Has Sweden’s controversial covid-19 strategy been successful?

Dear Editor

From Heba Habib's article I understand that Sweden's decision not to to mandate lock down has been a failure, because the population has not acquired herd immunity and because of the country's high mortality rate. I think it would be interesting to ask the same question about lockdown: How successful has lockdown been?

A longitudinal study carried out in Spain this summer has revealed a seroprevalence of SARS-CoV-2 infection in the Spanish population of 5% (Pollán et al 2020). This is not much lower than the 7.3% seroprevalence rate for Stockholm. When compared with the much more relaxed approach of the Swedish government, it would appear that the nationwide lockdown imposed in Spain has had only limited effect in reducing exposure to the virus. At its height the rate of deaths caused by COVID-19 in Spain was alarming and news reports suggested particularly high mortality in nursing and residential homes. Is there a significant difference in death rates between the two countries?

Considering the high economic price we are paying, I think it would be interesting to study in more detail the effectiveness of lockdown in different countries in preventing the spread of COVID-19, compared with Sweden's policy of voluntary social distancing. Which country has the most effective lockdown protocol and what can others learn from them?

References

Pollán et al (2020) Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. [Viewed 12th July 2020]. Available from: https://doi.org/10.1016/S0140-6736(20)31483-5

Dear Editor

I am writing to share my dismay at the editorial policy of BMJ after reading the article written by the freelance journalist Heba Habib on 12th June.

This article was published under the Coronovirus section of the BMJ's covid-19 hub, which claims to 'support professionals and researchers with practical guidance, online CPD courses, as well as the latest news, comment, and research from BMJ.' However, the article does not support any of these aims. It amounts to no more than a thinly veilled and political attack on the public health policy of the Swedish Public Health authority (Folkhölsomyndigheten) and Anders Tegnell in particular.

The inaccuracy and bias of this article is perhaps best evidenced by the rather glaring correction issued on 18th June 2020, just 6 days after it was published. Even this correction, which in its first instance had claimed that schools for under 16 years-olds had closed, was inaccurate. Swedish high schools did not close - lessons were conducted online but pupils were still able to collect their school lunches at school. The universities also remained open for teaching, although undergraduate courses were conducted online - some aspects of one-to-one teaching, e.g. where students conducted practical reseach projects, remained in effect.

Due to the tone and direction of the article, in my opinion that this was published with another agenda in mind. The fact that this article was written by Heba, who us a freelance journalist witout a declared scientific or medical qualification should be a warning sign for any editorial system. Heba has writen a number of such pro-lockdown articles in the past. No declaration about who paid for the article to be written was stated.

I think it is perhaps a sign of the times but it is deeply disturbing that the BMJ is willing to promote a feature article of this type.

Yours,

Jonathan D. Gilthope Ph.D.

Dear Editor
It was predicted that the number of COVID 19 cases would have reached 670 million cases if not for nations implementing Lockdown. WHO observed that the number of COVID 19 cases drastically reduced due to the implementation of lockdown, but after unlocking, numbers of cases have been logarithmically increased.
Global scenarios of infectious diseases and hotspots for a pandemic resurgence.
Infectious diseases are a leading cause of death; there have been several outbreaks of infectious diseases and have been documented since time immemorial. The spread of pandemic is a result of changes in human behavior including lack of social distancing, adequate hand hygene and land use patterns, increased commercial activity and travel, and inappropriate use of antibiotic drugs as it induces mutations in pathogens.
In developing countries, the range and burden of emergency infectious diseases are huge and of an enormous variety. There are a lot of new and re-emerging infectious diseases in different parts of the world. Due to globalization, there is increased travel, increased need for housing. Global warming, destruction of forests, Tsunami research into microorganisms has only added to the problem of the spread of these diseases. Prof. Boyle pointed out some developed country in some west, is looking for and collecting potentially dangerous bacteria and viruses around the world and to turn them into a deadly biological weapon. Prof Boyle added a long history of research and design for the intelligence agencies, including human experiments. Some universities have a long history of willingly permitting their research agenda, *researchers, institutes, and laboratories to be co-opted by the intelligence agency into researching warfare science. German scientists have performed experiments on people. During world war II many scientists have been doing bio-organisms experiments on people.

The global scenario shows that twenty diseases together with tuberculosis (TB), malaria, and cholera have re-emerged or extended worldwide since 1973, often in virulent and drug-resistant forms.(1) Thirty new emerging infectious disease agents have been identified since1973, including HIV, Ebola, hepatitis C, and Nipah virus, for which no appropriate cures available. Of the seven biggest disease killers worldwide, TB, malaria, hepatitis, and HIV/AIDS continue to increase, with HIV/AIDS and TB likely to account for the majority of deaths from infectious diseases in developing countries by 2020. In December 2019 a new organism created a disease known as COVID -19. Since the beginning of the year 2012, there have been outbreaks of avian influenza in Indonesia, Egypt, China, Cambodia, Vietnam, Bangladesh, and in Hong Kong Special Administrative Region. This includes the outbreaks of yellow fever in Cameroon and Ghana, and meningococcal disease in the African meningitis belt, with Lassa fever in Nigeria, and Undiagnosed illness in Cambodia. This also includes severe complications of Hand, Foot, and Mouth Disease (HFMD)caused by EV-71 in Cambodia has become endemic in different parts of the world like India, Cholera outbreaks in the Democratic Republic of Congo and Sierra Leone and Ebola outbreaks in Uganda and the Democratic Republic of Congo. In the developed world, the spread includes Hantavirus pulmonary syndrome in Yosemite National Park, United States of America Ebola MERS, and novel coronavirus infection in the UnitedKingdom. There are many more before and after 2012 but the worst-case scenario is the corona.
The regional trends suggest that COVID _19 effects will globally affect all countries and more so developing nations as a result of malnutrition, poor sanitation, poor water quality, and insufficient health care; the developed countries also will be affected due to the lack of a vaccine and no effective medication. The most vulnerable region of Sub-Saharan Africa will account for nearly half of infectious diseases caused by deaths worldwide. The motality for many diseases, including HIV/AIDS and malaria, exceed those in all other regions. In certain regions of Asia and the Pacific, where multidrug-resistant TB, malaria, and cholera are widespread, it is likely to observe a remarkable increase in infectious disease deaths, as a result of the spread of HIV/AIDS in South and Southeast Asia and it is likely spread to East Asia. A substantial increase in infectious disease incidence and deaths are likely in the former Soviet Union and, to a lesser extent, Eastern Europe also is likely to follow suit. Owing to an economic downturn, there has been a rapid increase in diphtheria, dysentery, cholera, and hepatitis B and C. Generally, uneven economic development has contributed to the widespread resurgence of cholera, malaria, TB, and dengue in Latin American countries. Regions of the Middle East and North Africa has substantial TB and hepatitis B and C prevalence but have limited some of the globally prevalent diseases, such as malaria and HIV/AIDS.
Apart from infectious disease, the rise in antibiotic resistance has caused havoc in treating disease. The rise in MRSA, MDR TB/XDR TB, New-Delhiβlactamases in developing countries have put a strain on the health system. Exotic bacteria like Burkholderia pseudomallei and B. cepacia complex infections are on rising leading to mortality and morbidity. Disturbing the flora and fauna of the forest has resulted in re-emergence of Arboviruses like West Nile fever, Chikungunya, and Dengue. But emerging infectious diseases have quadrupled in the last half-century largely because of increasing human encroachment into the habitat, especially in disease "hot spots" around the globe, mostly in tropical regions and bio experimented with modern air travel and a robust market in wildlife trafficking, the potential for a serious outbreaks

Strategies to forecast and prevent pandemics.
The key to forecasting and preventing the next pandemic is to understand what they call the "protective effects" of keeping nature intact. In the Amazon, for example, one study showed that an increase in deforestation by 4 percent increased the incidence of malaria by nearly 50 percent, because mosquitoes, which transmit the disease, thrive in the right mix of sunlight and water in recent deforested areas. If actions are not taken to tackle these problems it might become a major health issues which results in financial strain on the government. Artificial intelligence can be helpful to predict the pandemic spread at any time. Hygienic practices replacement of bad spitting habits social distancing lockdown measures is key to flattening the curve of COVID-19 spread. The prevalence and rapidity of spread were likely vastly underestimated initially. Areas with greater initial quantity of viruses introduction had worse spikes of cases.

Strategies at the community level:
Tactics used and measures taken by nations
On the macro level, the key anti-virus strategy for centuries has been quarantining the sick. The novel coronavirus pandemic has seen quarantine implemented on an unprecedented scale, with both the sick and the healthy "locked down" in entire cities and provinces for weeks or months. The more authoritarian the leader was the better control of the pandemic occurred. WHO recommends testing of suspected cases, contact tracing, strict quarantine
And Community preventive measures . ..
The recent pandemic has been controlled by east Asian countries so understanding the HAMMER and DANCE mitigation strategy.Taiwan famously had the perfect leadership in place for the crisis: Vice President Chen Chien-Jen was an epidemiologist and there were unified command and control, the messaging is singular, leadership is not just a matter of "what" but also "when."
An early gold standard for contact tracing, having integrated its health insurance, immigration, and customs databases, then mined the resultant big data with AI.
In Korea, you get these incredible screening and integration of treatment that can help in pandemic control, a lot of Western systems, the medical care is advanced but the integration is not that’s why US has had difficulties in stopping the pandemic.
Another tool to mitigate pandemics are Swift border closures ,this was done quickly by Vietnam and Taiwan — two countries that are politically wary of China — to Chinese citizens have been assessed as key reasons for pandemic control.
China is "the workshop of the world" and all Northeast Asia economies boast powerhouse manufacturing sectors, from light industry to high technology.
East Asia's manufacturing muscle, combined with prior experiences with pandemics and its social habits of mask-wearing, has allowed regional economies to churn out massive quantities of masks, personal protective equipment.
Western economies that have shifted heavily toward services have suffered shortages of test kits, PPE for medical workers, and even the most basic, low-tech anti-virus supplies for their populaces This has allowed surge of pandemics.
Could the variant of the virus in the West be deadlier than the version that emerged in the East? Viruses mutate, and according to research Most notoriously, in the "Columbian Exchange" a range of Old-World diseases wiped out 80-95% of the native population of the New World within 150 years
Could ethnic Asians today have a more in-built resistance to this disease than ethnic Westerners? Climate, perhaps in combination with Asian cultural and/or genetic characteristics, could potentially also help explain the low death tolls in Southeast Asia, which have warmer climates but are less prosperous.
But the epicenter of the pandemic could soon shift again – to low and middle-income countries, including those already fragile after years of conflict.

Newer strategies to contain pandemics
1. Mapping demand for medical supplies
Poor countries with low bargaining power and weak health systems will be further challenged by having to compete with rich ones for supplies of masks, ventilators, and other vital equipment.
In 2009, the civil society organizations created a tool that enabled researchers and activists to map the available supplies of essential medicines across Africa.
Adapting this idea for COVID-19, frontline workers, and emergency responders could use existing technology like Frontline SMS to report on missing or low supplies of key equipment to a common website. This could then be displayed on a map showing shortage locations.
This would enable governments to see the needs of different health facilities, or even their existing capacity in real-time detail. It also helps humanitarian agencies, businesses, and local manufacturers to respond where supplies are low.

2. Open-source local production
During other crises, organizations such as Field Ready have pioneered the localized production of humanitarian supplies – getting vital equipment quickly and cheaply into conflict zones. The COVID-19 response could incorporate ideas such as these and tap into the dynamism of the open-source design and engineering communities.
Covid-19 virus infection China Hubei Wuhan contagion spread which lead to great recession in most countries.
Frontline workers can use Frontline SMS to report on missing or low supplies of equipmen
Governments should consider designating local makerspaces that use tools such as 3D printing as "critical infrastructure", allowing them to continue to operate during the lockdown. Connecting them to hospitals and clinics could provide local level manufacturing capacity that could help with supplying essential items such as personal protective equipment (PPE) and some spare parts.
Successful designs could then be scaled up by local manufacturers with greater production capacity. This could be supported by a crowdsourced repository of open-source designs. A rapid vetting process for each published design to determine its field readiness and level of safety would provide valuable information.

3. Identifying community assets
There is already emerging evidence from many countries that crowded living conditions speed up the spread of COVID-19 globally, up to a billion people live in densely populated slums. In 2018, researchers in India estimated that an influenza-like respiratory disease would have a 44% higher infection rate among slum dwellers than the rest of the population – even with social distancing. This was shown in a recent pandemic spread in areas of India .
For people living in cramped conditions in slums, where many family members share a single room, self-isolating in the home is more difficult. Alternative measures will be needed.
Repurposing the likes of schools and churches those with COVID-19 symptoms to self-isolate quickly. In China, stadiums were converted into mass quarantine centers, helping to stem the risk of infection within family groups.In India hotels Resorts schools hostels were changed into quarantine centers.
Mapping tools such as Open Street Map could be used to identify the locations in partnership with municipalities, businesses, and community organizations. Humanitarian Open Street Map is already mobilizing its volunteer mapping communities, while Open Cities initiatives have substantial expertise in community mapping for crisis resilience.

4. Smarter surge response
Many countries already facing chronic shortages of health workers. But 89% of the global nurse shortage is concentrated in low and lower-middle-income countries. In India
This was not an issue
During the HIV/AIDS pandemic and Ebola outbreaks, countries rapidly trained and mobilized community health workers from affected communities. Community health workers could now be vital source in helping to track the numbers and symptoms of people with COVID-19.
Modifying symptom-reporting tools for community health workers to use would allow governments and humanitarian agencies to identify potential virus hotspots and deploy surge capacity. With a fast-moving pandemic and already-strained resources, governments and humanitarian organizations will need to focus and intensify their collaboration.

5. Medical hiveminds or Pandemic hub.
The pace of the COVID-19 pandemic is so fast that the usual process of sharing knowledge via journal articles is often proving too slow. Instead, doctors have been joining specialist discussion groups on social media creating a kind of medical hivemind to develop answers in real-time.
One of these, a Facebook group for registered physicians called the PMG COVID19 Subgroup has over 35,000 members worldwide. There may be a risk that mistakes could be amplified with this kind of rapid information sharing and content should always be viewed carefully and critically. But so far it has helped develop new treatment protocols.
In undeveloped countries with few doctors, mobilizing the collective intelligence of frontline health professionals and humanitarian agencies across the world may help to speed up the generation and distribution of relevant knowledge. Collective intelligence projects like We Farm, uses text messaging and machine-learning to match farmers in East Africa with others who can help answer their questions.
Past pandemics have shown that people with low literacy or proficiency in the main national language tended not to receive adequate public health information. Tapping into the global hivemind or pandemic hub would also speed up the creation of crowd sourced of commonly-used words associated with the virus in mother tongue and native languages.
We know from experience that humanitarian workers can struggle to absorb innovations during acute emergency responses. But time is critical and by focusing on repurposing existing tools and tested approaches, we might be able to help stem the next wave of the pandemic.

Strategies at the individual level
Protecting individuals and others from the spread COVID-19
An individual can reduce chances of being infected or spreading COVID-19 by taking some simple precautions:
Regularly and thoroughly clean your hands with an alcohol-based hand rub or wash them with soap and water. Washing your hands with soap and water or using alcohol-based hand rub kills viruses that may be on your hands. Maintain at least 1 meter (3 feet) distance between yourself and others. When someone coughs, sneezes, or speaks they spray small liquid droplets from their nose or mouth which may contain the virus. If you are too close, you can breathe the droplets in, including the COVID-19 virus if at all the person has the disease. Avoid going to crowded places where people come together in crowds and we are more likely to come into close contact with someone that has COIVD-19 and it is more difficult to maintain a physical distance of 1 meter (3 feet). Avoid touching eyes, nose, and mouth. Hands touch many surfaces and can pick up viruses. Once contaminated, hands can transfer the virus to your eyes, nose, or mouth and the virus can enter our body and infects us.
Make sure you, and the people around you, follow good respiratory hygiene, Which means covering your mouth and nose with your bent elbow or tissue when you cough or sneeze. Then dispose of the used tissue immediately and wash your hands. Droplets spread the virus. By following good respiratory hygiene, you protect the people around you from viruses such as cold, flu, and COVID-19. Stay home and self-isolate even with minor symptoms such as cough, headache, mild fever, until you recover. Have someone bring you supplies. If you need to leave your house, wear a mask to avoid infecting others. Avoid contact with others will protect them from possible COVID-19 and other viruses.
If you have a fever, cough and difficulty breathing, seek medical attention, but call through telephone in advance if possible and follow the directions of your local health authority. National and local authorities will have the most up to date information on the situation in your area. Calling in advance will allow your health care provider to quickly direct you to the right health facility. This will protect you and help prevent the spread of viruses and other infections.
Keep up to date on the latest information from trusted sources, such as WHO or your local and national health authorities. Local and national authorities are best placed to advise on what people in your area should be doing to protect themselves.
Safe use of alcohol-based hand sanitizers
To protect individuals and others against COVID-19, cleaning hands frequently and thoroughly. Usage of an alcohol-based hand sanitizer or washing hands with soap and water. Keeping alcohol-based hand sanitizers out of children's reach and also teach them how to apply the sanitizer and monitor its use.Avoid touching eyes, mouth, and nose immediately after using an alcohol-based hand sanitizer, as it can cause irritation.Do not use before handling fire.Remember that washing your hands with soap and water is also effective against COVID-19.

Conclusion
There is an enormous challenge to stop mitigating or altering the course of a pandemic some of the strategies will help contain the present pandemic.
The COVID-19 pandemic will leave our world significantly demoralized on account of its multipronged impact. Ranging from financial impoverishment, poor investor confidence, overturned career pathways, unemployment, it is likely to take a while before the wheels of prosperity gain full throttle. Ironically, the pandemic will leave behind no physical residue, but the psychological setbacks will be huge. A new brand of family, district, talukas, state, national and international Leadership will be sought. Those who are able to inspire will be the ones who will transform their stratospheres. Look at the countries which seem to have overcome the crisis- they have caring, sharing leaders who have inspired their people to hang in there and swim together. The brand of condescending leadership, who spit fire and walk chest-out proud-as-punch will have no impact at all. The ones who stands out will be the ones who will stand in, along with the people.
Reference
Citation: Dias E Global View of Infectious Disease. J Med Microb Diagn 2 2013: e116. doi:10.4172/2161-0703.1000e116

Dear Editor

Sweden does not have a herd immunity strategy and it is irresponsible for the BMJ to perpetuate this myth. Similarly, the decision not to ’lockdown’ is only 'controversial' because the media has framed it as such. It is also time for word ‘lockdown’ to be replaced with precise, non-sensational language that describes the measures taken.

Most of the media coverage has focused on country-level data, which is misleading. Region Stockholm has 91 deaths per 100,000, while Region Skåne, including Malmö, has about 15; Blekinge has the lowest, with 4.4 deaths per 100,000. I am still waiting for an article on "what we can learn from Blekinge’s approach to Covid-19.”

Sweden does not have a single approach to Covid-19; rather, its response is a mix of policies at national, regional and local levels, and in sectors outside of the health system such as public transportation. While a strategy may be set at a national level, the responsibility for implementation may be at a regional or local level. In Sweden social care, including elderly care homes, is run by municipalities while healthcare is run by the region/county. Municipalities also have a responsibility for public health education campaigns and for enforcing physical distancing in public and commercial spaces. In practice, the balance of responsibilities is blurry and can differ depending on the county and municipality. Much of the ‘public’ sector in Sweden is privatised, which raises further questions of responsibility (and blame).

Finally, what did Sweden do well? Compulsory physical distancing measures exacerbate social and health inequalities to a greater extent than voluntary ones. With some exceptions, people have continued to have access to regular and specialist care, and children have had access to education. The importance of a semi-normally functioning society cannot be overstated.

Sweden, and the Swedish approach, is much more multilayered than portrayed in the media, hindering serious policy evaluation.