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Feature Coronavirus

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

BMJ 2020; 369 doi: (Published 12 June 2020) Cite this as: BMJ 2020;369:m2376

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The controversy about the Swedish Strategy is more to do with its critics

Dear Editors

I too would like to share my concerns about the issues raised by the author in this article.

I of course would like to state clearly that I have no ability in understanding the Swedish language, and hence this limits my ability to find answers to my own questions.

However I would like to point out that the author relied on the premise that the Swedish government's strategy of managing the COVID-19 pandemic (misleadingly labelled as 'herd immunity' not just by inference in this article but also by many other governments and commentators who supported the alternative "containment" or "flattening the curve" type response) has failed and that the death toll is far higher than accepted in a comparison nation.

In this article these views were communicated in 2 consecutive paragraphs:

"Sweden recorded the most coronavirus deaths per capita in Europe in a seven day average between 25 May and 2 June. The country’s mortality rate was 5.29 deaths per million inhabitants a day (the UK ranked second with 4.48) according to Our World In Data, 2 an online research publication based at the University of Oxford.

And what of herd immunity? An ongoing nationwide study conducted by the Public Health Agency of Sweden on 20 May found that just 7.3% of Stockholm residents had developed covid-19 antibodies by late April—and that was the largest number of positive results found in the country".

Fellow readers need to consider the following background before contemplating this argument:

1. It has been well known that the official UK figures of COVID-19 deaths have for some time been focussed on hospital data and excluded care home deaths. The Office for National Statistics on 18 April 2020 listed about 8000 more deaths with COVID-19 mentioned on the death certificates (21 284) than the official government figures based on hospital deaths (13 917) (ref 1). Even with an (inadequate) adjustment made on June 1 to account for previously unrecorded COVID-19 deaths, it is obvious that the statistics this article relies on (ref 2) are more closely aligned with official government-approved figures than ONS figures. Furthermore there are concerns that a significant proportion of deaths in care homes has not been properly assessed and tested for coronavirus. Thus it is possible that the true death rate in UK from COVID-19 is as much as 50% more than that of official figures. The Swedish statistics for COVID-19 also suffer from similar problem with under-testing and may have missed about 20% of COVID-19 related deaths (ref 3) but the true death toll proportionately would still be less than in the UK and hence any inference that Sweden performed worse than the UK on deaths per million population would be obviously open to challenge.

2. The "just 7.3% of Stockholm residents had developed covid-19 antibodies by late April" has been widely reported on most media outlets openly critical of the Swedish strategy but very little detail is actually available for scrutiny on how this statistic was obtained from the news. While it has been mentioned in one source that this is based on 1100+ blood sample testing for antibodies from the laboratories, few details are available in the English medium on how these blood samples were selected and if they were taken from well persons in the community. Keeping in mind the well known finding that the COVID-19 antibodies in confirmed infected patients take at least 3-4 weeks to be detected on current blood testing technology, the late April result would reflect infection in late March to early April, which is pretty much within a few weeks of the Swedish government announcing their strategy and measures which included voluntary self-isolation of individuals with respiratory symptoms, discouraging travel, encouraging work-from-home arrangements (with distance learning for over-16s) and physical distancing of individuals at risk in addition to ban on large gatherings (initially 500, then 50). Therefore Stockholm residents with COVID-19 antibodies would have been expected to be far more than 7.3% by the time this result was announced in late May 2020.

It is however true that the planned surge in antibodies testing has not taken place as much as required, thus exposing the Swedish Public Health Agency to significant criticism for its response to COVID-19 with inadequate up-to-date data to monitor the immunity of its population to coronavirus.

What have the Swedes gained from their strategy? Their economy is expected to shrink by 6% this year and return to positive growth in 2021 (ref 4), just half of the UK's expected 11.5% reduction in GDP this year.

And if the Swedish strategy did work without needing the vaccine the other countries are banking on, they would not have to lockdown as much for the subsequent waves of the pandemic.

The jury is still out on the Swedish Solution; perhaps the winner will take it all.

2. Our world in data. Daily confirmed COVID-19 deaths per million, rolling 7-day average. 2020.

Competing interests: No competing interests

19 June 2020
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia