And while in North Macedonia, at this stage, such a strategy does not bring any credit to the Government (on the contrary, it increases dissatisfaction and insecurity), other Governments in the region (for various reasons such as elections or tourist season) enjoy great credit for the strategy which they implement.
This brief analysis presents data on asymptomatic cases, as well as national testing strategies aimed at preventing the spread of the COVID-19 infection.
Over the past two weeks, F2N2 in the process of monitoring detected headlines published on Internet websites, as well as inaccurate claims by individuals, directed at criticizing the system through comparisons of the number of infected people in the countries in the region.
Let’s get some things straight at the very start; every criticism is welcome and useful only if it is based on facts, and if it is constructive, that is if it offers solutions.
The attempts to create panic and a feeling of insecurity were detected through published statements and articles claiming that North Macedonia has turned into the Balkan Wuhan and is at the top of the list of countries worldwide with the highest rate of increase in the number of infected people. The article published on Infomax is actually an analysis “borrowed” from the New York Times, which shows the rate of increase in the number of infected people in each country in the world. The analysis is correct, in terms of the actual numbers shown, however, what the portals fail to mention is that there is an increase in all the countries in the region, somewhere more and somewhere less. Moreover, it is symptomatic that the disclaimer located at the bottom of the article (which has not been included by almost all of the websites in Northern Macedonia) indicates that the presented data are linear, or in other words, they do not take into account the strategies of governments for testing and keeping statistics related to COVID-19.
Thus, for example, the disclaimer states that some governments report only confirmed cases, while others report confirmed and possible cases. And there is also a group of governments that report on both types without separating the confirmed from the possible causes in the data. The New York Times notes that governments often revise data or report an increase in cases in one day, without historical revisions, which could lead to an incorrect pattern of daily reported numbers.
The increase of cases and the grounds for comparison between states
In the last two weeks, North Macedonia has seen an increase in the number of people infected with COVID-19. Given that we all want to make comparisons with the neighboring countries, the trend of increase in the numbers exists in each of them, but it is not as pronounced as in our country. And now, from a straightforward or black-and-white point of view, someone will say, “but in North Macedonia, the number of infected patients is the highest.” That is exactly the erroneous claim that causes manipulation and panic, provided the approach of the health authorities to the method of testing is not taken into account. It is even more erroneous to claim that one country is showing better results than another based on different comparison criteria.
On June 15th, 2020, the Minister of Health, Venko Filipce, explained that “86 percent of the infected patients are practically at home, while 14 percent are hospitalized.” This means that the country is faced with a strong wave of the COVID-19 epidemic, but what is encouraging is that there is a high percentage of asymptomatic patients and patients with the mild clinical situations who are undergoing home treatment. This has sparked a debate on social media, especially the part about so-called asymptomatic cases.
And while unilateral regional comparative analyses of the number of infected patients based exclusively on the criterion „number of infected” are abundant, what is missing is an analysis of the strategies and the testing decisions made by the epidemiologists. Namely, no one thus far has indicated what are the testing criteria of the countries in the region, which statistically speaking, has to be the basic prerequisite that needs to be met if someone wants to do a comparison of the numbers.
Or, simply put, could we compare which fruit is more nutritious, the apple or the orange, judging only by their appearance and the number (pieces) per kilogram, and thus determine their nutritional characteristics? Of course, that is impossible.
What does scientific research say about asymptomatic cases and national testing strategies?
On March 24th, 2020, The New England Journal of Medicine – NEJM(which was established over 200 years) published a scientific paper entitled “Asymptomatic Transmission, Achilles’ Heel of Current Strategies to control COVID-19“. Traditional strategies for controlling infectious diseases and preserving public health are largely based on early detection of the disease in order to prevent the spread of the disease. When COVID-19 erupted on the global stage, health authorities began implementing interventions that were used to prevent SARS virus infection in 2013. In general, these interventions included disease detection based on symptoms and subsequent testing and isolation. This approach is due to the similarities between the two viruses SARS-CoV-1 (SARS 2003) and SARS-CoV-2 (COVID-19). However, the development of COVID-19 has shown that they are different, namely, SARS 2003 was put under control in 8 months, resulting in 8,100 people infected in limited geographical areas.
In the case of COVID-19, as of 17.06.2020, more than 8,300,000 people have been infected in almost all countries in the world. This basic data alone are sufficient to accept the fact that different testing strategies are necessary. The scientific study explains a case of analysis conducted in a nursing home in the State of Washington, and the most important conclusion is that testing should not only cover those who clearly have symptoms but rather testing should cover all people who are at risk by virtue of having been in contact with those already infected, regardless of the fact that they have no symptoms.
This conclusion is important to this analysis because it focuses on persons living in such environments (nursing homes), where subjects have been in direct contact for a long time and share common spaces. This is very similar to the various family gatherings about which the health authorities reported in the past period, which have led to the formation of a high number of large family clusters. According to all the similarities, it can be concluded that the detection and isolation of asymptomatic cases can greatly inhibit the spread of the infection.
And while testing based solely on symptoms which are evident is possible, epidemiological evaluations about the spread of COVID-19 in skilled nursing facilities (as the one described by the study’s authors, “Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility“) strongly suggests that such an approach is inadequate. The study’s authors point out that the rapid rise of the infection around the world is clear evidence that the spread of the COVID-19 virus is the result of asymptomatic cases, and testing strategies need to be broader so as to include asymptomatic cases as well. Such claims also support the recommendation to wear protective masks (more details can be found at the US Centers for Disease Control and Prevention). Although the study only examines a small cluster in a nursing home, again, it is important to note that the environment in which these recommendations apply largely corresponds to the reason why large clusters of infected people appeared in Northern Macedonia.
On March 23th, 2020, The British Medical Journal – BMJ (which has been around for 180 years and publishes content from more than 70 medical and related scientific journals) published a study entitled “COVID-19: Identifying and isolating asymptomatic people helped eliminate the virus in an Italian village”. Italian scientists have proved that people who are positive to COVID-19 and who are not showing symptoms (or asymptomatic cases) can still infect others. In the same study, the researchers concluded that “isolating asymptomatic cases is crucial for controlling the spread of the virus as well as the severity of the epidemic.” In mid-February, residents of a village located 50 km west of Venice were tested. The results showed that 50-70% were asymptomatic cases, after which they were put in isolation, and within a period of 10 days there was a 90% reduction in the number of infected.
These scientific discoveries undoubtedly may and will have an INFLUENCE ON NATIONAL STRATEGIES AND TESTING POLICIES.
What are the testing strategies in Serbia, Bosnia and Herzegovina, Montenegro, Greece, Albania and Slovenia?
Within the framework of national strategies and testing policies, most countries in the region take into account two parameters that are common to all of them or in which there is only a small (insignificant) deviation in the approach. Each of these countries tests only and exclusively those citizens who have an acute respiratory problem and/or have developed some of the indicated symptoms of the disease such as fever, cough, difficulty breathing, and others. This means that if in a given family member with COVID-19 symptoms appear and the test shows that he is positive, while the rest of the members have no symptoms, they are not going to be tested, but rather they will be isolated and monitored for the next 14 days. If they develop any of the symptoms, then they are tested, and thus become part of the state statistics.
In addition to this, in Bosnia and Herzegovina, testing is performed exclusively on those who have developed a symptom and have a radiological picture for inflammation of the lungs or acute respiratory infection. The criteria are similar for Montenegro and Serbia, Greece, Albania, and Slovenia.
The spokesman of the Greek Ministry of Health, Sotiris Tsiodras, said: “If you are healthy and have mild symptoms, you should not be tested.” In Slovenia, it is possible to test citizens over the age of 60 who have mild or no symptoms at all. At the beginning of the outbreak of the pandemic, the Albanian government had limited the testing to people who had had contact with an infected person, chronically ill people, and people over the age of 65, which are considered the most vulnerable category. The Institute for Public Health of Montenegro has published questions and answers related to the coronavirus. One of the questions is “In which cases should a person be tested for SARS-CoV-2″. The answer states that the definition of a suspicious case is when the patient has three symptoms: severe acute respiratory illness, the absence of another proven etiological factor, and travel or vacation in China in a period of 14 days before the onset of the symptoms. In addition, for a person to be tested, it is necessary for him/her to have an acute respiratory illness or to have had contact with a confirmed coronavirus patient, stay or employment in a health facility where patients with confirmed coronavirus infection are treated. In other words, a person who wants to get tested for reasons of personal assurance does not have the opportunity if he does not meet one of the above conditions.
Serbia went a step further, deleting more than 4,000 active cases from its statistics, treating them as recovered patients on the basis of one negative PCR test and the passing of 28 days. The Institute for Public Health of Montenegro reacted to this Serbian practice, demanding clarification and calling it suspicious. If we look outside the Western Balkan region, we will see that both China and Norway have long since ruled out asymptomatic cases from their statistics.
So, the strategies and testing policies for COVID-19 of these states fundamentally differ and depart from the strategy that North Macedonia employs.
What is the strategy used by the Republic of North Macedonia?
According to the statement of the Minister of Health Venko Filipce, in North Macedonia, due to suspicion, especially in the last 4 weeks, about the development of large family clusters of infected, whole families with a large number of members are tested, where one or several members have shown symptoms and are positive for COVID-19. So, unlike all countries in the region, for the past 4 weeks, citizens who have not developed any symptoms and do not have an acute respiratory syndrome, but who have been in contact with a case confirmed positive for COVID-19, are being tested in North Macedonia. This is precisely the difference that precludes comparison of North Macedonia with any other country in the region, or simply put, everyone else waits 14 days (the period required to develop symptoms) before testing those who have been in contact with a person positive for COVID-19, whereas in our country it is being done immediately by testing all those who have been in contact with that person.
What is the result of this strategy?
The result is an increase in the number of active cases as well as the appearance of a huge number of asymptomatic cases. More than 3/4 of the total number of infected are not showing any symptoms, i.e. they have not developed the disease. According to official statements and data, one parameter that supports this claim is that only 15-20% of active cases have more severe symptoms and thus have been hospitalized. While the remaining 80-85% have either mild symptoms or no symptoms (asymptomatic).
Given this fact, it is very normal for the countries in the region to have fewer active cases when a huge percentage of those who are infected but have developed the disease (they have no symptoms) have not been tested.
Additionally, if we take into account the parameter time, the result of such a strategy, as far as North Macedonia is concerned, is that it could reap benefits very quickly because the situation is being controlled at a very early stage and a much more accurate picture and review of active cases is being obtained. For the other countries, maybe not immediately, but very soon, the same situation will have to develop, which will undoubtedly be much less pink than the one we see these days.
And while in North Macedonia, at this stage, such a strategy does not bring any credit to the Government (on the contrary, it increases dissatisfaction and insecurity), other Governments in the region (for various reasons such as elections or tourist season) enjoy great credit for the strategy which they implement. We ask you to judge for yourself which of these strategies is in the best interest of their citizens.
The need to revise the approach to the comparative analyses among countries in the battle with COVID-19
In the past period, we have witnessed daily comparisons between countries based solely on the number of infected patients. But is that the only criterion by which countries can be compared? Certainly not! Why, for example, do we not compare the numbers of people in self-isolation? Is not that a serious indicator of controlling the spread of the disease?
The pandemic is here, and will not disappear any time soon, there is no reliable cure, different tests are at different stages, predictions globally are different, the number of infected, not only in the region, but globally, is on the rise. Therefore, the primary concern should be the response to the pandemic, not just the number of infected patients.
Lastly, there is no system that can be sustainable without obeying the rules. Therefore, if anyone has ever had the illusion that this is a major global conspiracy and that the coronavirus is the same as a seasonal flu, take a good look at the numbers and the duration of this pandemic, because they say something completely different.
Therefore, the best protection is to respect the measures, because otherwise we will be counting and re-counting for a very long time, and in the end someone else will be to blame, never ourselves.
FINANCED BY
This project was funded in part through a U.S. Embassy grant. The opinions, findings, and conclusions or recommendations expressed herein are those of the implementers/authors and do not necessarily reflect those of the U.S. Government.
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