From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

 

Sweden’s response to the coronavirus pandemic – Update (May 2020)
Ulrika Winblad, Uppsala University, Sweden

As of May 13^th, 27,909 Swedes have tested positive for Covid-19, 3,460 of whom have died. Nationally, the incidence curve has flattened, but there has not yet been a significant reduction in new cases. The capital area of Stockholm remains the most affected region, but a significant number of infected people may now also be found in other regions. While a reduction in the number of patients in intensive care has occurred over the last weeks resulting in spare ICU capacity in several regions (30% of beds overall), the pressure on the health care system is still high in the most affected regions. Over time, the proportion of healthcare staff among the infected has increased, partly due to more systematic staff testing.

The main strategy of flattening the incidence curve in order to secure healthcare service availability continues unchanged, and the recommendations and restrictions previously issued by the Public Health Authority (PHA) pertaining to the public and community actors remain in effect. In contrast to other countries with stricter regulations, it has yet not been considered necessary to lift the restriction in the Swedish case.

Trust in public authorities, as well as the public’s compliance with recommendations, still appears to be relatively high. Daily press conferences are followed by nearly one million people, in which people are urged to continue implementing ‘social distancing’ practices. A recent survey indicated that the great majority of people have integrated behavioural changes such as avoiding public places and physical distancing into their daily lives. While shops and restaurants are open, they are often quite empty. Analyses of mobile phone data show that travels during the Easter weekend decreased sharply compared to previous years. Compliance is not total, however, and recent inspections by local authorities have led to the closure of several restaurants and bars in Stockholm due to violations of public health guidelines.

The per capita mortality rate in Sweden has so far been higher than in other Nordic countries, but lower than in other European countries such as Belgium, the UK, and Spain. The single most important factor is the spread of the coronavirus within nursing homes – a situation also seen in many other European countries. By the end of April, almost 90 percent of the total number of people who died of Covid-19 were 70 years or older, and of those, 50 percent lived in nursing homes and 26 percent had home care. Recent regional reports show that the majority of nursing homes in Stockholm had infected residents. Problems with high staff turnover, widespread use of hourly staff, poor compliance with hygiene routines and a lack of protective equipment have been highlighted in the media. The exact reasons for the excess mortality at nursing homes remains to be established, however. A recent national investigation shows that nearly all nursing home facilities have taken actions to prevent disease transmission such as staff training, isolation of sick residents, and the practice of basic hygiene routines. At the national level, a crisis response package was recently passed to improve staff training levels in nursing homes.

An issue currently under discussion is whether there is a need for clearer guidelines regarding the use of facial protection. So far, no general recommendation has been issued, and it is up to each facility to decide what protective equipment should be used under which circumstances. Authorities have pointed to a lack of evidence and concerns that the use of face protection could lead to a false sense of security and a reduced focus on basic hygiene practices. The lack of clear recommendations has, however, resulted in confusion and a harsh critique from some municipalities, unions, and staff.

Another issue of concern is the low rate of testing so far. Swedish laboratories have capacity for over 100,000 tests a week, but last week only 29,000 tests were conducted (mostly on staff). It may be that the decentralised governance structure has created problems organizing the testing, and there might be a need for more national steering and coordination in this sense.

Finally, Sweden’s governmental response to Covid-19 continues to arouse reactions from around the world. Although Sweden still receives criticism for its strategy, a more nuanced discussion about policy sustainability may be discerned as many countries begin to open up their communities and are searching for ways to balance the risks of further transmission with the need to return to normal. Looking forward, the severity of additional waves of disease transmission will be of utmost importance in establishing whether Sweden’s policy has been successful. While the data shows that Sweden’s policy has thus far resulted in a relatively high rate of infection, we remain far from knowing which strategies will lead to the most desirable long-term outcomes.

 

The Swedish response to the coronavirus pandemic – Original post (April 2020)

Ulrika Winblad
Uppsala University/Department of Public Health and Caring Sciences/Health Services Research

 

The first Swedish COVID-19 patient was diagnosed on January 31^th 2020. By April 8^th, a total of 8,419 people have tested positive and 687 people have died with the capital region of Stockholm being most affected. The measures taken by the government and the authorities consist of a combination of recommendations and regulations. So far, the emphasis has been on recommendations, but the approach has changed over time in response to changing conditions, gradually transitioning to also include stricter regulation. The Swedish response has been guided by epidemiologists working at the Public Health Agency of Sweden seeking an evidence-based approach. The main strategy as communicated by national authorities has been to flatten the incidence curve of the infection. The aim is thus to avoid overburdening the healthcare system, rather than to halt the spread of the disease outright, and to ensure that measures are implemented at the right time. The latter has particularly been considered important to alleviate the impact on individuals and businesses, and to ensure the sustainability of the policy over time. A clear focus in the response has been to stress individual responsibility for limiting the spread of the coronavirus by following the recommendations issued by the expert agencies.

The national authorities with a primary responsibility for handling COVID-19 are the Public Health Authority (PHA), and the National Board of Health and Welfare (NBHW). The public face of the response has mainly been representatives from these authorities, who communicate and advise the public through daily press conferences – particularly the state epidemiologist Anders Tegnell has become a frequent and popular voice on TV and radio. Overall, the communication approach is factual and based on scientific (epidemiological) evidence. The government and the PHA have close and daily contact but the Prime Minister, Stefan Löfven, has hitherto had a more withdrawn public role, mainly relying on the agencies’ communicators.

The PHA has issued several recommendations to protect at-risk groups and the elderly, and to reduce the burden on the health care system overall. Individuals are recommended to implement ‘social distancing’ measures, such as to stay home when ill, avoid unnecessary travel, limit contact with the elderly, and work from home if possible. Specific recommendations have also been addressed directly to those over 70 years of age to limit their social contacts. Quarantines have thus far not been introduced for any group of people in Sweden. Rather, incentives to encourage people to stay at home even with mild symptoms have been implemented, including a temporary relaxation of regulations regarding sickness leave benefits.

Interventions by expert authorities and the government have also been addressed directly towards community actors. For example, all universities, colleges and upper secondary schools have switched to remote lessons following a recommendation from the government on March 17^th. However, elementary schools and preschools are still open until further notice since it is considered, among other things, to put strain on essential sectors such as health care if parents have to stay home to care for their children. However, children, teachers showing any signs of cold, fever, cough, or similar are urged to stay at home, and can be sent home immediately. Over time, stricter measures have been introduced in several sectors. On March 24^th the Public Health Agency issued specific regulations for restaurants, bars, and cafes. These are now to take measures to reduce the risk of infection, including serving patrons only at tables, and restrictions on public events have been strengthened over time. Since March 29^th, all public gatherings and events with more than 50 people have been banned. On April 1^st, the government also imposed a ban on visiting nursing homes in response to the spread of the virus in such facilities in some of the larger cities.

Apart from the on-going work by healthcare providers to increase the number of intensive care beds available and secure the healthcare work force, national measures have also been taken to support Sweden’s highly regionalized health care system. The government has for example instructed the NBHW to establish a coordination function for intensive care units, and the agency has been appointed as the national procurement centre for medical, and personal protective equipment. The PHA meanwhile has been given the task of finding ways to increase testing for COVID-19.

Reflection on the response

Sweden’s governmental response to COVID-19 has been less focused on mandatory measures than elsewhere, leaning heavily on recommendations. This has led to harsh reactions around the world, especially from countries choosing a stricter approach. At first, the rationale behind Sweden’s ‘soft’ approach was not clearly communicated to the public and was also contested by many, including researchers and clinicians. Over time however, the PHA in particular has been consistent in clarifying the Swedish strategy; measures to ameliorate the pandemic must have a clear intent, be issued at the correct time, and be weighed against the consequences such as the negative effects of closing down schools on healthcare staff availability. Although not confirmed by national surveys, it appears Swedes are content with the softer measures, and that they feel the authorities have got the balance right. Despite the lack of legal mandates, many have chosen to self-isolate. Most people have also reduced their social contacts and have implemented social distancing, although the mobility of the population is probably higher than in countries with heavier restrictions.

While it is understandable why schools are not closed, there are reasons to be more sceptical about how elder care has been handled in the Swedish case. Recent reports show that a large amount of the deaths in COVID-19, particularly in the Stockholm area, are in nursing homes and the authorities consider this to be one of most serious problems at the moment. It was not until April 1^st that a ban on visiting elderly homes was imposed, which has been criticized as being too late. Concerns have also been raised about a lack of protective equipment. High staff turnover and the use of hourly employees may furthermore lead to deficiencies in hygiene routines, spreading the virus to users and staff. A reflection is that the response, to begin with, was mostly focused on the regional health and welfare sector, rather than on the municipalities who are responsible for social care including nursing homes.

The crisis has also highlighted the critical lack of inventories for medication and medical consumables in many regions and municipalities, resulting in a chorus of complaints from caregivers across the country. The national government’s responsibility for these matters has eroded over the past decades, not least through the deregulation of the national pharmacies in 2008. As the use of just-in-time inventory management practices increases, the national government may need to reconsider its role in safeguarding the supply of consumables, and how it relates to the responsibilities of the regions and municipalities in stockpiling these items. In this sense, it is a delicate balance to strike between a potent central government and a nuanced regional response adapted to local conditions.

On the whole, regarding the Swedish approach, it has not yet been considered appropriate to fine or ban inappropriate behavior. Instead, health authorities’ communication approach has been to explain and appeal to the ‘common sense’ of the individuals. The population had, particularly at the beginning of the crisis, difficulties understanding what some recommendations implied. The PHA nonetheless retains a high degree of civic trust, and has been reasonably effective in obtaining public compliance with its recommendations. It remains to be seen whether this strategy will lead to the desired outcomes, or if stricter regulations need to be implemented and enforced.

 

https://www.government.se/government-policy/the-governments-work-in-response-to-the-virus-responsible-for-covid-19/

https://www.folkhalsomyndigheten.se/the-public-health-agency-of-sweden/

https://www.socialstyrelsen.se/coronavirus-covid-19/

 

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