As the rampant spread of COVID-19 outpaces testing capabilities the world over, even superpower nations are left guessing at infection rates and scrambling to test indispensable healthcare workers. Mercifully, it’s an entirely different story here in Iceland. Boasting more than 18,000 COVID-19 tests processed at the time of writing, Iceland has screened the highest proportion of its population of any country in the world. Although the nation’s minute population is an ace in Iceland’s pocket when it comes to per capita statistics, Iceland is undeniably well ahead of the curve for COVID-19 screening, particularly general population screening.
Through its screening service and extensive genetic analysis of the virus, Reykjavik-based biopharmaceutical company deCODE has become a linchpin of Icelandic COVID-19 screening efforts. At its helm is the formidable Dr. Kári Stefánsson, deCODE’s founder and CEO.
Gruff, unabashedly opinionated, controversial, and armed with an acerbic wit and searing intellect, Kári is a force to be reckoned with (to witness, he threatens to walk out of this very interview just three minutes in, giving this reporter a minor cardiac before realising it’s his idea of a joke). Though he may seem an unlikely hero, Kári is now the knight in a shining lab coat heading the battle against Iceland’s invisible enemy, COVID-19.
Action Stations
The speed with which testing facilities were set up in Reykjavík has been one of the distinguishing features of Iceland’s pandemic response. In fact, the National University Hospital started screening for the virus on January 31st, almost a month before the first case was confirmed in the country.
“We are constantly on our toes,” says Kári. Just two weeks after the first confirmed COVID-19 case in Iceland, deCODE conducted its first virus screenings and 12 days later the first research paper was sent off to be published. In a matter-of-fact tone that makes the whole thing sound impossibly easy, Kári explains, “I proposed that we should go out and [begin screenings] and we did. That was on March 6th and it took us a week to set it up.”
“I was driving to work on March 6th and I heard the news about COVID in China,” Kári recounts. “On the news they were commenting on the lethality of the infection and they said that the estimation was that it would kill 3.4% of those who got infected. I was surprised because to be able to do that calculation you needed to know the distribution of the virus in the population in general not just in those who got seriously ill or were in the high-risk groups.” His scepticism about this estimation and empirical instincts as a scientist inspired the launch of deCODE’s drive-through screenings.
“I felt that it was necessary, not just in Iceland but for the world in general, to have a population where you knew the spread of the virus in the general population,” and so Iceland took centre stage as a case model for scientists studying the ways in which infection is transmitted.
Genetic diversity
Once samples have been taken, deCODE’s experts get to work analysing their genetic makeup, comparing their findings with the sequences of the original SARS-CoV-2 genome data from China. “What I’m most surprised by is the sequence diversity in the virus,” says Kári. “In Iceland we have found 130 mutations in the virus that have not been found outside of Iceland.”
It is unclear what this fast rate of mutation may mean. Kári has been cautious on numerous occasions in the past to make any predictions about this finding.
Much of deCODE’s current work involves tracing the origins of infections found in Iceland. The virus is mutating in different ways in different parts of the world. By identifying the distinct strings of genetic variants coming from different regions, deCODE has been able to determine that the majority of infections have come from Austria, Italy, and a little more surprisingly, the UK. A form of the virus found on the West Coast of the US has also been found in Iceland.
“Because we are sequencing the virus from everyone that is diagnosed you can determine on the basis of these the country of origin of the infection in every single individual in Iceland,” Kári explains. “One of the things that it does for you is that you can track the infection, you can determine how it flows through society, who is infecting whom, etc. And that is very important when you are trying to track infections, when you are trying to track contacts, to be able to use quarantine in an effective manner.”
Photo by Art Bicnick
An “honourable” virus?
It is widely understood that children experience a milder form of COVID-19, although there are tragic exceptions to this trend. However, deCODE’s statistical analysis suggests that the truth about the way the virus behaves towards children may be even more surprising.
“Children are not just less likely to become seriously sick if they get infected, they are much less likely to get infected at all. So when you put the two of these things together, children are relatively well protected against this epidemic.” Kári tells us. “Even though this virus is rather nasty, it occasionally shows honourable behaviour.”
And the virus’ “honour” extends to another demographic of society. As Kári explains, “women less likely to get seriously ill if they are infected they are less likely to get seriously infected than males.” In a paper released by deCODE researchers on the early spread of COVID-19 in Iceland, targeted testing carried out by the National University Hospital of Iceland showed that 14.6% of men tested positive in comparison to 9.5% of women.
It remains unclear as to why susceptibility to the virus differs between genders and age groups and Kári was cautious not to suggest reasons, instead explaining that “this is the first epidemic by this virus and our ability to predict the ways in which a new virus behaves is limited, so everything we are seeing is sort of new and surprising.”
Test, test, test
deCODE’s published research into the early spread of COVID-19 in Iceland concluded with a stark warning: “The 0.9% frequency of the infection in the population screening indicates that the virus is spreading to the extent that unless we increase the screening effort we are likely to fail in our efforts to contain it.” This is a statement Kári stands by.
“Unless we increase testing, we are not going to be able to contain the infection,” he confirms. “We need to continue to test because our earliest results show that there is a substantial spread of the virus outside the high-risk groups in the material we tested. I think [the infection rate] in the population is closer to 0.5%. We need to identify a substantial proportion of those [cases] in order to be able to contain the infection.”
Kári believes 50,000 to 100,000 tests will be needed if Iceland is to contain the virus. Although testing up to a quarter of Iceland’s population may seem ambitious, he assures us it is entirely feasible . “I’m absolutely convinced that we will succeed in doing it. We have to do it, we have to continue the screening or else we will not succeed.”
There is a small obstacle between Kári and his goal: availability of the supplies required for testing. Having recently overcome a shortage of nasal swabs, Kári discloses that deCODE is “a little bit concerned about reagents.” Kári revealed to the Grapevine on March 31st that deCODE only has enough reagent stocks for about 9 days. “We are scouring the world for more and I hope that we will find some,” he said.
Photo by Art Bicnick
Next Steps
The next step in Kári’s plan is to extend testing into rural communities. Although the epicentre of Iceland’s epidemic remains the capital area, COVID-19 has now reached every region of Iceland and deCODE is looking to improve access to tests across the country. Testing kits are due to be sent to East Iceland and the Westman Islands in the next couple of days.
“I think we are going to use exactly the same approach to the people in the countryside as we do in Reykjavík,” Kári explains. Healthcare workers will take samples, which will then be sent to deCODE’s headquarters for analysis. Kári favours drive-through testing clinics even in more remote regions and firmly rejects the idea of home-testing due to the increased risk of unreliable results.
Speaking from personal experience, Kári explains the uncomfortable nature of nasal swab testing could affect the reliability of self-sampling. “It tickles enormously when it’s put up your nose and I don’t think that you can trust that people will do it properly. Bear in mind, the test when [carried out by medical professionals] is only 75% [accurate], so there are about 25% false negatives. I think that the error that comes from self-sampling would cause a bit of a mess.”
Community spirit
The hard work of around 120 deCODE employees has underpinned Iceland’s COVID-19 testing efforts and will continue to be vital in the months to come if Kári is to reach his lofty testing goal.
“This is an extraordinarily committed group of people” Kári reflected with obvious pride. “There are people at deCODE who are working 18-hour days. No one asks when they can go home, no one asks to be compensated for these long hours. This is all fuelled by community spirit, which is absolutely boundlessly beautiful. These are good people, it’s very nice to see people come together like this at a difficult moment. It’s beautiful.”
In fact, Kári’s praise does not stop there, he has also been impressed by the behaviour of the general population.
“The world is in a bit of a panic in general. Except for Iceland, people here seem to be taking this with serenity. I haven’t noticed any panic whatsoever. The stores haven’t been raided, people aren’t hoarding food, people aren’t hoarding toilet paper like people seem to be doing elsewhere. I have been very impressed. This is a nation of unruly people in general. People who are difficult to control—typically people who have difficulties behaving when everything is fine—but in the face of a crisis like this, we seem to be performing spectacularly.”
He even had a kind word to say about the Icelandic government. Well, sort of.
“We have very good public health officials, we have a very responsive system and what I think is particularly noticeable about the way in which we have [approached] this is that the government has left it completely in the hands of the public health officials. There has been no instance where the politicians have intervened in what the public health officials have been doing.” Smiling sardonically, he adds, “We have been fortunate that our politicians have either been wise enough not to intervene or too lazy to do so.”
Photo by Art Bicnick
Looking forward
Although we are still in the eye of the storm, Kári is already looking ahead. An outspoken critic of government healthcare expenditure in the past, Kári hopes Icelandic society can learn something from the painful experiences of the pandemic.
“I don’t think that we are financing the health care system well enough. I am hoping that this epidemic will change the balance in our society. I am hoping it will change the way our society works. I’m hoping it will be less materialistic and [the focus will be] on the things that bring us together rather than the ones that drive us apart… one aspect is that we will spend more on community spending things like healthcare, schools etc. But we’ll see.”
“I insist that we are going to come out of this as a better society,” Kári adds in a confidently optimistic tone. “Come hell or high water, we’re going to make sure we come out of this better.”
As deCODE continues to scale up screening, we can only share Kári’s hope that all the hard work done now to track and contain the virus in Iceland and increase global understanding of COVID-19 bring us closer to making his post-pandemic predictions reality.
As ever, those looking for more information or advice should go to the Icelandic Government’s excellent COVID-19 help page.
Tune into our daily COVID-Cast for a deeper dive into the day’s developments.
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