Policy responses for Turkey - HSRM

Turkey


Policy responses for Turkey

3.2 Managing cases

The COVID-19 Scientific Advisory Board (CSAB), established by Ministry of Health (MoH) on January  2020 has made “COVID-19 National Risk Assessment” on January 22. The CSAB created regularly updated guidelines on the management of patients with suspected or confirmed COVID-19 including general information, case definition, case management, infection control and isolation, patient care and treatment, in line with the growing scientific knowledge and spread of disease. The first version was published on January 24 2020, and includes the guide, presentations, case definitions, case management algorithms, treatment algorithms, contact algorithms, banners, brochures, information notes and videos. It has been constantly updated according to scientific developments, the course of the disease in the country and experiences from the field. All these documents are published on the Ministry of Health website.
 
In general, severe or critical COVID-19 patients are treated at (now designated) pandemic hospitals, while other patients with mild symptoms convalescing at home or suspected cases are being followed by primary health care facilities, such as family health centers and district health directorates.

Probable and confirmed cases are required to undergo isolation and treatment as follows:

• Home isolation and monitoring with treatment from primary care providers as appropriate:  cases who are aged 50 or below, have mild clinical symptoms and do not have risk factors (hypertension, diabetes, chronic lung disease, chronic heart disease, chronic renal failure or immunodeficiency etc.) and bad prognostic factors (blood lymphocyte count<800/ μl, serum CRP>40 mg/l, ferritin >500ng/ml, D-Dimer >1000 ng/ml)

• Hospital isolation and treatment: severe and critical cases

Detailed algorithms and treatment protocols are defined in the Ministry of Health document "Guidance to COVID-19" (https://covid19bilgi.saglik.gov.tr/depo/rehberler/COVID-19_Rehberi.pdf).

There is designated phone line (184 Advisory Line) and phone App (Life fits home/stay at home) through which people can submit their current status of symptoms to identify probable new cases. The system validates the inputs using a person’s National ID Number and directs the patient to the most appropriate care provider for probable cases. With the phone app, the density of infected patients can be seen in the region where the person is located and it is ensured that the follow-up and contacts are easy to find.

Once a probable case is defined, the Communicable Diseases Department of the Provincial Health Directorate is notified. The case is managed in coordination with the Provincial Health Directorate. 

Protocols to be followed by the health institution (hospital) treating the case
•        Personnel to record cases to the Public Health Management System (HSYS) and follow-up daily, should be designated at each inpatient treatment institution. 
•        All the cases complying with the COVID-19 probable case definition are be recorded into “e-pulse” application through the Hospital Information Management System (HBYS) with the U07.3 ICD 10 case code.
•        All the cases, including probable cases, are recorded within the HSYS. Public Health Management System (HSYS) is used for case-based follow-up. The case tracking module created in the HSYS, monitors all cases and hospital processes, people who come from abroad and are quarantined at home, and the contacts of the confirmed cases. Patients, contacts and people in the risk group who are followed up at home in the HSYS module are monitored by the Provincial / District Health Directorates field teams and family physicians. A mobile app called filiation/contact and isolation tracking system/FITAS follows up positive cases and their family relatives, colleagues at work, and contacts. This app also follows up patients, and can trace compliance with physical isolation.
•        A COVID-19 test is requested through the HSYS by taking appropriate samples* from the cases.
•        Probable/confirmed cases are treated at the designated ‘Pandemic Hospitals (Hospitals of Ministry of Health, Public and Foundation University Hospitals, and private hospitals) in isolation.
•        Treatment and follow-up is done at the Pandemic Hospitals or at home according to the decision of the physician (see Section 1.3 Isolation and quarantine).
•      Hospitals that have a 2nd level adult ICUs serve as a pandemic hospital if pandemic hospitals are inadequate.
 
Responsibilities of the Provincial Health Directorate
The provincial health directorate:
•        Enables the samples taken from inpatient health institutions to be quickly and appropriately sent to the related laboratories.
•        Enables the research of the epidemiological link between the cases if there is a suspicion of case clustering.
•        Ensures that the contacts of all the cases recorded within HSYS are traced, contacts are listed and recorded within HSYS.
•        Follows the daily tracking status of the inpatient cases which are recorded within HSYS.
•        Enables people coming from abroad, people who have been in contact with a probable case and the individuals who are confirmed cases and have decided to be monitored at their houses, to be monitored by the Family Medicine Service.
•        Coordinates the contact tracing and positive case tracking to be done by field teams and monitors daily.
•        Coordinates the monitoring of people coming from abroad who have decided to be monitored collectively and follows their daily monitoring.

On August 5, The MoH documented new approaches regarding managing COVID-19 cases at home: positive cases with mild symptoms shall be treated at home and all contacts shall be tested at home. Quarantine and the treatments of these patients will be closely monitored by filiation teams – epidemiology investigators and tracers. If there are not enough medical personnel in a province, then filiation teams will consist of muhtars (heads of local governments), teachers and other public employees. Tracing teams investigate patients and attempt to  find other possible infected individuals (contact tracing). They are also in charge of performing the COVID 19 test on suspected cases, and monitor patients that remain at home, e.g. whether they are taking their medications and follow their symptoms.
According to the Ministry of Health's treatment guidelines for pediatric patients under the age of 18, possible adverse effects of drugs in children should also be taken into account when making a treatment decision. Currently, treatment in childhood should be evaluated separately for each patient. Drug treatment may be planned for children with risk factors and severe symptomatic cases. Hydroxychloroquine sulfate is not approved for use in children under 6 years of age. If it is to be used, "Informed Consent Form" should be filled. The pediatric treatment guide for COVID 19 patients available at:
https://covid19bilgi.saglik.gov.tr/depo/rehberler/covid-19-rehberi/COVID-19_REHBERI_COCUK_HASTA_YONETIMI_VE_TEDAVI.pdf

Since March, Turkey has initiated 18 drug and vaccine projects to treat and prevent COVID-19.

On August 4, the City Health Directorate in Ankara ordered hospitals to save at least half of all clinical service beds for COVID-19 cases. All unoccupied intensive care beds were then reserved for COVID-19 patients. All elective surgical procedures were suspended.

Local initiatives to curb the spread of COVID-19 in the different provinces

As part of the efforts to strengthen public health measures to contain the virus, Kırıkkale was selected as a pilot province to implement new inspection and enforcement rules. The Province Pandemic Control Centerin Kirikkale became operational on August 5, 2020. The duties of this center has been to manage and control audit teams and to record data about violations of COVID-19 regulations. Approximately 100 mobile epidemic warning teams and 10 expert inspection teams were formed within the province. The audit teams are checking as to whether citizens and workplaces comply with COVID-19 related measures.  The control center also includes a call center where violations to COVID-19 regulations can be notified; a database will be established for all inspected businesses, public transportations including taxis and individuals who violate these measures. In order to complement the control center, the "Hayat Eve Sığar Güvenli Alan (HESGA)" app allows citizens to report violations to COVID-19 preventive measures conducted by businesses, public transportations, and taxis online. If this pilot proves to be effective, it will be expanded to all provinces.

Sources:
https://www.aa.com.tr/en/health/turkey-showing-progress-towards-making-virus-vaccine/1931349 
https://www.cnnturk.com/turkiye/son-dakika-ankarada-artan-kovid-19-vakalarina-yonelik-yeni-tedbirler
https://www.aa.com.tr/tr/koronavirus/kirikkalede-salgin-denetim-merkezi-faaliyetlerine-basladi/1932221