Bosnia and Herzegovina and Serbia are countries in the Western Balkans that have emerged from the former Yugoslavia and share some degree of similarities including organisation and structure of their health care. The impact of the COVID-19 pandemic on countries in Eastern Europe has only recently received some attention. It remains unclear how some of the Central and Eastern European countries managed to keep the number of cases low in the first wave of the pandemic (1). However, by mid-March 2021, six of the 10 countries with the highest mortality rates per 100,000 inhabitants were from Central and Eastern Europe (1). Stark differences also exist in the prevalence of chronic kidney disease between Western and Eastern Europe (4). These may be partly explained by the prevalence of diabetes, raised blood pressure, obesity and tobacco use is higher in Eastern than in Western Europe (4). However, surprisingly little is known about the impact of COVID-19 on the provision of care in nephrology in these countries.
On a worldwide basis the incidence of COVID-19 in dialysis centres varied hugely and ranged from 2.5% to 19.6 (Table 5). Here, we report data from the Western Balkan on a background of very scarce or non-existent data in the region overall. Remarkably, despite our overall circumstances, the overall incidence was therefore not as high as reported in more developed countries. In Tuzla, the overall incidence of COVID-19 positive RRT patients during 11 months in both studied periods was 9.58% (32 out of 334) patients, and in Niš 22.65% (94 out of 415).
Table 5
Review of literature data on incidence of COVID in the dialysis population
Authors | Patients | Incidence | Time period |
Ma Y et al. (China) (1) | 42 (230) | 18,3% | Jan – March 2020 |
Corbett RW et al. (USA) (2) | 300(1530) | 19,6% | From 13th of March when 1 case was noted during upcoming 6 weeks |
Milia V et al. (Italy) (3) | 25(209) | 12% | March 2020 |
Alberici F et al. Italy (4) | 94 (643) 4 dialysis centers | 15% | March 2020 |
Goicoechea M et al. (Spain) (5) | 36 (282) | 12,8% | March 12th to April 10th, 2020 |
Yau K at al. (Canada) (6) | 11 (237) | 4,6% | April – May 2020 |
Wang R et al. (China) (7) | 5 (201) | 2,5% | February 2020 |
Rincon A et al. (Spain) (8) | 36 (192) | 18,8% | March 20 – April 21 2020 |
Keller N et al. (France) (3) | 123 (1346) 8 dialysis centers | 9,1% | March 5 – April 28 2020 |
Creput C et al. (France). (9) | 38 (200) | 19 | March – April 2020 |
Santacruz et al. (Ecuador) (10) | 37 (159) | 23,2% | April – September 2020 |
Lano G et al. (France) (11) | 129 (2336) 11 dialysis centers | 5,5% | March – May 2020 |
Mazzoleni et al. (Belgium) (12) | 40 (62) | 65% | March – April 2020 |
Valeri AM et al. (USA) (13) | 114 (900) | 13% | March – April 2020 |
Our study showed that in both centres, in the first time period, from February to the end of June 2020, the incidence of COVID-19 positive ICHD patients was significantly lower (4.81%) than in the second time period, from July to the end of December 2020 (18.13%). However, the incidence in the general population was also higher in the second period: At the end of June 2020, 4453 COVID-19 positive patients (0.136%) were reported in Bosnia and Herzegovina, and 14564 COVID-19 positive patients (0.167%) in Serbia, while in December 2020 a total of 110985 patients were reported in Bosnia and Herzegovina (3.39%) and 337923 patients in Serbia (3.87%). Of note, the second period featured a relatively quick cessation of lock-down restrictions as well as free entry to both our countries whereas a complete lockdown in Bosnia and Herzegovina and Serbia was in force during the first period.
In our study mortality for chronic HD patients with COVID19 for Tuzla was zero in the first wave, and 25% in the second wave, while for Niš it was 31,25% and 25% respectively. The overall mortality for patients with RRT (chronic HD, CAPD and renal graft) for Tuzla was 0 in the first and 16,67% for the second wave, and for Niš it was 45,45% and 23,44% respectively. In comparison in ERACODA (5) the 28-day probability of death was 21.3% (95% confidence interval 14.3–30.2%) in transplant patients and 25% (95% CI 20.2–30%) in dialysis patients that went up to 33.5% for hospitalized dialysis patients. For comparison a multicentric French study (6) of 2336 patients reported that 81% of patients were hospitalized and 28% of patients died whereas others have reported mortality rates between 10% and 43% (7) (8) (9) (10) (11) (12).
Of note, recommendations of the medical professionals and decisions of COVID-19 crisis respond teams in both countries diverged most of the time. As an example, restrictions were significantly eased during Orthodox Easter and Christmas and political elections in Serbia and during the Eid in Bosnia and Herzegovina, which was followed by an increase in COVID-19 cases in both countries.
We put a lot of resources into infection control measures and into education of staff and patients as one of the few strategies available to us. Our efforts were hampered by lack of adequate PPE and the absence of an organised effort for vaccination for anyone except for medical staff. In addition we did not have capacity to ensure the recommended distance or mechanical barriers between HD patients, and we did not have sufficient isolation rooms, or separate transport of all suspected cases. We had to hospitalize all COVID positive HD patients for we lacked isolation facilities for outpatient dialysis while reorganizing night shifts for suspected cases (symptomatic but PCR negative and those with positive contacts) and those discharged from COVID hospitals. Hospitalization per se could be attributing factor for high mortality especially in frail patients (13). In ERACODA (5), it was also noted that mortality was very low in dialysis patients who were not hospitalized.
It is also useful to briefly compare infection control measures between the two centres (Table 2). Niš had better protective equipment, namely KN95 face masks for staff and surgical masks for patients while staff in Tuzla had only surgical masks and patients were wearing cloth masks. An Irish study emphasized the importance of wearing masks in dialysis centres (15). Remarkably, there is no national authority in Bosnia and Herzegovina that would issue or coordinate such regulations but mandatory wearing of masks for all patients and staff was introduced in the Tuzla Dialysis Centre in January 2020, and triage before entering the Dialysis Centre in February 2020, which may have contributed to low incidence and mortality during the first wave. It is difficult to compare our infection control measures to those taken elsewhere in our region. One report from Slovenia (16) described better PPE, a more favourable nurse-to-patient ratio and distance between dialysis beds but also noted the lack of individualised transport for COVID-19 positive patients.
There were other differences between the two centres. The centre in Niš had access to a number of mobile reverse osmosis devices which facilitated dialysis of acute patients at several isolated locations (COVID hospitals). In Tuzla, there were only 4 mobile dialysis machines for all acute patients. This shortage led to a situation where continuous RRT methods could not be offered any longer and there were no funds to purchase additional equipment. This situation was further compounded by shortage of trained dialysis nurses which may explain the very poor outcome in patients with AKI and COVID-19, who had to be dialyzed.
The COVID-19 pandemic has affected many different countries with different circumstances globally and an ideal approach to fighting infection does not exist. Flexibility of the strategy (22) is key to preventing the spread of infection and timely planning can overcome some the effects of the pandemic (23). Another area that also deserves consideration is pan-European cooperation and support which has worked so well in other areas for example during the earthquakes in Turkey and Armenia (24). We suggest that the European Renal community considers ways in which nephrologists in affluent well developed European countries can help their counterparts in less well developed countries in situation like this.