Martin Kadai on why Saaremaa is special, death statistics and restrictions

Martin Kadai.
Martin Kadai. Source: Siim Lõvi/ERR

Estonia is counting all deaths of people with the coronavirus, irrespective of the immediate cause of death, Martin Kadai, head of the Health Board's emergency medicine department, tells ERR in an interview.

The emergency situation has now been in effect for three weeks in Estonia, yet Saaremaa is seeing dozens of new COVID-19 cases every day. Why are we seeing so many new cases on an island where mobility restrictions several orders of magnitude more severe than those imposed for the rest of Estonia remain in effect?

We need to realize that the spread of this disease has its own dynamic. The cases we are diagnosing today reflect past infections. Sometimes from two weeks but at least a week ago.

The same goes for all kinds of measures. The results of restrictions introduced today will manifest in a week's time at the earliest, two weeks' more likely. This characterizes the spread of the disease on the island where effects of tougher measures are expected to start manifesting in the coming days.

The emergency situation has been in effect for three weeks, while the spread of the disease is not slowing in Saaremaa. What did they do wrong?

It is hard to say what has gone wrong. This disease is difficult to combat and treacherous as 80 percent of people who catch it only develop mild to moderate symptoms. We also know it could pass without producing any symptoms at all, while the person is still contagious.

It is an extremely difficult malady to combat. Today, we are only registering severe cases, where symptoms have very clearly manifested.

When it comes to Saaremaa, the disease reached the island sooner and had more time to spread when compared to the situation on the mainland.

How many people who initially tested negative for the virus have since then been diagnosed in Saaremaa?

Again, it is hard to say as we have not compared test results. What we know is that Saaremaa has seen the most people tested and has the most confirmed COVID-19 cases per capita today. We have tested around 10 percent of the island's residents.

Intensity of testing is not the only factor here, but it is a fact that the disease is widespread in Saaremaa.

Võru was another outbreak site, while the region is not producing dozens of positive COVID-19 tests today – in a situation where the area and people's movements there are much harder to control. How did Võru manage to avoid mass infection? Or are people yet to take ill on a massive scale there?

What we can say today is that professional and intensive action has been taken in Võru, including in terms of testing.

I would like to hope the Võru outbreak and the virus spreading locally there is under control. This is quite clearly reflected in the fact we are seeing much fewer patients in need of hospitalization in the area, as confirmed by the local hospital.

This is encouraging and the South Estonia Hospital and local family doctors have been active in organizing testing.

Can we see a pattern in Saaremaa in terms of who is getting ill in the conditions of the emergency situation? Where is the disease spreading on the island?

Saaremaa is so small that it is difficult to pinpoint a trend there. Testing of the staff of Kuressaare Hospital revealed that a lot of healthcare professionals had contracted the disease.

We have also diagnosed patients and employees of Saaremaa nursing homes.

But we cannot highlight a particular group or area there. It seems the disease has spread all over the island.

When the news first broke of the disease having reached a Saaremaa nursing home, the social minister said it should be checked whether people have observed the visitation ban. What did you find?

There have been signals to suggest visitation restrictions were not being observed. But it rather concerns nursing home patients leaving and returning to the premises as opposed to guests sneaking in. It is a problem when talking about special care homes that have patients who are somewhat different. That is why we decided to stop all movement in and out of nursing homes.

How is it possible so many employees of the Kuressaare Hospital have been infected?

Healthcare workers belong to a risk group, coming in contact with a lot of patients. The disease manifests very differently and might be difficult to diagnose, meaning that contact with a patient whom the health worker does not suspect of having it is enough to catch it if they are not wearing protective equipment.

Do I understand you correctly in that Saaremaa medics underestimated the spread of the disease and failed to use personal protective gear as often as they should have? Did it only turn out later that most people turning to the ER were coronavirus positive?

Going back to the time when the disease might have been spreading more freely, while personal protective gear is widely deployed today, such equipment is not commonly used outside of a crisis.

Around 5,000-6,000 people with similar symptoms turn to doctors in Estonia every week as there are a lot of these viruses out there and finding COVID-19 patients among them is very difficult. That is where you might forget to stay vigilant.

Head of treatment at the Kuressaare Hospital Edward Laane told me the week before last that medics who come into contact with coronavirus patients are not quarantined but continue working until they show symptoms due to acute staff shortage. What is your opinion of that decision?

It has been inevitable to a degree.

We need to look at the spread of the disease and activities in different stages. In a situation where you know for a fact that a considerable part of your staff has been infected, the only other option would have been to shut down the hospital. And you cannot do that. You need to start making concessions based on the situation by having healthy employees continue working so the people of Saaremaa wouldn't lose access to other medical services.

Why did you not dispatch anyone to help them in a situation where you knew the disease had spread in the hospital?

We have a Defense Forces field hospital in Kuressaare with rotating staff. They are supporting the Kuressaare Hospital both in terms of coronavirus patients and people in need of other kinds of medical attention. We also need to look at the time we became aware of different things.

The people of Saaremaa are worried that while the elderly and chronically ill are being tested, younger and middle-aged people still go to work because companies are allowed to stay active. Does the Health Board feel the government should order companies that do not offer vital services to shut down?

That is very difficult to decide from the Health Board's perspective. It concerns a compromise between public health and the functioning of the economy and society as a whole. Every such decision needs to happen through an effects analysis of what it would mean for life on the island.

Testing parameters and including new target groups will be discussed today (Monday – ed). We want to revisit our testing criteria and include new groups if possible.

What will those new groups be?

That is yet to be discussed. We will meet with family doctors today. Our goal in broadening the testing criteria is to understand whether the county data we have today is realistic or whether we should opt for targeted testing.

Having only a modest number of cases in some counties can make you complacent, while it's possible the figures are low because not enough people are tested.

The Health Board also wants additional restrictions on movement for Hiiumaa. Could a corresponding decision be made and if so then when?

The board has made a corresponding proposal to the social minister because Hiiumaa has a lot of elderly people who are vulnerable to the disease.

We also need to consider the local hospital's capacity for taking care of patients with severe conditions, which is extremely limited. All such patients would have to be transported to the mainland that would present its own set of problems.

You've said restrictions should be based on the local situation. In which areas do you perceive the need for additional restrictions?

To answer that, we need to first define what we want to achieve. We need to keep the spread of the virus under control in Estonia. We are very likely not capable of eradicating the virus or stopping it from spreading entirely. It is a matter of deliberation – we could lay down even stricter restrictions, but it is not a final solution.

The solution and our main goal is to keep the spread of the virus in check so it would not overwhelm our capacity for treating people, so we could help everyone in need of hospital and intensive care.

We need to consider practical solutions for isolating these areas, which once again brings us to the question of what halting economic activity completely would mean for our economy.

It has long been said that this week and the next will be the toughest. How is that defined?

Experts believe this week and the next will very likely show us where this disease is going. Whether it will continue to infect more people, whether it will slow down or go into retreat.

There is a lot of uncertainty involved still. Should that solution manifest by May, it would support the hypothesis of the virus being a seasonal occurrence, meaning we would have temporary reprieve for the summer. If that hypothesis is overturned, we will have no choice but to continue attempts to contain its spread.

Unless, of course, there is a scientific breakthrough and a safe and effective vaccine or treatment is found.

Based on what could we gauge how well the Estonian medical system has managed the virus?

The main criterion is whether the number of new cases is kept within the scope of hospitals' capacity to treat people. It has been kept there so far, our medical institutions are taking care of patients and stand ready to accommodate hospitalization on a much bigger scale.

Secondly, we have not seen much-dreaded exponential growth of new cases, suggesting that quarantine, early detection, counseling and determining people's contacts have added up to a functional set of measures.

Statistics only covers cases confirmed by laboratories today, while family doctors are diagnosing the disease based on clinical indicators. How many coronavirus patients who have not been tested could we have in Estonia?

A diagnosis code has been created for family doctors that allows patients to be diagnosed based on clinical symptoms and the possibility they've been in contact with an infected person. The board hopes to get new data on this from the healthcare information system this week.

Because the World Health Organization has been unable to define a coronavirus death, have all people with the disease died of the coronavirus in Estonia or have some of them died with it so to speak?

It is always the decision of the person who registers the death what to put down as the cause of death and contributing factors.

It is clear that the direct reason is often something else as many people who die of COVID-19 have serious chronic conditions.

In Estonian coronavirus statistics, we count all people who die while diagnosed with the virus as casualties of the disease regardless of the immediate cause of death. Also, those who are diagnosed after they die.

Most coronavirus patients are women. Is there an explanation for why the disease seems to be targeting women?

We have not carried out an in-depth analysis, but it is likely this difference manifests among elderly patients, and we know that we have more elderly women than men in Estonia.

I cannot help but ask again whether the people of Saaremaa hoped their home across the sea would save them from the worst of the disease and adopted a less serious attitude toward isolation rules at the start of the emergency situation. Could that be the reason the coronavirus is running rampant there?

I do not think the people of Saaremaa somehow took quarantine rules less seriously. To think that would be unfair toward them.

But it is interesting how a disease that started in China will end on an Estonian island.

The Defense Forces field hospital is up and running in Saaremaa, while Dr. Arkadi Popov is looking for a suitable location for such a hospital in Tallinn. When will the need for a field hospital arise in the capital?

Setting up a field hospital in Tallinn is a last resort. It is the absolute worst scenario we have. We have run the simulations for such a plan, but it is a tier four option. A measure for when nothing else works.

Which tier are we at today?

Tier one – meaning that hospitals can make do with their own resources, with the exception of Kuressaare where we have sent additional resources.


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Editor: Marcus Turovski

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