, obstetrics and gynecology have been tested and the results are pending, they are in isolation as high risk contacts.  Seven mothers and their newborns from Shtip, Radovish, Pehchevo and Makedonska Kamenica are in isolation. 

The Army of North Macedonia has 29 active COVID-19 cases as of 24 June 2020. Three of the patients are hospitalized, and the others are in isolation and undergoing home treatment. Most of the patients are from the units in Skopje and Kumanovo.

COVID-19 returns to Debar: The first cases of people infected with the SARS-CoV-2 in Debar were confirmed on February 26 this year. It was a married couple from Centar Zupa, who returned from Italy and after that 11 people were registered on March 13, a month of state of emergency was declared. In the first phase, 51 people were registered, of which 47 recovered and four died. Fifty days later, on 5 June a COVID-19 case was registered as a woman from the village of Dolno Kosovrasti. Since then, 31 cases have been registered, 18 of which were registered on 21 June 2020. This is the largest number of registered cases in one day since the beginning of the pandemic.

As of 23 June 2020, the laboratory in the Hospital in Bitola is making its final preparations to engage in testing of the hospitalized patients in the hospital but also in the region which will contribute to decreasing the testing burden on the laboratory of the Institute of Public Health.

The weekly Laboratory Workshop for laboratory health professionals took place on 26 June 2020, and focused on the topic of “Biodiversity Measures Related to COVID-19 and Laboratory Risk Assessment”.

The Epidemic and Health Emergency Operation Center for North Macedonia at the Institute of Public Health under the leadership of the Minister of Health: WHO worked closely with the Ministry of Health in refurbishing and equipping a dedicated space for real time epidemiological monitoring of outbreaks at the Institute of Public Health. This is part of the USAID emergency funds entrusted to WHO earlier in the outbreak for strengthening North Macedonia capacity in the COVID-19 response. This center is the first and so far only structure in a Ministry of Health among ministries in the Western Balkan countries. The official launch of the center is planned for after the election.

On 6 October 2020, based on a recommendation from the Commission for Infectious Diseases, the Government approved the algorithm for acting in schools in case of suspect or confirmed COVID-19 case among students.