Policy responses for Finland - HSRM

Finland


Policy responses for Finland

1.4 Monitoring and surveillance

On February 13th 2020 the novel coronavirus was included in generally hazardous communicable diseases by amending the Government Decree on Communicable Diseases.

On March 31st THL announced using the WHO ICD-10 code for coronavirus suspects, in addition to the ICD code for laboratory confirmed cases used earlier.(1) In reporting, probable COVID-19 cases are also advised to be defined as suspected cases.  Probable cases are defined on case history and symptoms, where the diagnosis is not confirmed by laboratory tests or the test results are not yet available.

Contacts are defined as persons who have been face-to-face with an infected person or in the same room for over 15 minutes.(2) They include, for example people residing in the same household or their visitors; people who have travelled with an infected person; people who work with or are in the same classroom as a COVID-19 infected person. Contacts are also defined as healthcare personnel who have treated a case, or laboratory personnel who have dealt with a COVID-19 sample.

 THL provides guidance on testing nationally, but contact tracing is done on the ground of judgement of the responsible medical officer. Practices between regions can vary. In regions with less cases contact tracing can be still done more actively, depending on resources and judgement of responsible medical   officer. Testing and contact tracing have not been part of core strategy of THL, but guidance suggests this should be done on the ground of judgment of available resources regionally and not reported in publicly available sources. On April 22 2020 government made explicit statement on moving to test, trace, isolate and treat –strategy expanding testing and contact tracing and continues to prepare the use of a mobile app for this purpose (5)

Therefore, contact tracing is implemented at different intensity depending on the area and its epidemiological situation. Some hospital districts have been able to trace all the cases in their area. Otherwise contact tracing is implemented more widely and has been continued with new cases even if transmission source of all the previously detected cases are not known.  Those in close contact with the infected person are contacted and they are told about the possible infection and self-care instructions for those with mild symptoms, and about seeking care if they get severe symptoms. Contacts are advised to avoid social interaction and travelling and to follow symptom development over 14 days after exposure. A physician may order a contact person to be quarantined, if the person’s situation does not allow for self-isolation. High risk groups are considered in these decisions (persons over 65 and those with chronic diseases).

The infectious disease register run by THL (THL/TTR) gets notifications of all COVID-19 tests, positive and negative, but only from laboratories that are contracted to carry out public services. As of 29th April 2020, in total 89800 COVID-19 tests had been conducted and reported to the THL infectious disease register. Laboratories testing privately are not similarly obliged to notify testing activities, unless the test is positive, in which case private services also have to notify the case to the register. The three largest private healthcare organisations, Terveystalo, Mehiläinen and Pihlajalinna, conduct tests also, with Terveystalo and Mehiläinen reporting their tests conducted online. THL/TTR announces the testing and infection situation every day at 9:30 (4) and THL typically also updates this information daily on their website. This situation is based on the information collected from hospital districts. Regional information is also collected through different open access data bases and reported daily.  

In addition to COVID-19 laboratory tests, THL has also collected data on the numbers of COVID-19 patients hospitalised and attended at intensive care as well as COVID-19 deaths. The data are collected from the chief medical officers of the hospital districts. Regarding deaths, under-reporting was detected in the Helsinki region in mid-April; the reported numbers had covered only hospital deaths but did not cover deaths at the Helsinki City nursing homes. The correction of the under-reporting on April 17 increased the cumulative death count by around one third.

Symptom self-reports are possible at a national eHealth service site Omaolo. The system may give the user an instruction to contact health services for assessment but it is not used for case reporting. In addition, Helsingin Sanomat, a national newspaper has launched a reporting site for COVID-19 symptoms together with Futurice (a company specialised in digital solutions) and University of Helsinki.(3) Several other media have joined the initiative since its launch on March 28. The web based Omaolo COVID-19 symptom self-assessment application (symptom checker) has been available in Finnish, Swedish and English languages from March 16, 2020. In total, over 775,000 self-assessments have been performed. From mid-July, daily numbers of self-assessments have been more than 10,000 and some 2,000 daily have been recommended to seek healthcare emergency services.

Contact tracing has become a key part of the Finnish exit strategy. However, the adequacy and requirements for contract tracing in practice has not been clear. THL is responsible for coordination of contact tracing and is currently exploring the need. According to MSAH interview it is now estimated that most contacts have been traced. There are in total 460 persons working in contact tracing, and it is estimated that about 220 more are needed in the summer (7). In practice, most tracing takes place in the decentralized context in cities and by local government officials. Contact tracing has mostly been expanded through internal rearrangement of existing work-force and inclusion of senior medical students. Minor support has been allocated for teaching resources for contact tracing capacity and five million euros have been made towards digital solution on contact tracing expected to be available in mid June/ July 2020 (7,8). The mobile option is expected to provide potential to reach contacts in public places. The cabinet office assumes that: “With a mobile app, the exposed persons could be reached faster and more extensively. Through the application, people could receive instructions and they could also report their own exposure to healthcare service. (9)” However, it is unclear to what extent a voluntary app would reduce the need for human contact tracing workforce how much it potentially increases the number of contacts. Privacy and data protection issues remain important and  formal consultation of the mobile app was open until 5.5. (10). This is because questions on applicability, privacy and data protection issues have been raised with Commission communication on guidance on apps on COVID19 addressed in Parliament on 24.4. (11)

In late April, MSAH prepared a proposal for a roadmap for the introduction of a mobile application to support the tracing of coronavirus infections in Finland. The proposal was circulated for comments until 5th of May 2020. The application to support the tracing of transmission chains, and its back-end system, would be implemented in a manner ensuring fundamental rights, data protection and data security. The use of the application would be voluntary and free of charge, and the processing of the data would be based on personal consent. The application would use mobile devices’ Bluetooth technology for contact tracing. 

On 11th May the government released a statement that summarised comments on a mobile application for tracing transmission chains of the coronavirus (12). The comments received by MSAH indicated that it is considered justified, but should protect privacy and be voluntary. Comments considered it helpful but that evidence and impact assessments are needed. The government state that it takes these comments into account as well as the progress and evidence from other countries. On 18th May Vaasa Central Hospital started the first three-week simulated pilot project with mobile application Ketju (13). The application utilizes Bluetooth technology to keep an anonymous record of encountered people, when they also have the application installed (14). No personal information is collected, and the users have no access to its data. When user records a confirmed COVID-19 infection to the application, it automatically sends a notification to those exposed by that user. At June, South Karelia Social and Health Care District (Eksote) will start another pilot project to test if robocalls could support contact tracing.

In May 2020 MSAH prepared a draft proposal to amend the Communicable Diseases Act in order to create legal basis for the mobile application, and on 11th June the Government proposed these amendments to enter into force on August 31st at the latest and remain in force until 31st of March 2021 (16). THL would be responsible for providing an information system based on mobile technology, The Social Insurance Institution (Kela) for maintaining its back-end system and The National Cyber Security Centre, which operates within the Finnish Transport and Communications Agency, for the data security. This system would not replace the tracing work done by healthcare units, but to run parallel to it.

In response to demands of open information, the situation analysis and modelling team of MSAH and THL started publishing weekly corona situation analysis.  The analysis and updated situation is published weekly, with the first weekly update published on 15.5.2020.

The Finnish Institute for Health and Welfare started testing of the Corona smartphone application on Aug 4. The application is planned to be fully available in September. (17) The mobile application “Koronavilkku” to be introduced in September will improve traceability. Capacity for contact tracing is to be enhanced in all areas and a national centre for contact tracing is established for oversight, focus on border issues and utilisation of data from national covid-19 app “Koronavilkku”. Contact tracing capacities nationally and locally will be strengthened and quarantine measures and processes improved to ensure timely and meaningful action. Finally, gathering of data on testing and contact tracing will be improved with linkages to other data gathering measures, follow up and oversight, including on access to testing ensured. (16)

On Aug 31st smartphone application for contact tracing “Koronavilkku” was released to public. (18) As previously described in this section, it is a decentralised app that uses Bluetooth technology to collect information of other nearby users; which it utilizes when calculating probabilities of exposure. Before its release, it was subjected to comprehensive scrutiny of supervisory authority Traficom. In this scrutiny, no significant vulnerabilities emerged and the application was approved as secure. Though the usage of this application is voluntary, several public petitions have been made to increase its utilization especially among the youth and student populations. (18) On Sep 21st Koronavilkku had been downloaded approximately 2,100,000 times – accounting for 38% of the Finnish population. Though the usage of this application is voluntary, several public petitions have been made to increase its utilization especially among the youth and student populations. (18) On Oct 7th  Koronavilkku had been downloaded approximately 2,300,000 times – accounting for 42% of the Finnish population.

While the mobile app provides one means to reach contacts, the more traditional human resources have been responsible for most of contact tracing. Further resources have gained by training existing and new personnel for this task. In September about 3000 persons registered to online free contact tracing course by THL, Tampere University and University of Eastern Finland and over 1000 already completed the course. On 14th of October THL started gathering contact information of individuals, organisations and communities outside of public sector interested in participating in contact-tracing carried out by hospital districts and municipalities. By forwarding contacts THL aims to assist hospital districts and municipalities in recruitment of personnel for contact tracing.(20)

Sources:
1. THL (31/03/2020) https://thl.fi/fi/web/tiedonhallinta-sosiaali-ja-terveysalalla/-/thl-on-paivittanyt-ohjeet-covid-19-virusinfektion-kirjaamisesta-potilastietoihin-varmistamattomalle-koronaepailylle-oma-icd-10-koodi?redirect=%2Ffi%2Fweb%2Finfektiotaudit-ja-rokotukset
2. THL (03/04/2020) https://thl.fi/fi/web/infektiotaudit-ja-rokotukset/taudit-ja-torjunta/taudit-ja-taudinaiheuttajat-a-o/koronavirus-covid-19/toimenpideohje-epailtaessa-koronaviruksen-covid-19-aiheuttamaa-infektiota
3. Helsingin Sanomat (28/03/2020) Oire
4. THL (16/04/2020) https://experience.arcgis.com/experience/d40b2aaf08be4b9c8ec38de30b714f26 
5. Finnish Government (22/04/2020) https://valtioneuvosto.fi/en/article/-/asset_publisher/10616/hallitus-paivitti-suomen-koronavirusstrategiaa-rajoitustoimia-mahdollista-purkaa-asteittain-ja-hallitusti
6. THL (29/04/2020) https://thl.fi/fi/-/uudenmaan-vaestossa-vain-harvalla-esiintyy-uuden-koronaviruksen-vasta-aineita?redirect=%2Ffi%2F
7. Teittinen P (6/5/2020)HS Selvitti: Hallituksen koronastrategia nojaa tartuntojen jäljittäjiin, ja heitä tarvitaan pian parisataa lisää. https://www.hs.fi/politiikka/art-2000006497822.html 
8. MSAH (2020) Kontaktien jäljityssovelluksen käyttöönotto covid-19 –epidemian hallinnan tueksi: esitys etenemisestä. 21.4.2020. Available from: https://stm.fi/hanke?tunnus=STM053:00/2020   
9. MSAH (2020) Preparation for introduction of an application to trace chains of transmission continues - proposal for a roadmap circulated for comments. Press Releaste. Available: https://valtioneuvosto.fi/en/article/-/asset_publisher/1271139/tartuntaketjuja-jaljittavan-sovelluksen-kayttoonoton-valmistelu-jatkuu-esitys-etenemisesta-lausunnoille 
10. Lausuntopyyntö esityksestä kontaktien jäljityssovelluksen käyttöönotosta Covid-19-epidemian hallinnan tueksi. Available: https://stm.fi/hanke?tunnus=STM053:00/2020
11.  European Commission (2020) Guidance on apps supporting fight against covid19 pandemic in relation to data protection. Brussels 16.04.2020. C(2020)2523final. 
12. Finnish Government (2020). https://valtioneuvosto.fi/en/article/-/asset_publisher/1271139/lausuntoyhteenveto-mobiilisovellus-hyodyttaisi-tartuntaketjujen-jaljittamista
13. Vaasa Central Hospital (18/5/2020) https://www.vaasankeskussairaala.fi/potilaille/ajankohtaista/uutiset/2020/ketju-sovelluksen-pilotointi-alkaa-vaasan-keskussairaalassa/
14. Ketju (2020) https://ketjusovellus.fi/en/
15. THL – Coronavirus situation report (2020) https://thl.fi/fi/web/infektiotaudit-ja-rokotukset/ajankohtaista/ajankohtaista-koronaviruksesta-covid-19/tilannekatsaus-koronaviruksesta/koronaviruksen-seuranta
16. Finish Government (11/06/2020) https://valtioneuvosto.fi/en/article/-/asset_publisher/1271139/koronaviruksen-tartuntaketjujen-katkaisua-tehostavaa-mobiilisovellusta-koskeva-lakiesitys-etenee?_101_INSTANCE_3qmUeJgIxZEK_languageId=fi_FI
17. Corona application trial starts. Press release Aug 4, 2020, Finnish Institute for Health and Welfare  https://thl.fi/en/web/thlfi-en/-/corona-application-trial-starts-on-tuesday 
18. Koronavilkku (2020) https://www.koronavilkku.fi
19. Universities of Finland, Unifi (2020) https://www.unifi.fi/uutiset/rehtorit-suosittavat-etta-koko-yliopistoyhteiso-ottaa-kayttoon-koronavilkku-sovelluksen/ 
20. THL 14/10/2020 https://thl.fi/fi/-/thl-keraa-listaa-jaljitystyosta-kiinnostuneista-tarjolla-tukea-kuntien-ja-sairaanhoitopiirien-tartunnanjaljitystyohon