It is also challenging for a doctor to perceive the overall situation
Friday 27.3. my surgery was canceled, so I agreed with the hospital supervisor that I will write some kind of snapshot of the situation for COVID, because in addition to the surgeon's profession, my passion has been cell biology and hence, I have some biologist sight to this evil new form of life. The covid-19 pandemic is challenging for us doctors as well to comprehend, the features of the disease settle on the grounds of several specialties, including epidemiology, and no expert can easily control the overall picture. As orthopod, I have some profound information of the use of masks, but since the first news of the disease, I have tried to keep track of everything acutely published, I have discussed with experts from various sectors, especially in intensive care, and in addition I have been following the statistics. I start and end my day with case and death figures by country and besides statistics, I whatsapp my friends all around the globe to get the first-hand experience information. As with many phenomena, information is beginning to be available in abundance now, and the real challenge now is to distinguish between essential and irrelevant data.
Petri Lehenkari is professor at the Faculty of Medicine of the University of Oulu and chief physician at Oulu University Hospital. Photo: Pekka Peura (Kaleva)
The importance of factual knowledge and scientific interpretation is crucial
It was my view, as soon as the first reports came that the COVID virus was a pandemic that all we doctors feared for a long time, actually forever, as these kinds of events have emerged all throughout history. The cause of pandemic is again a virus, specifically a coronavirus that has previously shown unprecedented destructive power and pandemic potential. For this reason, I began immediately to follow the infection figures reported in the media, drew the curves with a spreadsheet program, and also sent them to a friend who was more proficient in mathematics, with whom we found that the figures reported by China could not be true. The math just didn’t match the previously reported amount of infection spreading. In my opinion, mainly for this reason, other countries did not get a true picture of the situation and could not react quickly and firmly enough to the spread of the virus. An authoritarian society may be effective in treating the disease and setting quarantines, but not in disseminating information, which is why this interesting creature was allowed to spread as a global phenomenon.
Now, huge amounts of information about the situation are constantly being generated and policy makers will certainly have difficulty updating their own views and making the right decisions. It has become clear that this situation will last possibly up to two years. It is very likely now, that decision-making becomes more politicized, and medicine cannot be the only science that influences the decisions and actions the governments take. COVID does not really hit the plot of any medical expert properly, which is why the WHO and THL are also looking for and updating their positions, and the picture is constantly changing as countries are also reacting to each other's actions. Here in northern Finland we have totally open border with Sweden and the decision makers at south are really struggling to make a decision whether the border should be closed or not. Many of the health care workers at the Swedish site are from Finland. In the models, the measures feedback the numbers and the models have to be updated all the time. People at north are getting impatient at the moment and it is getting increasingly difficult to understand, why Finland should participate in carrying any of the consequences of the more liberal Swedish approach to quarantine and other measures.
There are probably many reasons for withholding information, China is probably a case of its own, but lack of publicly available data is a problem also in the USA, where the disease is spreading most at the moment. It would be really important to have more detailed information on why so many young people there are seriously ill!
As a pandemic, however, from a human point of view, this is a reasonably good choice from mother nature, as the virus is not as deadly as previous entrants and the disease is, in principle, easy to limit and controllable. So, we can now learn our lessons for even worse scenarios. The problem, on the other hand, is that many people unknowingly get COVID because of scarce symptoms, and the disease can be unknowingly spread more easily.
Viral biology explains almost everything
Like all viruses, COVID must enter host cells. The COVID virus is able to do this by binding to the ACE2 receptor, which is found almost everywhere in the body. Angiotensin, a blood pressure regulator, and the drugs that effect it, bind to the same receptor. Possibly for this reason, some of these drugs cause coughing symptoms in hypertension. Therefore, we think that the power of the virus to cause a disease is higher, especially in the underlying diseases that affect the regulation of blood pressure. Therefore, for example, in children who do not usually have blood pressure problems, the overall viremia and disease are much lower. ACE2 receptor function can be defective in many ways. The role of ACE receptor in the action of the virus is speculative but fits well with the findings: male mortality is double that of women, and children and adolescents are moderately asymptomatic, and even at age-standardized female mortality is roughly half that of men. Men smoke more often and use antihypertensive drugs, men are more obese, have diabetes and other diseases that affect the severity of the disease caused by the virus and possibly also the entry of the virus into the cells in our body.
Here is the first important message: stop using tobacco, including e-tobacco, and avoid any extra salt by now! In this way, everyone can alleviate the disease if it happens. In addition to the virus entering the body, the disease is affected by how the body can get rid of it. As we age, the ability of our immune system weakens. This and the above together explain the targeted coronavirus mortality. For example, the influenza virus is delivered to cells by a completely different mechanism. Therefore, its relative mortality is higher in younger age groups. Like in influenza, secondary, i.e. post-viral, bacterial infections are also likely to play a role, but we do not yet have enough information about this.
Human biology explains a bit more
The RNA virus is only a foreigner to our immune system, which is usually able to treat effectively many coronavirus types without state-level isolation / restriction measures. However, this is not the case with the current COVID virus, as it is unknown to our body. The coronavirus is indeed one of the common flu viruses, but it is in this form completely new to our species. Most likely, the entire pandemic has been caused by a single virus that has undergone a mutation allowing migration to our species.
The origin of the virus will never be known for sure, but the primary host is probably a bat, whose immunology is very different from ours. Before us in the chain of infection there may also be intermediate hosts where the virus may have mutated and become the dangerous form. In any case, the COVID virus, like the SARS and MERS viruses, is new, and therefore the immune response required by the virus to cure the disease may be deficient. On the other hand, the immune reaction to the virus can also start to destroy our own body and encountering the virus can be a bigger challenge for practically anyone, including young people.
Due to the severe disease, some patients get ARDS, lung failure, failure of other internal organs, MOF, and eventually death. No experimental drug necessarily contributes significantly to these pathological reactions, which is why the current treatment of COVID patients is based on the support on the body's own essential functions, oxidation and the natural course of the inflammatory response. Medicines may be aimed to suppressing the immune response or suppressing the distribution of the virus. There are several controlled trials going on and we hope to have the tools to treat the most severe diseases and reduce mortality through this as well. One approach to treat the disease is to use plasma from recovered patients. There are case studies suggesting a benefit and more research is on the way.
In mild cases, everyone who is ill or at risk of illness can take rather simple measures that contribute to the illness severity by themselves. People in the northern region should take care of adequate vitamin D intake when they are healthy, in case of illness it is worth resting and controlling fever with ordinary paracetamol and NSAIDs. No experimental medication has yet proven to be very effective and no individual should experiment. Not with Chloroquine, even if the president of the USA recommends it. Just listen to doctors. If a medicine is shown to be effective and safe, it will be told to all in open and given to those who need it. Some of the old medicines have been found to have an effect on the replication of the virus, but previous experience suggests that no medicine will be very effective. Of course, the chains of infection and the spread of the virus are not affected in any way by drug treatment.
Laws of epidemiology is the roadmap
COVID is particularly contagious, well-preserved outside the body and causes a wide range of diseases from mild to severe. Thus, in terms of the spread of the virus, the strategy of the virus is fireworks in all possible directions. In addition to the spread of the virus, mortality is affected by many things. Getting a small or large viral load at the beginning of an infection is one of the key issues. The virus multiplies exponentially in our body, but so do our white blood cells. If the amount of virus is small, the body has hours more time to get its own defenses in order. Therefore, those exposed to the sick can get even severe illnesses and if someone in the family becomes ill, it is worthwhile to create isolation at home and all the healthy ones will start to function almost like in a hospital.
At the population level, the spread of the virus, and in particular mortality, is indeed influenced by many variables. One is the structure of the population. The second is the structure of health care. The third is general approach of the population and response to, for example, restrictions and regulations and recommendations of the authorities. Thus, the rate of spread of the virus is a multifaceted issue. I have already anticipated, and I still consider Finland can follow one of three scenarios in the acute phase of the virus to spread, which is drastically influenced by the actions of our government and us individuals:
1st scenario, the worst: 60–70% get sick, total mortality from the virus 2–3%, means 70,000 people in Finland, lasts 3–6 months
2nd scenario, the most likely: reasonable control measures will slow down the epidemic and the vaccine will protect the herd, 20–30% will become ill, the total mortality from the virus will be 1–2%, in Finland about 10,000–20,000 people, will last 3–6 months
3rd scenario, totalitarian quarantine: 1–5% get sick, total mortality from the virus 1–2%, in Finland about 100–2000 die from the disease, lasts 1–3 months.
These figures are intentionally estimated at the top range in terms of mortality. Luckily, in this epidemic, the virus is reasonably kind; the accident is that it is new to our immune system. At its highest mortality seems to rise to the same level as we had in World War II after Russian invasion. The difference is that the period when my grandfathers were protecting our country, mortality occurred in the course of almost 5 years, while now with 1st scenario the mortality would occur in a catastrophically short time, completely out of control of any civil system. Italy is experiencing the consequences of this and so are some US states. However, the situation is being reacted to in the face of the facts, so hopefully the situation is also changing for better in these countries. In my other homeland, England, more drastic measures are now finally taken, even the Queen has jumped in the game and the populist himself has had access to herd protection without a vaccine to alleviate the disease. Churchill always avoided unnecessary risks but never feared about the necessary!! Get well soon Boris!
The situation analysis is most important and should be based on science
Everyone is thirsting for research information about the COVID situation, and fortunately a democratic and open society will be able to produce it quickly and reliably with an unprecedented rate of scientific peer-to-peer publishing. It is therefore very important that we all adopt a common picture of the situation, especially through the best and most reliable information. This is particularly important for politicians, but also for ordinary citizens, whose behavior has crucial effect on the spread of the disease. If every person limits social contact for a total of 2 weeks, humanity will survive the situation in 4 weeks. If people are forced to the altar of stock prices and the economy and ignore the now really fast-moving first wave of infection, mortality will be at the level of the 1st scenario, and the economy will never recover from that shock effect. Donald: It's worth listening to Sauli, our president. The economy will be ok if people are ok.
A contradictory situation analysis is not in anyone’s interest. Due to the realization of the possibility of a pandemic, we doctors have been trained in this for twenty years, so it can be assumed that every doctor trained in Finland and elsewhere knows about these modern basics, which I summarize here. All university/high expertise level hospitals have excellent experts to assess the local situation, and while many are now trying to use the situation to pursue their own goals, we should base all decision-making on the information.
Here in the North, the rather reasonable and almost moderate measures take us to the scenario 3 without totalitarianism due to distances and low population density and high living standards. In fact, I am worried most about how this situation will be used in the developed countries in the economic war, oil-war, etc. As a weapon, in particular, I fear disinformation distributors and panic mongers and equally COVID-happiness ecstasy. Reasonable human action is now a priority in this situation. I would believe that, although we have an unusual situation, we can still rely on parliamentary decision-making with its machinery, and all countries should be on guard to attempts of rapid political takeovers. The educational background of today's decision-makers in Finland ensures that the research knowledge is absorbed and used and finally decisions are driven by science and common sense, less by authority.
The future will continue after the COVID pandemic
In the big picture, the mortality mainly affecting the elderly population, is, from the point of view of just passed deep ecologist Pentti Linkola’s thoughts 'recovery of populations'. Pension funds might also appreciate the situation, if the stock market can somehow be saved. For individuals, this is a terrible life-threatening catastrophe for many. Asymptomatic spreaders of the infection are children and people who have only mild disease do not isolate themselves or even know that they have the disease. The most affected are the elderly and we men. I have tried to explain that we men do not have the word wonderful in active use, because our lives are mostly varying degrees of suffering, except when Finns overcome Sweden in ice hockey or England win France or vice versa. This was a mandatory relief in this writing...
The adult population is in a disease-neutral situation, usually recognises or suspects symptoms, able to function, prepare, isolate, and generally does not spread the infection if appropriate precautions are taken. Students and workers, society's gross domestic product producers, are mainly in this set. However, people with underlying diseases need protection. Quarantine is a different matter than isolation. Isolation must be done for anyone who has or has reason to suspect viral infection; quarantine must be carried out on those who have been exposed or for whom no information can be obtained. There is no clear vision yet on the duration of the isolation. I personally consider the isolation to be good for at least one week after patient’s condition has improved, but hopefully the information on this will be clarified soon. Isolating the sick and the vulnerable healthy people is a different matter and requires wisdom and judgment. Implementation must still be carefully considered in human terms and especially, as the risk of an epidemic is likely to continue for a reasonably long time. Wise decision-making without mastering these basics is impossible, can lead to excesses, unforeseen effects, and drive us toward systemic crisis and chaos.
At the heart of success is the individual, whose actions affect the situation of the nation, even if the individual doesn’t see the effect. Fortunately, we have a well-educated, moderate and reasonably healthy population that now has its own key role to play in the situation. I myself assumed that people in Finland would have restricted their movement and activities more voluntarily. However, this did not happen, and I consider the measures now being taken by the state to be the only possible ones. In my opinion, the more liberal situation in Sweden is to some degree misinterpreted in Finland. In Sweden, the force of recommendations may be as great as in another country the use of force and sanctions and more coercive measures. I would like the Finns to listen to the recommendations in the same way and act on them. Admittedly, according to recent figures, Sweden is likely to have to bow to the eradication policy that we and Norway are already pursuing, rather than the recommendations.
Finally: the way out
It is an indisputable medical fact that the only final way out of coexistence with the COVID virus is that almost all of us at some point suffer from the disease and the knowledge of defeating the virus becomes part of the memory of our immune system. Herd immunity requires very high population-level immunization, with estimates ranging from a minimum of 70% to a maximum of 90%. The vaccine can prepare the body for this and usually relieves the disease significantly. Therefore, right at the initial stage, vaccine development has been made a priority and is the real way out of the situation after the initial stage of infection prevention and containment. Luckily the manufacturers have realized the serious situation and rather than competing are now co-working to hasten the production of different vaccines and vaccination strategies. Clinical trials are already under way.
We hope that vaccines are effective, but this is not yet known with certainty. It is a totally different thing for an individual to get this disease under vaccine protection than without it. For this reason, the only acute path out of the first wave of disease caused by the virus now, is the complete eradication, complete prevention of the spread of the virus - herd protection and herd intelligence developed to fight the virus just now. I believe that this conclusion will eventually be accepted everywhere, and that time will be bought so that the populations of the entire planet can be vaccinated.
There will be unprecedented demands on vaccine production. Vaccines should be targeted as in seasonal influenza, to at-risk groups, the rest of the population will be able to acquire immunity to the disease, but also healthy and fit should receive vaccination comprehensively as soon as possible. I estimate that mass vaccinations will start at the end of 2020 and be completed by the end of 2021. It is happy co-incidence that the northern hemisphere is facing summer, making it more difficult for the virus to spread. But after the summer comes autumn and a riskier time and the virus will still be amongst us.
Ubiquitous social isolation prevents the spread of the disease and thus slows morbidity to tolerable levels. In addition to the vaccine, it is appropriate to set up more comprehensive COVID testing to enable both situation management and restriction targeting. This will further help control the spread of the virus. Diagnosis can be made from patients with blood antibodies and those who have acute disease, from saliva and pharynx. The equipment capacity required for mass testing in routine medical laboratories is inadequate and it is likely that we have to borrow real time PCR machines from research laboratories. As the situation continues, a new type of biometric data may need to be introduced. An individual who does not have a detectable virus and who is immune to the disease is, in practice, at very low risk and their isolation is not justified. It might even be valuable to be able to identify such immune individuals. They could, in principle, treat the sick with a lower risk of recurrence or donate plasma with antibodies to those who are more severely ill. Admittedly, this is speculation. We do not yet know what kind of protection the disease provides, and there are separate cases where the patient may have become infected again.
Finland's way out
Finland has one of the most equal and public health care systems in the world. We have the arsenal to fight for every death caused by COVID and to do so in the best ethical and medical way possible. The Finnish Institute for Health and Welfare (THL), our national authority, and the political decision-making system are constantly evaluating which scenario to go with. THL also evaluates the effectiveness and harm of various restrictions and prohibitions. The mortality caused by the virus will cut the mortality caused by the restrictive measures quite soon, so the only way for Finland to cope with this, even with reasonably few scratches, is to act uniformly and accurately under the control of THL. It became very clear to me at an early stage that expertise in the various institutions at the local level is simply not enough, so restrictive measures must be nationally managed, but applied and targeted locally. The common task of all is now to maintain social order and stability. Finland is a developed democracy with an efficient civil service and responding to the situation is in no scenario an insurmountable problem in our circumstances. We are likely to stop the cycle of infection and in the next few weeks there may be an opportunity to take a step back, start to sort out the chains of infection again and limit the progression of the infection by milder means.
A Finn’s way out
Washing hands is an obvious obligation for everyone now, but besides washing one should also disinfect hands with an alcoholic rinse, avoid toughing face and mouth and take care of the skin of hands by greasing, keep nails ultra-short and, wear gloves when moving in common areas. All should be a bit like surgeons now.
Last but not least, we should all start using face protectors. The virus is spread through the upper respiratory tract, either through contact or droplets, even aerosols. All of these can be stopped using any face protector. The protector protects others, not the wearer themselves. I challenge anyone with a sewing machine to make a variety of protectors, instructions can be found online. Fabrics of different thicknesses can affect the amount of airflow. The protector is a tube, a patch, any arrangement that prevents dripping and contact with the nostrils and mouth. A visor is one way, though clumsy. Could teachers make this a craft project and grandmothers and moms and sewing machine skilled fathers and other fellows take the sewing machines out of the closet? Europeans do not come to terms with masks easily but if the protective gear is cut from an old night dress with personal flavor, it will be cool to wear a one.
Schedule is important
It is good to see that this situation will not last forever, but it will not be over quickly either. The first wave is likely to have arrived and been dealt with by summer 2020, but restrictions will continue across summer 2020, most likely everywhere. Vaccinations will begin in late 2020. COVID will most likely be won by the summer of 2021, but even after that it may sneak along with other viruses seasonally. It will not able to cause a pandemic like this, but a pandemic will be caused by another organism, most likely another RNA virus. Society should not be caused to collapse, but it should be organized differently. Finally, the whole planet has a common enemy, we should fight it firmly and with dignity to each other and after this war, we should have a common peace with some new strategies of survival. Changes to schedule are possible.
Main photo: Elena Schweitzer (Adobe Stock)
Last updated: 14.4.2020