No country in the world knows the exact total number of people infected with SARS-CoV-2, the virus that causes COVID-19 disease. All that is known is what can be learned from the official records kept by health authorities based on the results of the tests performed. All infections that are laboratory confirmed are considered confirmed cases.

This means that the number of confirmed cases depends on the number of performed tests by country and the choice of who is going to be tested. No testing, no data. For the number of tests performed and for the results given by different test models, each country has similar, yet diametrically different views and approaches. The question is whether the numbers of patients and deaths as a result of COVID-19 from different countries can be compared at all, i.e. whether such comparisons give reliable results.

The Balkan countries do not have a consistent strategy when it comes to COVID-19 testing. Thus, almost every country says that they follow the recommendations of the WHO, but it seems that these recommendations in each country are interpreted differently. For example, in most countries in the region, postmortem tests are not performed, i.e. people who have died of other reasons are not tested for COVID-19. This was confirmed by the Macedonian Minister of Health Venko Filipče, as well as the President of the Macedonian Commission for Infectious Diseases, Dr Zarko Karadzoski. However, in North Macedonia, such postmortem tests have been performed since the beginning of the epidemic, in order, as they say, to have insight and greater control over the situation. Also, unlike other Balkan countries, in North Macedonia, a person must have two negative tests to be considered recovered.

Dr Aleksandar Stojanov, a longtime epidemiologist and recently acting director of the Center for Public Health, as well as a member of the Macedonian Commission for Infectious Diseases, says that when it comes to the number of tests performed in Macedonia one fact should be taken into account – the health policy demands that even those who died in a car accident, and then proved to be positive for the infection are recorded as COVID-19 deaths.

– Recently we had a man who hanged himself and had a positive postmortem COVID-19 test. In reality, he had died because he hanged himself, not because he was positive of COVID-19, and yet we have recorded that he had died as a result of the virus. There are traffic accidents in which people die, and if it is proven that they are positive of the virus, we record them as COVID-19 victims, says Dr Stojanov. He believes it is necessary to clear such records to get the real death toll.

– Many countries in Europe follow the principle that all those who have died outside the hospital should not be considered COVID-19 deaths – he added.

Dr Stojanov explains that when it comes to testing, states follow the general recommendations provided by the World Health Organization.

– It would be ideal if all citizens in the country were tested. But realistically, no health system can withstand it. Our laboratories could not achieve this. China has tested six million people and has a total population of 1.5 billion. Mass testing is a great option, but we do not have the chance to realize it – explains Stojanov.

In neighboring Serbia, the number of positive cases is on the rise. More than 50,000 tests were performed there last week. In the same period, about 2,500 tests were performed in Montenegro, about 2,800 in Albania, 6,300 in Slovenia, and 8,266 tests were performed in North Macedonia over one week. In fact, according to Serbian authorities, in the past week alone, Serbia has conducted two and a half times as many tests as all of these countries combined. However, this is to be expected, given that Serbia has the largest population and the highest number of registered cases of COVID-19 in the region.

In Serbia, all citizens who have symptoms of coronavirus and who have been in close contact with an infected person have the right to free testing. Testing is also mandatory for patients undergoing surgery and certain procedures, such as bronchoscopy.

From the end of May, a test can be performed on personal request, and swabs are taken in institutes and public health centers, as well as in hospitals. The personal request test costs 50 Euros and the procedure is such that the citizens first transfer the money to the given bank account, and then schedule a test at an institute, health center or hospital.

Serbians complain that in addition to waiting for the results for a long time, hospitals sometimes refuse to test them, even though they claim to have symptoms. Citizens are complaining about crowds of people and long queues in front of the COVID-19 centers where the tests are being performed.

With about 300 new cases per day registered in Serbia in recent weeks, there appear more and more claims that there is a difference between those who have died because of the COVID-19 and those who have died with the COVID-19.

The case of the now-deceased former selector of the Serbian national football team, Ilija Petkovic, is one of the hallmarks. Petkovic was recently admitted to hospital with a perforated ulcer of the duodenum, but after being tested, he was found to be positive for coronavirus. He died a few days later, and one of the members of the Serbian Commission for Infectious Diseases, Dr Branimir Nestorovic, told the media that Petkovic did not die from the coronavirus but from bleeding due to the perforated ulcer.

This case, according to Dr Stojanov, would enter the statistics in North Macedonia as a coronavirus patient and deceased.

In Albania, since the beginning of the epidemic, testing has been limited to those who have had contact with an infected person. Chronically ill people, as well as people over the age of 65, who are considered the most vulnerable, can also be tested.

Albanian authorities claim they are implementing the World Health Organization (WHO) protocol, testing only people with symptoms and those who were in contact with infected people. The local technical committee of experts, after numerous accusations and criticism from the public regarding the testing strategy, said that the COVID-19 tests are based on expertise and a model selected according to WHO recommendations, to detect cases, monitor their situation and break the chain of infection.

In countries such as Albania, where there is a large local transmission, the WHO has recommended that the model testing-detection-treatment should be used. People with symptoms are tested, then everyone who was in contact with the infected person is detected, and after that confirmed positive patients are isolated and treated.

In neighboring Bulgaria, only people with symptoms are tested. In certain settlements or areas where clusters with a large number of patients appear, random tests are performed. A doctor or health inspector will refer you for testing.

In Kosovo, as in other countries in the region, those with symptoms and those who have been in contact with an infected person are tested.

For countries facing clusters (such as the countries in the region), the World Health Organization recommends that all suspicious cases be tested.

“When clusters become large, it is critical that testing of suspected cases continues so that cases can be isolated, contacts can be quarantined, and chains of transmission can be broken,” reads the recommendation of the WHO.

According to the World Health Organization, there are three cases of suspected coronavirus carrier:

  1. A patient with acute respiratory illness (fever or at least one symptom of respiratory illness, such as cough, shortness of breath) who, in the past 14 days has traveled or resided in locations where there has been local transmission of COVID-19.
  2. A patient with an acute respiratory disease who has been in contact with a registered or suspected case of COVID-19 in the last 14 days.
  3. A patient with severe acute respiratory illness (fever or at least one symptom of respiratory illness, shortness of breath; who needs to be hospitalized) who does not have an alternative diagnosis that fully explains the clinical picture.

WHO recommendations are that in the setting of limited resources in areas with community transmission, prioritization for testing should be given to:

  • people who are at risk of developing severe disease and vulnerable populations, who will require hospitalization and advanced care for COVID-19;
  • health workers (including emergency services and non-clinical staff) regardless of whether they are a contact of a confirmed case;
  • the first symptomatic individuals in a closed setting (e.g. schools, prisons, hospitals) to quickly identify outbreaks and ensure containment measures.