Wednesday, April 29, 2020

How is Sweden's Coronavirus Health Policy Working So Far ?

A trauma surgeon and trained epidemiologist in California gives an eye-opening update on how Sweden's Coronavirus strategy has been playing out so far:

"There has been a lot of talk about Sweden and how they are going about business as usual during this SARsCoV2 outbreak. Some reports on Sweden range from "no one is dying in the streets there" to "they will be sorry". 

Let's unpack the talk about Sweden and their mitigation practices.

First some numbers: Sweden has a population of 10.23 million people. The median age is 41. 88% of people live in urban communities. The population density for all of Sweden is 64 people per square mile.

Stockholm, Sweden's capital and largest city has a population of 1.2 million with a population density of 10,500 people per square mile when including the urban surrounding area. 

Putting that in perspective New York City has a population density of 26,403 people per square mile.

The first death from SARsCoV2 in Sweden was in early March and as other countries like Norway and Denmark were locking down Sweden chose a different model than the ones put forth by the Imperial College in London or the Information Health Metrics Evaluation group at the University of Washington.

It is true Sweden did not lock down the country. And because of that I see Sweden as a kind of soft nonpharmacological intervention (NPI) control group.

Here is what they did and did not do:

*Grade schools remained open so parents can continue working.
*People have been asked to practice social distancing but are not mandated to do so or stay home.
*Many Swedes say they are not "huggy" people so keeping their distance is easy.
*Masks in public are not mandatory though some people chose to wear them.
*Without a formal lockdown however the mass transit in Stockholm is less crowded and cities less populated.
*Just like here in the US more people are working from home in Sweden.
*Sweden modified many businesses to reduce close contact.
*There are no large gatherings like sports. The teams play but there are no fans.
*Gyms and pools are open.
*Bars are open but you can only drink at a table not at the bar itself thereby limiting crowds and contact.

Below in the comments are the Swedish Public Health Agency recommendations, which sound pretty familiar.

Contrary to all of the talk about how Sweden's approach toward voluntary mitigation their cases and deaths are higher than their neighbors they snuggle next to (Norway: cases 7660, deaths 206 and Finland: cases 4740, deaths 199).

Their new cases parallel the United States log or exponential curve, a level steady number.

Sweden's new case doubling time is 18 days (the US is 18 days as well).

According to the Swedish Intensive Care Registry before the SARsCoV2 pandemic Sweden had 526 ICU beds.

That capacity was increased to 1131 beds as of April 24 and further by the construction of military tent hospitals shortly after that.

On April 24, 533 ICU beds were filled with COVID19 patients. By April 28th the Swedish ICU registry data, attached below, shows the number of ICU patients has doubled to 1,372.

The demographics of those critical care patients are similar to those in the US with an average age of 59.

Deaths, the final grim metric to look at, paint a less than rosy picture for how the Swedish model of minimal mitigation is working.

The doubling time for deaths in Sweden is 13 days (it is 13 days in the US as well). Good news right? No.
When we look at deaths per capita, per one million people.
Not such good news.

The total number of cases in Sweden as of today (4-28) is 19,621 and the deaths 2,355.

This gives the country the dubious award of being in the top 25 COVID19 prevalence countries and the highest number of deaths for all Nordic countries.

Their current death to case rate gives them a Case Fatality Rate of 12.

This is partially due to the abysmal testing Sweden is doing, even worse than the testing by the US. The rate of testing is 5 tests to yield one case of SARsCoV2.

The economic impact of the SARsCoV2 pandemic on Sweden is hitting their business sector nearly as hard as the rest of the EU countries.

Many business owners are experiencing financial uncertainty. Employees are being laid off and receiving government support.

Sweden's government has begun to intervene with a proposal that employers will now be able to reduce their employees' working hours by up to 80 per cent and that central government will cover the majority of the cost as well as assume the entire cost of all sick pay during April and May.

The government has begun injecting capital into small businesses in order to keep them solvent. Overall the forecast is for Sweden's low debt era to end due to the pandemic and its bailout.

So overall do I think Sweden's no lockdown approach is working?

Well the numbers don't lie so I say a polite….no. But I would be happy to see if they prove us all wrong in the long run once "the fog of war" fades.

One area to watch for is what if any difference in mental health challenges are experienced by people living with mandated mitigation versus Sweden’s voluntary version.
Dr. Eileen Natuzzi, MD, MPH, FACS
Acute Care Surgeon

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