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THL Q&A: We have to find a way to live with the virus

We asked THL your questions.

Terveyden- ja hyvinvoinnin laitoksen tiedotustilaisuudessa johtava asiantuntija Jussi Sane ja ylilääkäri Taneli Puumalainen.
Chief Specialist Jussi Sane of the Finnish Institute for Health and Welfare answered questions posed by our readers. Image: Eleni Paspatis / Yle

With Finland counting 5,000 confirmed cases of coronavirus at the time of publication, people have a lot of questions.

How long will the coronavirus outbreak last? Why are schools being reopened? Is there going to be a second wave of the coronavirus epidemic in Finland? Should I wear a mask?

Jussi Sane, Chief Specialist and Team Leader (Preparedness and Response) at the Finnish Institute for Health and Welfare (THL) answers questions posed by our readers.

Schools reopening

1. Isn’t it a risk to open schools when there is so much we don’t know about the disease? Even if children don’t get very sick themselves, we don’t know what kind of role they play in the transmission of the virus.

The understanding that we have right now is that infection in children is relatively rare compared to other age groups. It is a mild disease in kids where they develop little to no symptoms based on evidence from our studies. Of course, there are exceptions.

In Finland, we haven’t had any kids with severe infections needing hospitalisation or intensive care and this is in line with data from other countries. There are also studies indicating that the transmission of the virus from kids seems to be lower than in adults. It is not as effective as it is in adults.

We examined a school exposure situation in Finland where a nine-year-old with symptoms spent a day in school in March. Fellow students and a football team the child practised with had to be quarantined, but we didn’t observe any secondary infections — no one got infected from the child. Recent studies from France also looked at an asymptomatic child who attended school and interacted with a lot of people, but no secondary infections were observed.

Of course, we need more data to confirm this. We are currently conducting studies on a couple of school exposures and also examining households to see how the infection spreads to learn more.

When it comes to the decision of opening schools, obviously you have to look at how the disease behaves in children but the government and other actors also have to weigh in the negative effects of closing schools. You can’t keep schools closed forever. It is the same in every country. You need to find a good balance. You can never eliminate risks completely when it comes to any infection or threats in society. But you can reduce risks in many ways and then balance it with the pros and cons of school closure.

Masks

2. Would it help slow the spread of the virus if everyone wore masks in public places, even if they are homemade or fabric masks because of the shortages?

At the moment, there is no clear scientific evidence on this. THL and the Ministry of Social Affairs and Health’s guidelines state that there are situations where you have to use masks like in healthcare. But when it comes to the general public using masks, specifically if it is homemade, the matter is not that simple — there may be risks associated with that as well. You have to know how to use them. If you have the infection or are symptomatic, the mask could protect people around you to some extent. But it is less effective to protect yourself by using masks, based on current information. To impose an obligatory mask rule, you really have to look at all factors and risks involved.

3. So should people wear masks when they go outside?

People can do that, but it is important that they get guidance on how to use masks and how not to use them. Because there are risks if you use masks without learning how to put them on and take them off. The Finnish Institute of Occupational Health FIOH has advice on how to use face masks correctly.

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Maskeja
There has been a lot of conflicting information surrounding the usage of masks in public. Image: Alexander Piragis / AOP

4. What is THL’s official recommendation on masks?

At the moment, THL and the Ministry of Social Affairs and Health don’t give any recommendations for using masks in public spaces. We are not inventing this ourselves — we are looking at WHO (World Health Organization) and ECDC (European Centre for Disease Prevention and Control) guidelines and recommendations which are pretty much in line with what we are saying.

Situation in Finland

5. How many people have recovered from Covid-19 in Finland?

According to a preliminary estimate by THL, 3,000 people have recovered from the disease. But this is a difficult question to answer. I never understood how other countries, especially in Asia are documenting the recoveries. Maybe in their system, all patients are in the hospital even when they don’t need to be. Here in Finland, around 80-90 percent of the infections are mild and are recovering at home. We are of course looking into discharge registers in hospitals and recording the number of cases in hospitals and fatalities, but we are not following up on recoveries of those at home on an individual level.

But because we were facing the pressure of having to release information, we took a different approach. The current number on our website is a crude estimate based on the confirmed cases in our national infectious disease register. If we have samples on day X and then nothing else is recorded on the list two weeks after that, no recordings of hospital sessions, no death, it acts as a proxy for the recovered. We don’t have any other way to check if the person has no symptoms on a daily basis.

6. Is there a risk of reinfection? Has Finland seen any cases of recovered patients getting reinfected?

We are not aware of any case of reinfection yet. We are aware of cases where people have been sick for a long time, become asymptomatic for a while and then the symptoms may peak again and they may end up in hospitals. That’s the biphasic nature of this disease. It could just mean they are suffering from the same disease for a long time. At that point, even if you test positive, it doesn't mean you are infectious, the test could be detecting the remnants of the virus — its RNA and DNA . We don’t have any evidence of any proper reinfections.

7. What is the estimated case fatality rate for coronavirus in Finland?

Case fatality is something around four percent — but it is only taking into account detected, laboratory-confirmed cases. This is not the same as infection fatality rate which is probably lower. We don’t know exactly yet, we are looking into it.

We need to understand more about the actual risk of infection, risk of death in different age groups. We can say from our statistics that in total only 14 cases of fatalities have been reported in those under the age of 70.

8. How does it compare with the original estimates from THL?

The outbreak in Finland is pretty much in a stagnant phase right now and has even stopped in a way. We are not seeing any increase in the numbers. The basic reproduction number or R0 as it is called is way below one right now. If you look at our predictions on how many people will need hospital and intensive care, the observed number in the Helsinki University Hospital district followed our predictions pretty closely in the initial phase, but now it is actually falling way below our predictions. So it can be said that the outbreak is not growing at this point.

9. Has Finland already experienced the peak of its epidemic?

Talking about peak is simplifying the matter. We didn’t really have the proper ‘peak’ that people talk about, where an epidemic has a beginning, a peak and end. We haven’t really seen that type of a typical peak.

10. Is there likely to be a ‘second wave’ of coronavirus cases especially if the social restrictions are lifted?

Of course, as in any country, there is a risk of a second wave of infections in Finland. We are not going to get rid of this virus anytime soon. As long as the virus is circulating globally, there is always a risk of another outbreak.

Social distancing and other measures to reduce the risk of infection have been keeping the numbers down. But we can’t live like this forever. Of course, people would agree that we have to start lifting restrictions gradually, but not open everything at the same time.

If and when there will be more contact between people, it is likely to lead to more infections. The goal is to keep it at a manageable level.

The negative effects of lockdown also pose a big problem. We don’t have healthcare if we don’t have taxpayers and we need to ensure that our healthcare in general is functional in the future.

Testing, disease and recovery

11. When will antibody testing be available?

There are a number of tests out there at the moment but we don’t know how well they all work. The sensitivity and specificity are important parameters. We along with other agencies are evaluating proposals from clinical laboratories. All labs need permission to perform the tests and if they implement an antibody test, they need to go through a regulatory process. The processes are ongoing right now.

I would say antibody testing is not yet available but will be soon. Of course, the interpretation of the tests are important — you have to look at test results with experts to understand what they actually mean.

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Koronavirusnäytteitä
THL experts say antibody testing will be available at laboratories soon. Image: Pasi Takkunen / Yle

12. If someone has the antibodies to the virus, does that mean they are immune and can safely go out? How long can this immunity last?

We have studied our coronavirus cases and we did see that they develop antibodies. But whether this makes them immune or not, nobody can be sure of that. A lot of assumptions are made based on how things work when it comes to other viruses. I would say it is likely that you develop immunity, but how long-lasting this immunity is, nobody knows.

Also, there are studies showing that a number of people who encounter the virus or who might be infected — especially if they get mild or asymptomatic infections — may not produce antibodies as quickly or to the same level as people who experience more severe disease. Their antibodies may not even be detected in the test. But we can’t be sure if it means they don’t have immunity. They could have cell-mediated immunity, an immune response that does not involve antibodies. A lot of questions are out there, but we will get more answers in the near future.

13. Is there a plan to handle asymptomatic cases who might spread the virus? How long do asymptomatic carriers of coronavirus remain infectious?

This is being currently discussed and we haven’t finalised our official guidelines on this yet. We have been looking into how other countries, specifically Nordic countries are handling asymptomatic cases.

We don’t know for sure how long asymptomatic carriers remain infectious because we don’t know exactly what stage of the infection the individual is in when the virus is detected. With regular symptomatic cases, even if they have mild symptoms, we do know that often within a week or eight days from the onset of the disease, you can find the infectious virus and isolate the virus. But after eight days, you can detect the DNA or RNA of the virus, but it doesn’t mean the virus is infectious. In such cases, it is easier to define the isolation period — you have to stay home for at least seven days and be asymptomatic for two days before you can go back to work.

But with asymptomatic cases, it is difficult to understand the phase they are in. But isolation of two weeks is a safe bet in any case.

14. How long does it take for a person to recover fully from coronavirus?

We don’t have the exact numbers because we are looking at this from a macro level. Of course, it also depends on every individual, but if you have a typical mild infection, it is probably over in a week or sometimes even less. But clinicians should be asked how long they keep patients in hospitals — it could vary from days to weeks.

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Ihmisiä kävelyllä.
It is safe to exercise outdoors as long as you maintain social distancing, THL expert said. Image: Henrietta Hassinen / Yle

15. What precautions should people take when they go outside for a stroll, hike or run?

The general guidelines apply here — follow government recommendations and keep a distance. If you meet people or go into shops, practice hand hygiene and cough hygiene. These are the most important precautions.

I think it is important that people do go out, exercise, run, walk and enjoy outdoor activities because it keeps people healthy. It is not healthy to stay indoors all the time. You need to find a good balance — people should be able to go outside and lead a healthy lifestyle but at the same time, remember the rules and maintain social distancing.

Treatment plan

16. What treatments are being used for Covid patients in Finland?

This is a question better posed to clinicians. But right now, there is no specific treatment for Covid-19. A lot of work is in research and development currently. There are ongoing trials in Finland which are looking at different drugs and treatments to see how effective they may be. But right now, clinicians are treating patients as per guidelines, which I am not in a position to comment on.

17. What have the results been so far?

We do know from our intensive care register that most of those treated in the ICU have been cured as of now. At the moment, the recovery rate of patients in the ICU has been pretty good.

18. How does the Covid-19 test work? Is it standard across the country? What labs are being used for the tests?

Almost all the labs performing Covid diagnostics across the country are using PCR (Polymerase Chain Reaction) tests — which are used to directly detect the presence of an antigen, rather than the presence of the body’s immune response. There could be different versions of the test or different suppliers — it could be an in-house test or a kit from a company — but the principle is the same and they all need to obtain permits to perform them.

Mythbusters

19. Does UV light kill the virus or disinfect things brought from outside the home?

UV lights are of course used in labs to kill viruses. But I wouldn’t be able to comment on the efficacy of any specific kind of UV light that is being asked about or UV light from the sun. It probably doesn’t.

20. Will milder temperatures affect the virus transmission rate?

There are a lot of hypotheses and studies on this matter but I don’t think there is any clear conclusion. We know that influenza disappears in Finland when spring and summer comes. But it is not clear whether it has anything to do with temperature and humidity or other factors. It is likely that it has more to do with the way we behave during summertime. People are not indoors as much and are active outdoors and these factors can affect transmission. It is always an interaction of different variables. I don’t think anyone has proven that temperature has any correlation to how coronavirus behaves.

21. Is it enough to clean floors, door handles and other surfaces with soap or dishwashing detergent if there is no disinfectant cleaner? What are effective product ingredients to look out for?

Standard disinfectants and soap work effectively to eliminate the coronavirus on surfaces. There is no specific ingredient to look out for.

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Mies pesee käsiään kylpyhuoneessa.
Good hand hygiene can help reduce risk of infection significantly. Image: Tiina Jutila / Yle

22. Can the virus spread in public places like supermarkets, pharmacies just through talking, breathing and being in close proximity to people?

Like I said earlier, reducing risks is important, but we can never eliminate risks completely. Or we could, but then we would spend our lives indoors which wouldn’t be healthy for anybody. You cannot eliminate the possibility of getting infected by just being inside a supermarket even without social contact, but it is a low probability. We know that the main form of transmission is close contact with an infected person.

23. As a pregnant registered nurse, how can I protect myself and my unborn child while working? Are pregnant women in the ‘at-risk’ group?

This has been discussed extensively around the world. There is still no clear evidence that pregnant women are specifically more vulnerable to coronavirus. As we know pregnant women are in general more susceptible to a lot of infections and the same amount of care and caution should apply in this case as well. Regarding pregnant health care workers, hospitals and employers may have tailored recommendations for their staff. But pregnant women in general are not classified as a risk group for coronavirus.

Finland’s strategy

24. Realistically, how long will it be before we can go back to normal life?

I don’t think anyone has the answer to that. Of course, you don’t want to talk about the health of people and the economy in a way that contradicts each other. But we need our society to be back at work in order to sustain our welfare society. We have to find ways to aim for some sort of normal again. It will take a long time to go back to exactly how things were before, especially when it comes to travel and people’s behaviour. We just have to find a way to live with the virus for a while.

25. What are the preconditions for switching to a track and trace strategy? Is there a specific R0 figure or other data points you are tracking?

Part of Finland's ‘hybrid strategy’ is to increase testing, and increase self-isolation and quarantine. The aim is to keep the outbreak at a level that is manageable. The most important risk groups are the elderly and we have to find ways to protect them better. We are getting new information every day, testing evidence, updating our risk assessments and making predictions — all this contributes to the decision making. But there is no specific number or data point that will dictate how we act.

Track and trace is also a part of the strategy. The regions have been employing this method for a while now. But if the case numbers drastically increase, we need to find more effective ways to track and trace.

We have to look at coronavirus control and response from a more comprehensive point of view and also factor in the negative side effects of the lockdown and isolation. We are taking gradual steps right now. Schools will be reopened soon and next steps will be discussed in the coming weeks. We’ll see what the government decides next.

You can find answers in English to more frequently asked questions about the coronavirus on the THL website.

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