Policy responses for Finland - HSRM


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. On December 18th THL announced new guidelines for coding Covid-19 diagnosis, which distinguish between acute infections, suspected cases and sequelae to Covid-19 (24).

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.
The Koronavilkku app will receive an update at the beginning of March 2021 enabling the users to get tested based on their exposure notifications. Until now, the users who have received an exposure notification have been advised to get tested only if symptoms appear. (33) The wide use of the “Koronavilkku” app has not implied reported substantial benefits for contact tracing in practice (35). The time required to release of the code can become challenge also for its use to inform users of potential exposure.
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)

THL has gathered information of COVID-19 exposures and new transmissions in comprehensive and upper secondary education during the autumn term. The exposures have increased along with the accelerated epidemic situation yet transmission is not common in the school environment. (21)

Increasing infection rate has created challenges for contact tracing. By 16.12.2020, 3354 persons have completed the free national online course with over 3000 persons agreed to have their contact information on THL list to support to contact tracing (22).  As the epidemic has expanded and pleas for new contact tracers emerged in March 2021 over 12,000 persons have applied to the course. The course will continue during spring 2021 (32).  Contact tracing involves health professionals from public services, but also medical students and, from the autumn of 2020, others. For example, Helsinki has cooperated with local religious community in support of contact tracing work (23).  While contact tracing has been able to stretch locally, the challenges for contact tracing have become pressing as numbers have risen in February 2021. Helsinki, Espoo and Vantaa have expanded personnel working on contact tracing sourcing people with health background from private sector, voluntary associations, congregations, and in most constrained Vantaa also from the army.(36) Challenges have emerged from travel both within and between countries, new variants, and contract labour, for example, in building sites and ship yards.

On Dec 6th 2021, the Finnish COVID-19 app was made interoperable with applications developed in other EU/EEA countries and Switzerland (25). The cross-border exchange of health data occurs only with users’ consent. Individual persons cannot be identified from data which will be disclosed through a secure gateway service produced and provided by the European Commission.

By January 13th, THL had reported of total 61diagnosed cases caused by mutated Covid-19 variants in Finland (26). THL emphasizes both rapid identification and strict 14 days quarantine of those exposed to these mutated variants. Beyond travel restrictions, the appearance of these variants has not immediately resulted in stepping up other restrictive measures.

On Jan 15th THL recommended rapid testing of all passengers who stayed in a country with high incidence of mutated Covid-19 variants within 14 days before arriving to Finland (27). On Jan 18th THL announced they will expand the sequencing of Covid-19 samples to identify any already existing strains of mutated variants in Finland (28). Sequencing of all samples taken at borders will continue. In addition, THL advised sequencing of both all samples taken in care facilities with rapidly spreading Covid-19 – and of five random positive samples weekly from each laboratory throughout the country. According to the updated national COVID-19 testing strategy, samples from divergent transmission clusters are sequenced as well (34).

According to the situation room report of Helsinki Graduate School of Economics COVID-19 infections in Finland have concentrated most heavily to the adult individuals with the lowest incomes, nevertheless infections have also affected highest income groups.  The report also assessed the infection risk among different occupations and results showed that largest risk for COVID-19 infections are among nursing experts, nurses, personal care workers and other health care professionals. (29)

On Jan 20, 2021, five hospital districts, including Helsinki and Uusimaa, Kymenlaakso, Päijät-Häme, Kanta-Häme and South-West Finland, are in the spreading phase of the epidemic. In the acceleration phase are the hospital districts of South Karelia, Pirkanmaa, Central Finland, South Ostrobothnia, Vaasa, Pohjois-Savo, North Karelia, North Ostrobothnia, Kainuu and Länsi-Pohja as well as the Åland Islands. The remaining five hospital districts are on the stable level of the pandemic, nevertheless individual cities or municipalities might defined to be on different level than the rest of the region. (30)

On Feb 2, THL reported that RNA copies of COVID-19 were detected in wastewater analysis throughout the country (31). This supports the COVID-19 incidence observed in individual testing.

At the end of February, the COVID-19 situation rapidly worsened across Finland with a sharp increase in incidence of new cases – mainly among both working-age adults and young adults and especially due to the UK variant (total of 1,205 confirmed cases). In Feb 22nd-28th the weekly number of new cases (over 3,900 / 71 per 100,000 inhabitants) increased by 400 and was the highest since the start of the epidemic. This rapid worsening involves 16 out of 21 regions, but affects particularly those of Uusimaa, Southwest Finland and the Åland Islands. The estimated basic reproduction number has increased to 1.15–1.35 (90% probability). The worsening situation has rapidly burdened hospitals, which at that point had 221 COVID-19 patients in inpatient care and 37 in intensive care. While this burden has focused particularly on Uusimaa, the capacity of intensive care has not been threatened on the national scale. Moreover, by 3rd March a total of 759 COVID-19 deaths had been reported. However, threshold for people getting tested is currently low: the number of COVID-19 tests has almost doubled in February compared to December. In Feb 22nd-28th, over 137,000 tests were carried out. (37)

Regional Administrative Agencies (AVI) claimed they lacked a clear mandate to act especially on border measures, but as well on other measures which restricted businesses. These included further measures to support border control and contact tracing, as well as lack of information sharing. Government proposed further amendments to the Communicable Diseases Act (1227/2016) until the end of June 2021. This process also allowed the Parliament Constitutional law committee to reaffirm mandate provided by the Act with respect to border controls, which Administrative Agencies had interpreted narrowly.  Permanent amendments included expanding premises where isolation and quarantine can take place, access to information and possibilities to seek involve other agencies, e.g. Border Patrol (38) Government has submitted to Parliament a proposal for amending two sections of the Communicable Diseases Act concerning the rights of Regional Administrative Agencies and physicians to decide on compulsory health examinations (e.g. testing) and section 22 on obligation to those who have or have been exposed to a communicable disease to provide information about themselves (39) The amendments entered into force on March 29 2021. (40)

THL and MSAH informed on April 22nd that the new COVID-19 cases in Finland have decreased over the past five weeks indicating improvement. The incidence of cases was 80 per 100,000 inhabitants over 14 days between April 5th and 18th, when it was 134 per 100,000 habitants the two previous weeks. The estimated basic reproduction number has decreased to 0.75-0.90 (90% probability). The incidence has decreased in almost all hospital districts, especially in the Helsinki and Uusimaa, where the incidence was the highest. (41)

On April 27th THL informed that three cases of the COVID-19 caused by the new variant originally detected in India, have been detected in Finland (42). In addition, in the end of March 2021, the UK variant causes already approximately half of the new COVID-19 cases detected in Finland. (43)