What now for Sweden and covid-19?BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n3081 (Published 22 December 2021) Cite this as: BMJ 2021;375:n3081
“Swedish statistics do not differ from other European countries,” Anders Tegnell, the state epidemiologist who has been the face of Sweden’s infamous pandemic strategy, tells The BMJ.
“After two years of pandemic Sweden does not stand out. We are not the best, but we are definitely not the worst.”
In contrast to the stricter, often lockdown focused, approaches of many European countries—including its neighbours in Scandinavia—Sweden’s strategy has relied on individuals taking responsibility under non-binding recommendations.1 In the first six months of the pandemic, the government enacted extensive work from home measures for those that could, as well as remote learning for over 16s.
The public acquiesced and there was little debate about the stance, bar a group of 22 scientists who were outspoken about the high number of coronavirus deaths among the elderly, which was significantly higher than that of its Nordic neighbours—131 per million people compared with 55 per million in Denmark and 14 per million in Finland, which all adopted lockdowns.
Tegnell was among those insistent that the lockdowns imposed by other countries were excessive. Compared with other major European countries the number of overall cases and deaths in Sweden was low—just under 93 000 cases and 6000 deaths by 1 October 2020 compared with over 118 000 cases and 10 000 deaths in Belgium, which has a similar overall population size, or the 606 000 cases and 32 000 deaths seen in France and other larger countries, according to Our World in Data.
But by winter 2020 a second wave with the new alpha variant brought a spike in cases.2 In the six months between October 2020 and March 2021, the country saw 657 309 positive cases and 12 826 deaths.
The government’s measures were sharply criticised in an 800 page report (the second of this sort) published in October 2021 by the Swedish Corona Commission3—the government commissioned inquiry into the pandemic response—which it noted were both late and insufficient, and called preparedness “non-existing.”
This was followed in November 2021 by a report from the Royal Swedish Academy of Sciences,4 proposing the establishment of an independent expert unit for future pandemics, stating that authorities were “inadequately prepared” in terms of knowledge as well as equipment such as face masks, and that high mortality during the first two waves of the pandemic was because of “mild and tardy” measures to prevent the initial spread of infection.
Sweden’s King Carl XVI Gustaf labelled Sweden’s handling of the pandemic a “failure” in his end of 2020 TV speech. Then prime minister Stefan Lofven agreed. “The fact that so many have died can’t be considered as anything other than a failure,” he said.
Anders Vahlne, a professor of virology at the Karolinska Institute and one of the scientists critical of the Swedish response, told The BMJ that it was shameful that the whole pandemic had been in the hands of a few civil servants who acted and reacted slowly, lacking flexibility and still not clearly acknowledging that the virus was airborne.
A year on, as the country faces up to a second winter of the pandemic and both delta and omicron variant threats, experts The BMJ spoke to are clear: Sweden’s situation remains precarious.
Going in circles
The second wave hit Sweden in the autumn of 2020. By December intensive care units (ICUs) in and around Stockholm—the epicentre of the country’s pandemic throughout—came close to maximum capacity for the first time, forcing the government to reintroduce restrictions. In January 2021, these were expanded to include the recommendation, though not a mandate, to wear masks on public transport.
By 15 March 2021, the government approved new pandemic powers to allow for further measures, if required, over the next 12 months. These include limiting the opening hours or number of people (one per 10 m2) allowed at gyms, shops, and other businesses, and in public spaces like parks and beaches.
The shift seemed to work. Case numbers dropped and by the start of June, restrictions were removed gradually until all were lifted by the end of September. By 1 November, the Swedish Public Health Agency (Folkhälsomyndigheten, FHM) even withdrew its free polymerase chain reaction (PCR) testing service for anyone who was already fully vaccinated.
A major reason was Sweden’s vaccine rollout. Of a population of 10 million people, 80% are fully vaccinated and 85% have received a first dose, though there are differences between regions and among ages, with lowest rates among those between 20 and 40 years old.
But the respite has lasted barely two months.
A sharp rise in cases in November and new concerns over the omicron variant have forced the government to act again. Demand for testing in Stockholm is challenging the capital’s laboratory capacity; since the start of November the number of tests has increased from 89 743 a week to 281 654 in the week up to 8 December. In college town Uppsala the need is so great that the region is now gathering strength to scale up operations “thanks to the staff who work nights and weekends” Mikael Köhler, head of healthcare for the region of Uppsala, told the media on 15 December.5
Since1 December 2021, a valid covid-19 vaccine pass has been required at indoor public events and public gatherings of over 100 people that don’t have any other infection control measures in place (such as social distancing or a limit on the number of people per group).
On 8 December, the government again asked the public to work from home and wear face masks on public transport. Vaccine passes for access to restaurants, gyms, leisure and culture centres, and shopping malls, as well as long distance public transport, are also under discussion. Free PCR tests have been reintroduced for the public, including the fully vaccinated.
In a press conference, new Swedish prime minister Magdalena Andersson repeatedly stressed the importance of vaccination. “Vaccines are important for your health and for the health of the whole society,” she said, “We must protect ourselves and the others.”
Is the healthcare system prepared?
Karin Tegmark Wisell, general director of the Public Health Agency, said at an 8 December press conference that “the current situation is not considered critical yet.” On 14 December Tegmark Wisell reported that the number of newly confirmed cases and hospital admissions had increased by about 30% and intensive care admissions by 20-25% over the previous seven days. At the same time, the figures are relatively low; 68 covid patients were in ICUs on 14 December compared with about 400 during the peak of the infection a year ago. Currently just over 3000 cases are being confirmed per day; in December 2020, the highest figure was over 11000. “If the increases continue, new restrictions can be announced as early as next week,” Tegmark Wisell said.
But Johan Styrud, chief physician at Danderyd Hospital and chairman of the Stockholm Medical Association, worries that the vaccination rate, after a good start, has stagnated. He told The BMJ that “before any other restrictions, more work should be done to reach more and more citizens with vaccinations.”
Johan Bratt, head of healthcare for the region of Stockholm, told The BMJ that the hospitals of the region have achieved a high degree of flexibility in the past year, with constant dialogue with FHM. Björn Persson, director of intensive care and thoracic surgical services at Karolinska University Hospital, told The BMJ that Sweden’s hospitals are now much better prepared and know how to increase the number of ICU beds quickly, though wards are still facing a shortage of specialised nurses.
However, Persson expressed frustration at the crowds he sees in public where hardly anybody wears a mask. “There is a risk that citizens think that the pandemic is over when all restrictions and general advice are lifted” he says.
The common thinking among most healthcare workers was that some restrictions should have been kept in place throughout the year. Some think schools should also have been at least partially closed, as in the first wave.
Bratt thinks the next wave will likely not see as many deaths thanks to the high rate of vaccination. But he warns that, “The truth is that the number of patients in need of intensive care increased during the past week. It is the beginning of a negative trend with a high flow of patients with covid-19, seasonal flu, and other common diseases.”
Vahlne says he remains “deeply concerned” about the Swedish situation. “With a low contagion in the summer, we should have started to test and trace and kept using some precautions such as masks, for example,” he says.
But Anders Tegnell says that there is still disagreement among scientists about which measures are effective against the spread of infection. “This is what we are still struggling to understand: some measures work in some places, but it is difficult to see patterns.”
“Countries that went through lockdowns are not doing that much better,” he insists. Vaccination is the only measure that definitely works, he says. But he does not anticipate having to make vaccination mandatory, as Austria has done.
“Obligation does not work by law in Sweden, and it would make people lose trust for vaccines” he says, “We should work more on spreading information about vaccines that most of the time, unfortunately, gets diluted by wrong and confusing messages.”
Commissioned, not externally peer reviewed.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
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