Web EpiMonitor

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 relatively late after importation.

What about the best strategy going forward when case counts have declined significantly.

The voluntary approach may only be feasible in a country where the level of trust in government and health officials is high. Evidence for this is that “fake news” and misinformation have had little influence on the Swedish population, according to Tegnell. Thus, the Swedes may have had the luxury of taking a longer view because they did not miss as many early cases and did not have the pressure to do something drastic to prevent an anticipated wave of new cases. It was their intention from the outset to implement what they thought would be sustainable measures acceptable in a trusting population that values personal responsibility and is likely to heed public health guidance.

Collaboration Key For Unity

Also, the Swedes have a history of working together in different segments of the health system, so that achieving a unified strategy was possible even though local jurisdictions make final decisions. Tegnell did not agree that having a decentralized system such as in the US was antithetical to achieving a unified national strategy since that outcome is what Sweden has created beforehand on other topics and it replicated that unity in the present pandemic situation.

Coronavirus cases and deaths in Scandinavian countries and the US

Source Worldometer, May 24, 2020    ■

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