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Pandemic: Sweden fears overreaction and follows a relaxed strategy

Tuesday, March 31st 2020 - 09:17 UTC
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Although Sweden has now banned gatherings of more than 50 people, this excludes places like schools, restaurants and gyms which remain open. Photo: David Keyton/TT Although Sweden has now banned gatherings of more than 50 people, this excludes places like schools, restaurants and gyms which remain open. Photo: David Keyton/TT

A growing number of Swedish doctors and scientists are raising alarm over the Swedish government’s approach to COVID-19. Unlike its Nordic neighbors, Sweden has adopted a relatively relaxed strategy, seemingly assuming that overreaction is more harmful than under-reaction.

Although the government has now banned gatherings of more than 50 people, this excludes places like schools, restaurants and gyms which remain open.

That’s despite the fact that 3,046 people have tested positive. Although Norway has the most confirmed cases (3,066) in Scandinavia, COVID-19 fatalities in Sweden are highest by far at 92, compared with Norway (15) and Denmark (41).

People now are taking sides, with some arguing that publicly criticising the authorities only serves to undermine public trust at a time when this is so badly needed. Others are convinced that Sweden is hurtling toward a disaster of biblical proportions and that the direction of travel must change. The truth is that of all these opinions, none is derived from direct experience of a global pandemic. No one knows for sure what lies ahead.

In epidemics, prediction models help guide the choice of interventions, assess likely social and economic impacts, and estimate hospital surge capacity requirements. All prediction models require input data, ideally derived from past experience in comparable scenarios. And we know the quality of such input data is poor.

Most current COVID-19 prediction models use data gathered from the COVID-19 epidemics in China and Italy and from past outbreaks of other infectious diseases such as Ebola, influenza and other coronaviruses (SARS and MERS).

But demographics and patterns of social interactions differ from country to country. Sweden has a small population and only one real metropolitan area. Ideally, we would need data from Sweden on the community spread of COVID-19, but this requires screening programs that do not currently exist.

The little reliable data on COVID-19 in Sweden concerns hospital admissions and fatalities. This latter can be used to get a “poor man’s estimate” of community transmission, providing approximately how many fatalities occur among those infected. But with a two-week lag between diagnosis and death, this a very blunt instrument with which to guide decision making.

In Sweden, the public health authorities have released simulations to guide “surge requirements”. This is the extent to which hospitals will need to boost their capacity to deal with the high number of very ill COVID-19 patients that are likely to need specialist care in the coming weeks.

From these simulations, it is clear that the Swedish government anticipates far fewer hospitalizations per 100,000 of the population than predicted in other countries, including Norway, Denmark and the UK.

The corresponding number of deaths in Sweden predicted using the UK simulations are much higher than the Swedish government’s simulations suggest. The reason appears to be that Swedish authorities believe there are many infected people without symptoms and that, of those who come to clinical attention, only one in five will require hospitalization.

At this point, it is hard to know how many people are asymptomatic as there is no structured screening in Sweden and no antibody test to check who has actually had COVID-19 and recovered from it. But substantially underestimating hospital surge requirements would nevertheless be devastating.

Like in many other countries, the spread of COVID-19 is quite uneven in Sweden. Most cases have been diagnosed and treated in the greater Stockholm area, and lately also in the northern county of Jämtland – a popular destination for skiers. On the other hand, some other geographical areas are relatively spared, at least for the moment. In the third largest Swedish city, Malmö, still only a few cases have been hospitalized at the time of writing.

There is no doubt that the epidemic will spread, but the speed of this is disputed. The national Public Health authorities are also skeptical about the need for lock-down in most of the country, but discussions are now ongoing to enforce such an intervention in the capital area.

There are several arguments supporting the current official Swedish strategy. These include the need to keep schools open in order to allow parents who work in key jobs in health care, transportation and food supply lines to remain at work. Despite other infectious diseases spreading rapidly among children, COVID-19 complications are relatively rare in children.

A long-term lockdown is also likely to have major economic implications that in the future may harm healthcare due to lack of resources. This may eventually cause even more deaths and suffering than the COVID-19 pandemic will bring in the near term.

The best estimates of the COVID-19 case-fatality ratio (CFR) – the proportion of those infected who die – is currently 0.5 to 1.0 per cent. By comparison, the 1918 to 1919 Spanish flu had a 3 per cent CFR in some parts of northern Sweden. A century ago, Sweden was recovering from World War I, even though the country stayed neutral.

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