HEPL blog series: Country Responses to the Covid19 Pandemic

Denmark’s Response to the Coronavirus Pandemic

The first Danish COVID-19 patient was diagnosed on February 27. As the number of cases increased during the following weeks the government reacted with a series of preventive and capacity enhancing measures. Government intervention has been decided by a National Security Council headed by the Prime Minister and Ministers of Justice, Foreign Affairs, Defence, and Finance, the Permanent Secretaries and supplemented by the Minister of Health, the Director of the National Health Authority and the Director of  Statens Serum Institut. The first known meeting of the expanded Security Council took place on February 27^th. The Prime Minister has taken strong leadership throughout.

Preventive measures, triage and testing
On January 22^nd the National Health Authority announced that they had been following the developments in China and considered the risk to Denmark as low. This was upgraded to a moderate risk on February 25^th. On February 27^th the first COVID-19-infected Dane was identified as having returned from Northern Italy. Social distancing measures were first introduced on March 3 with recommendations that all citizens returning from pandemic hotspots should stay at home for two weeks. On March 6th the Government urged that all activities with more than 1,000 people should be postponed or cancelled. On March 11^th it was announced that kindergardens, schools, colleges and universities would be closed, effective as of March 14^th. On March 18th emergency legislation unanimously passed Parliament  that prohibited gatherings of more than 10 persons. The Government may reduce this even further according to legislation from March 31st. Restaurants, shopping centers, sports facilities, shops and businesses with close contact have been closed since March 18th. Access for visitors to hospitals, nursing homes etc. is very restricted. Dentists are closed for non-acute treatment and prisons are closed to new prisoners and visitors.

All non-critical public sector employees have been required to work from home since March 13th. Private sector firms have been asked to use work-at-home as much as possible. Child care facilities, schools, universities and other educational institutions have been closed (converted to online/digital teaching) since March 14^th.

Danish borders have been closed since March 14^th except for visitors with a recognized/creditable purpose.

On March 15^th, as part of a social pact between government, unions and employers a far ranging fiscal relief plan to support private businesses that had suffered a dramatic decline in turnover or had initiated dismissals was put in place.  This plan has been augmented several times since.

There are national guidelines for triage/referral of COVID-19 patients. They are implemented through emergency and primary care phone consultations as patients are not allowed to visit primary care or hospitals directly. Persons with mild symptoms are generally advised to stay at home until symptom free for 48 hours. People with severe symptoms are referred to testing in a hospital setting. As of March 25th, the criteria for testing are expanded to also include persons with mild symptoms in specific risk groups (elderly, people with chronic conditions, pregnant women and infants and health care personnel).  The testing strategy has been debated and some disagreement between government and the health authorities emerged.

Laboratory capacity is believed sufficient, but there is a shortage of some of the supplies for testing (plastic trays, chemical substances, pipettes). A total of 912 persons were tested from 27^th Jan to 7^th March. Since 8^th March, the daily number of people tested has been below 1,000 except for a peak of 1,800 on 19^th March  and close to 1,200 on 18^th and 19^th March. The Danish Health Authority has signaled that it aims to increase the number of daily tests to 5,000-10,000 as resources become available.

When COVID-19 is confirmed, the responsible health care practitioner must ensure that the patient or other health care practitioners inform the people who have been in close contact with the patient from onset of symptoms until 48 hours after the end of symptoms. Close contacts are made aware of symptoms that could be related to COVID-19 until 14 days after close contact.

Treatment capacity
All non-critical elective operations have been postponed and the general one-month waiting time guarantee has been suspended. This has enabled hospitals in the public sector to divert/free up capacity to corona-related services. There is a designation of departments and sections, but no hospitals are dealing exclusively with COVID-19 patients yet. At present (April 1^st) there is more than sufficient hospital capacity.

The Danish Health Authority has published a status document with assessment of the need for ICU and ventilator capacity. The document outlines two scenarios based on data from China and Italy. It is estimated that the number if ICU beds and the 925 ventilators in the public sector will be sufficient if the Danish development follows the pattern from Italy. Additional capacity may be included from private hospitals and the armed forces.

There are shortages of some protective equipment (masks, hand sanitizer, etc.). Several measures have been taken to alleviate this.

Workforce
Most health care personnel are supposed to maintain regular practices. However, a number of extraordinary measures have been taken to supplement regular activities, and to support personnel.

Nurses from (elective) surgical departments have been redeployed to deal with COVID-19 patients and fast track retraining of health care professionals is in place, to enable work in ICUs and ventilator facilities. Emergency child care facilities are provided to allow health care workers to stay at work. Students and retirees have been invited into the workforce (each of the five Danish regions have established a ‘job bank’ for this purpose). Private (pharmaceutical) firms allow medically trained staff to contribute in the health system.

Helplines have been manned by volunteers from the armed forces (the Home Guard), supervised by clinicians and medical students, to maintain capacity at the hospitals.

Several Danish regions have established psychosocial support functions for health workers.

Reflection on COVID-19 response in Denmark
The Danish response has been based on a political willingness to act swiftly and with relatively radical measures, when it became clear that the COVID-19 pandemic had spread to Denmark. There has been a remarkable political consensus behind this strategy, and the political and professional leadership have largely been in agreement over the courses of action, while realizing the uncertainty of the evolving situation. In hindsight, it might have been prudent to employ a more aggressive testing and containment strategy in the early phase, where skiing tourists returning from Italy and Austria appear to have been major factors in spreading the virus.

The partial shutdown has been costly for many businesses, and for the Danish economy in general, but the Parliament has been united in passing very large economic relief measures. At the time of writing (April 1^st) it appears that the pandemic will have a less radical trajectory than in several other European countries, and that the health system capacity will be sufficient. The Government has therefore announced that it contemplates a gradual easing of the shut down within 2-3 weeks. All in all, it appears that the Government strategy and the behavioral responses in the population have been instrumental in slowing the course of the pandemic and reducing the pressure on the health system. However, the economic costs have been very significant and it is uncertain whether the same results might have been achieved with less costly policy measures.

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