THE EPIDEMIOLOGICAL situation in Croatia is surprisingly favorable, considering that we have allowed hundreds of thousands of tourists from all over the world to come with no serious restrictions.

The Coronavirus Task Force announced on Sunday that only 61 new cases and no deaths had been recorded. Yesterday, we had 45 new cases and one death. There are currently 586 active cases in Croatia, 121 patients are in hospital, and eight are on a respirator.

The situation in our neighboring countries is significantly worse, especially in Serbia and Bosnia and Herzegovina, where new cases are counted in three-digit numbers, and deaths in double-digit numbers.

At the same time, according to the eVisitor system, there are currently more than 830 thousand tourists in our country, and more than 660 thousand of them are foreigners. Most of them come from Germany, Slovenia, Austria, and the Czech Republic. Tourists from countries like the USA, where the pandemic in full swing, can enter Croatia without getting tested or quarantining. 

According to the data we received from the Croatian National Tourist Board, from January 1 to August 9, 2020, 5.2 million arrivals and 33.6 million overnight stays were achieved in Croatia, with 4.2 million arrivals and 27 million overnight stays being from foreign guests. Over the past weekend alone, foreign tourists accounted for more than 1.8 million overnight stays.

We should all be satisfied with such results. But some people are understandably questioning whether our epidemiological data are credible or if they were embellished because of the tourist season.

How to know if the situation is really epidemiologically favorable?

How can we know if data is embellished or not? The results can be influenced in different ways. For example, the Croatian health care system could test fewer people to get a low number of infected people.

Therefore, experts believe that the number of infected people is not the best measure of the epidemiological situation in a country or region, and it should not be the only number that is taken into account. For a complete understanding of the situation, three key factors need to be monitored: the number of infected, the rate of positive cases in the total number of tests, and the number of deaths.

However, different states also have different ways of calculating deaths, so some deaths from COVID-19 can be attributed to underlying diseases.

Finally, for an objective view of the situation, it is also important to follow trends - whether the number of sick and dead is increasing, whether it is stagnant or decreasing. Finally, it is important to take into account the numbers of new patients, hospitalizations, and deaths in relation to the total population.

Should we test more people?

One of the logical explanations for the surprisingly favorable Croatian epidemiological data could be that Croatia is testing relatively few people.

Serbian President Aleksandar Vucic has repeatedly said that Serbia would have significantly fewer infected people if it tested as little as Croatia.

In late July, he almost openly accused Croatian authorities of embellishing the situation, saying Serbia had made a different decision on testing than Croatia and Bulgaria because they prioritize people's health and lives, and not "political numbers."

This thesis is partly supported by the fact that only 727 people were tested in Croatia on Saturday. Out of those, 61 (8.5%) tests were positive. A total of 129,379 people have been tested in Croatia since the beginning of the pandemic, and a total of 5,649, or 4.7% of the tests were positive (see interactive map below).

This is a relatively high percentage, above the European average. Only Bulgaria (4.9%), Romania (6.5%), Spain (7.4%), and Ukraine (8.7%) have a higher percentage of us. Even Sweden, which had an even higher percentage of positives than Croatia in July (7.9%), improved its statistics. Serbia currently has a slightly lower percentage of positives - 3.3%. However, the numbers of active, hospitalized, and deaths in the neighboring country are significantly higher.

Ozren Polasek, Head of the Department of Public Health and Head of the Center for Global Health at the Medical Faculty of the University of Split, believes that we have a very good epidemiological situation in Croatia and that everything is under control. He does not agree with Vucic's accusations.

"Serbian authorities reacted badly, and they are now trying to find an excuse," Polasek says.

He explains that the percentage of positive tests can vary significantly:

"I used to think that Alemka Markotic was wrong for imposing restrictive testing. But in the end, we should look at mortality. As long as the mortality isn't high, we have the situation under control even with a lower number of tests. We are currently at an optimal point when we look at the number of tests compared to uncontrolled disease outcomes."

Epidemiologist Branko Kolaric from the University of Rijeka believes that it would be impossible to hide a bad epidemiological situation in any democratic country.

"Very quickly, the numbers of hospitalized, people on respirators, and deaths would increase. It is impossible to hide."

Is the number of deaths embellished?

Croatia is also doing well in terms of the number of hospitalized and the number of deaths. So far, a total of 158 patients have died. With 38.24 reported deaths per million inhabitants, Croatia is one of the most successful in the fight against COVID-19 in Europe. Even neighboring Slovenia has more deaths per million inhabitants (57.72). With 94.2 deaths per million, Hungary and Serbia are significantly worse than Croatia, and Montenegro and BiH with over 100 are even worse (see interactive map below). Belgium, Great Britain, Spain, Italy, and Sweden have the worst numbers in Europe.

It should be noted that there is no standardized rule on counting COVID-19 deaths.

Polasek says countries' policies can differ widely.

"Belgians count anyone who dies while having COVID-19 as if they died from COVID-19. Germans will not count anyone as dead from COVID-19 unless it is clear that their death was caused by the complications of COVID-19. Croatia is somewhere in the middle. It is inconvenient that there is no standardized definition to distinguish clearly who died from COVID-19 and who with COVID-19," says Polasek.

Kolaric agrees with that assessment.

"In Croatia, everyone who has COVID-19 and dies from something that could be the result of that infection is counted as having died from COVID-19. Any death that is possibly related to COVID-19 is counted as death from COVID-19 in Croatia. More precisely, the cause of death is determined to be a sequence of pathophysiological changes caused by the disease, in this case, COVID-19 ", explains Kolaric.

So, we can say that Croatia is doing well by that criterion as well. Is it possible then that there are some other possible explanations for such a favorable situation despite so many tourists?

Tourists, especially young ones, will not get tested in Croatia

One of the possible explanations for why we do not have more infected people could lie in the fact that lately, more young people have been getting infected, especially in clubs and various hangouts, and as young people generally have milder symptoms, they often don't get tested.

When it comes to infected tourists, it is expected that they will be reluctant to get tested while on holiday in a foreign country. If those foreign tourists are young, it is very likely that they will not get tested either in Croatia or upon their return home unless they have to, as is the case in Germany. Many will recover from COVID-19 with no medical intervention, as they would recover from a cold or flu. Getting tested in a foreign country would only complicate things unless the symptoms are severe.

Recently, 10 German high school students and two Italian high school students tested positive after returning home from a vacation on Pag. German media reported that their graduates' trip was organized by a travel agency specializing in party travel. They felt the first flu-like after returning from vacation, but this does not necessarily mean that they got infected in Croatia. Since the incubation time of the SARS-CoV-2 virus is between 2 and 14 days, and sometimes up to 27 days, it is possible that some of them were already infected and then spread the virus during the trip. Of course, it is also possible that they got infected in a club in Croatia.

Kolaric says that it is very likely that we have more infected people than the numbers show. He also believes that we should consider the number of locals infected in tourist towns to determine how tourism affects the spread of the coronavirus.

"We could determine if we have a problem with tourism if we monitor whether we have a significant increase in the number of infected among the local population in tourist towns," says Kolaric.

Young people getting infected could be a problem in the long term

We could say that tourism is not as dangerous as it was believed it would be. The people getting infected are mostly young, and the number of active cases is low, as well as the number of hospitalized people and the number of deaths.

Polasek says that young people will become the main carriers of the virus.

"In the spring, the epidemic spread primarily through semi-closed systems, among the elderly. It is currently spreading primarily among younger people who are more mobile and not afraid of the virus. This is good in a way because they are less likely to experience severe symptoms or die from the virus, "says Polasek

"Many young people are even openly denying the existence of the coronavirus. They are tired of being afraid of COVID-19, and they wish they could just turn it off and say it's over. Older people are more careful because they understand the risks. So far, we have had about ten different viruses that young people have recovered from as easily as they would from a trivial cold. For young people, COVID-19 is also a relatively trivial disease, at least in terms of symptoms," explains Polasek.

However, young people who get infected during the summer holidays will return to their families and infect those at risk. Finally, research has shown that COVID-19 can cause problems that will affect young people in the long run.

The problem of nightclubs

Both scientists agree that the biggest hotspots at the moment are nightclubs. However, this problem is not easy to solve. If we close night clubs, young people might rebel. Also, politicians generally want to keep a good relationship with club owners.

Polasek says that we are now in the phase of finding out what is dangerous and what isn't.

"Some things that we did not consider to be as dangerous, like weddings, turned out to be a problem. On the other hand, we thought tourism might cause problems, and it turned out not to be as dangerous. Clubs are definitely a problem. Every country is different, and we are now trying to determine what is dangerous to Croatia," says Polasek.

Kolaric mostly agrees.

"Nightclubs are a serious problem because they can infect many young people who will not have more serious symptoms. I was not in favor of opening clubs in June. It is very difficult to keep a distance in clubs. People get drunk, shout in each other's faces, they hug and kiss. The risk is high there, even higher than at weddings," says Kolaric.