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Jury Still Out On Whether Or Not
The Swedish “Soft Containment” Strategy Against COVID-19 Is The Right
One
Many
countries hard hit with COVID-19 outbreaks have applied harsh social
distancing measures to flatten or decrease their epidemic curves.
Thousands of lives may have been saved if initial predictions from
epidemiologic models were accurate at the time. However, the economic
and social consequences have been severe, and some publics are anxious
to resume a normal life. In the US, some states are reopening their
economies sooner than what public health authorities are recommending.
All
Eyes On Sweden
Countries which undertook harsh, mandatory social distancing measures
are keen to discover if the significantly less harsh approaches taken
in Sweden can offer any guidance about the best way forward from here.
Many are looking for the right balance between retaining strict
measures to save lives and allowing people to return to more normal
lives.
Swedish Strategy
What
more specifically has been the Swedish strategy and is it a success
story? Does it provide lessons? The following article was written
after reviewing multiple articles and interviews by Swedish and other
officials.
The main
features of the control measures in Sweden were to encourage social
distancing without requiring it. The allowable crowd size was limited,
however, restaurants and businesses were allowed to stay open and
children
below secondary school age were allowed to stay in
school. People were encouraged to work from home, and sick persons
were advised to stay home from work with pay. Travel was discouraged.
Goals
The economic and
social disruption appear to have been significantly less in Sweden
than in the US and somewhat less than other European countries. This
strategy is often referred to as a “herd immunity” strategy, but in
fact is more a byproduct of the Swedish approach than its primary
purpose, according to Anders Tegnell, the country’s lead
epidemiologist.
Sustainablility
The Swedes understood
from the outset that any control measures had to be sustainable, that
is, feasible and acceptable over the longer term since no vaccine was
considered likely to appear for months or even years. The main goal
was to avoid overwhelming the health system, however, this is
precisely the risk entailed by their voluntary, soft containment
strategy. Without adequate constraints on social interactions, cases
could climb dramatically and overwhelm the health care system. Even in
the best case scenario, one could expect that Sweden would have to
accept a certain number of preventable deaths in the short term that
would be avoided in other countries adopting harsher measures. This
has not been stated publicly in multiple media accounts reviewed by
the Epi Monitor.
Success?
Has the strategy
succeeded? The answer is that it is too soon to tell. There are some
features of the Swedish situation which suggests that their gamble has
paid off for now in that they have avoided social and economic
disruption on a large scale. However, the deaths per 100,000 in Sweden
are much higher than in neighboring Scandinavian countries. As stated
above, some of these excess deaths should have been anticipated as the
result of a softer containment strategy. By themselves, they do not
point to a failure of the Swedish strategy, at least not yet, but they
may reflect a more fatalistic or realistic streak in the Swedish
mindset.
Nursing Home Deaths
At least 50% of the
deaths in Sweden have been in nursing home residents, according to
Tegnell, and there was an admitted failure to prevent introduction and
proper management of cases in these facilities. A stricter lockdown
strategy might have prevented more COVID-19 infections and reduced the
chances of introductions into a high risk population. Still if the
nursing home deaths are excluded, Sweden’s death rate is still several
fold higher than neighboring Scandinvavian countries. (See table on
page 11).
Epidemic Curve
At present, the
epidemic curve or weekly case count is decreasing according to Tegnell
from 90 to 70 or less per week. The first reported antibody study on
approximately 1000 persons from the Stockholm area found that only
7.3% have antibody, much lower than the 25% Tegnell has estimated
might have been produced by their less strict strategy.
The health system in
Sweden has not been overwhelmed and the Intensive Care Units have not
exceeded 80% of their capacity. Tegnell suggests that Sweden could
expect to have a smaller second wave of COVID-19 in the fall and
winter if the virus remains endemic or returns later in the year. But
now this prediction seems ill-founded if antibody levels in the
population remain in single digits.
Sweden As Model?
The big unanswered
question is whether the lower death rates in other Scandinavian
countries which took drastic measures will eventually rise to catch up
with the death rate in Sweden which took a less strict approach. For
now, their rates are lower. In theory, other countries with harsh
measures may have only postponed some deaths that will come later if
population level immunity is truly significantly lower after the first
wave of cases.
Feasibility
Is Sweden’s volunteer
strategy coupled with guidance from health officials workable in other
countries?
The question about the
rightness or wrongness of the Swedish strategy may
be moot if
other countries could not
make the
Swedish strategy work.
Context
Matters
As
Tegnell has acknowledged, context is crucial. He states clearly that
the Swedish approach would not have been a good idea in countries that
were hard hit to begin with or became aware of cases only |