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HEALTH

Explaining the science behind Sweden’s relaxed coronavirus approach

A growing number of Swedish doctors and scientists are raising alarm over the Swedish government’s approach to COVID-19.

Explaining the science behind Sweden's relaxed coronavirus approach
Photo: David Keyton/TT

Written by: Paul Franks, Professor of Genetic Epidemiology, Lund University and Peter M Nilsson, Professor of Internal Medicine – Epidemiology, Lund UniversityThis article is republished from The Conversation under a Creative Commons license. Read the original article.

Unlike its Nordic neighbours, Sweden has adopted a relatively relaxed strategy, seemingly assuming that overreaction is more harmful than under-reaction.

Although the government has now banned gatherings of more than 50 people, this excludes places like schools, restaurants and gyms which remain open. That’s despite the fact that 3,046 people have tested positive. Although Norway has the most confirmed cases (3,066) in Scandinavia, COVID-19 fatalities in Sweden are highest by far (92), compared with Norway (15) and Denmark (41).

People now are taking sides, with some arguing that publicly criticising the authorities only serves to undermine public trust at a time when this is so badly needed. Others are convinced that Sweden is hurtling toward a disaster of biblical proportions and that the direction of travel must change. The truth is that of all these opinions, none is derived from direct experience of a global pandemic. No one knows for sure what lies ahead.

In epidemics, prediction models help guide the choice of interventions, assess likely social and economic impacts, and estimate hospital surge capacity requirements. All prediction models require input data, ideally derived from past experience in comparable scenarios. And we know the quality of such input data is poor.

Most current COVID-19 prediction models use data gathered from the COVID-19 epidemics in China and Italy and from past outbreaks of other infectious diseases such as Ebola, influenza and other coronaviruses (Sars and Mers). But demographics and patterns of social interactions differ from country to country.

Sweden has a small population and only one real metropolitan area. Ideally, we’d need data from Sweden on the community spread of COVID-19, but this requires screening programmes that do not currently exist.

The little reliable data on COVID-19 in Sweden concerns hospital admissions and fatalities. This latter can be used to get a “poor man’s estimate” of community transmission, providing approximately how many fatalities occur among those infected. But with a two-week lag between diagnosis and death, this a very blunt instrument with which to guide decision making.

In Sweden, the public health authorities have released simulations  to guide “surge requirements”. This is the extent to which hospitals will need to boost their capacity to deal with the high number of very ill COVID-19 patients that are likely to need specialist care in the coming weeks. From these simulations, it is clear that the Swedish government anticipates far fewer hospitalisations per 100,000 of the population than predicted in other countries, including Norway, Denmark and the UK.

The corresponding number of deaths in Sweden predicted using the UK simulations are much higher than the Swedish government’s simulations suggest. The reason appears to be that Swedish authorities believe there are many infected people without symptoms and that, of those who come to clinical attention, only one in five will require hospitalisation. At this point, it is hard to know how many people are asymptomatic as there is no structured screening in Sweden and no antibody test to check who has actually had COVID-19 and recovered from it. But substantially underestimating hospital surge requirements would nevertheless be devastating.

Uneven spread

Like in many other countries, the spread of COVID-19 is quite uneven in Sweden. Most cases have been diagnosed and treated in the greater Stockholm area, and lately also in the northern county of Jämtland – a popular destination for skiers. On the other hand, some other geographical areas are relatively spared, at least for the moment. In the third largest Swedish city, Malmö, still only a few cases have been hospitalised at the time of writing.

There is no doubt that the epidemic will spread, but the speed of this is disputed. The national Public Health authorities are also sceptical about the need for lock-down in most of the country, but discussions are now ongoing to enforce such an intervention in the capital area.

There are several arguments supporting the current official Swedish strategy. These include the need to keep schools open in order to allow parents who work in key jobs in health care, transportation and food supply lines to remain at work.

Despite other infectious diseases spreading rapidly among children, COVID-19 complications are relatively rare in children. A long-term lockdown is also likely to have major economic implications that in the future may harm healthcare due to lack of resources. This may eventually cause even more deaths and suffering than the COVID-19 pandemic will bring in the near term.

Herd immunity

The best estimates of the COVID-19 case-fatality ratio (CFR) – the proportion of those infected who die – is currently 0.5-1.0%. By comparison, the 1918-1919 Spanish flu had a 3% CFR in some parts of northern Sweden. A century ago, Sweden was recovering from the first world war, even though the country stayed neutral.

Internal transportation and communication systems were less developed than in many other countries at the time, which helped slow the spread of the epidemic. In the short term, this was perceived to be a good thing, but because herd immunity  – whereby enough people have been infected to become immune to the virus – had not been initially achieved, there were at least two additional epidemics of the Spanish flu virus within a year. The second wave of infections had a higher mortality rate than the first wave.

Learning the lesson from this, many people in Sweden are now optimistic that it can achieve herd immunity. Compared with the Spanish flu, COVID-19 is less severe, with many infected people believed to be asymptomatic. While this contributes to a more rapid spread, it also means that the threshold for “herd immunity” is about 60%. This may be quickly achieved in countries that do not have intensive mitigation or suppression strategies.

This may also lower the risk of further waves of the epidemic. So when we probe the lessons learned from the COVID-19 pandemic in the future, there will likely be a lot of focus on the success or failure of Sweden’s relatively relaxed initial approach. This would take into account not just the loss of lives from the pandemic, but also longer term social and economic negative consequences and the deaths they may cause.

Ultimately, given the uneven and relatively modest spread of the virus in Sweden at the moment, its initial strategy may not turn out to be reckless. But going forward, Sweden is likely to have to impose stricter restrictions depending on jow the virus spreads, especially in metropolitan areas or when the healthcare system is under severe strain.The Conversation

Written by: Paul Franks, Professor of Genetic Epidemiology, Lund University and Peter M Nilsson, Professor of Internal Medicine – Epidemiology, Lund University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

 

Member comments

  1. Sweden must act on urgent basis due to the nature of this epidemic rather than going on with traditional slow approach. This slow approach entails a great risk as we must learn from the situation In neighboring countries.

  2. This should be categorized as an “opinion” piece, not an article, as it is lacking unbiased fact-checking.

    Namely, the entire section about data and modelling, as well as the paragraph stating that the low severity of Covid-19 leads to a herd immunity threshold of 60%. In fact, that threshold is calculated based only on Ro – this is a fundamental concept in Epidemiology, which makes me doubt the credibility of these authors.

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HEALTH

EXPLAINED: What to do if you face a long wait for healthcare in Sweden

Sweden theoretically has a "healthcare guarantee" limiting your wait to see a GP to three days, and to see a consultant to three months. The reality is somewhat different. Here's what you can do if you face a long wait.

EXPLAINED: What to do if you face a long wait for healthcare in Sweden

What is Sweden’s ‘healthcare guarantee’? 

Sweden’s “National Guaranteed Access to Healthcare” or vårdgaranti, is a right to care, protected by law, that has applied in Sweden since 2005. You can see the latest version of the relevant laws here and here. Here is a summary of the guarantee on the website of the Swedish Association of Local Authorities and Regions (SKR).

Under the system, all patients are guaranteed:

  • contact with a primary care centre by phone, in-person, or by video-link on the day they seek care 
  • an appointment with a doctor, nurse, physio, or psychotherapist within three days of seeking help 
  • an appointment with a specialist doctor or consultant within 90 days of seeking help 
  • treatment or operation within 90 days, if the specialist considers this necessary 

Does the guarantee mean I have a right to treatment? 

No. If the doctor at the primary care centre, after examining you and questioning you, decides that there is no reason to refer you to a specialist doctor, they do not need to do so. 

Similarly, if the specialist doctor, after examining you, decides that no treatment is necessary, then your case is considered completed.  

Can the waiting times to see a specialist or to get treatment be longer than 90 days? 

Absolutely. In fact, they very often are. 

According to the Swedish Association of Local Authorities and Regions (SKR), in February, 32 percent of patients had been waiting 90 days or more to see a specialist, and 43 percent of those who had seen a specialist had been waiting for treatment for more than 90 days.  

The situation in primary care was a little better, with 80 percent of those seeking care in contact with their primary care centre on the same day, and 83 percent having their case assessed by a doctor or nurse within three days. 

In addition, if you agree with your specialist doctor that you are willing to wait longer for an operation, then that wait doesn’t get counted in the statistics. 

So what can I do if I’ve been waiting longer than the guaranteed time? 

In reality, it’s actually less a guarantee than a target.

In primary care, there is no way for individual patients to complain that they have had to wait too long to see a doctor or nurse, or to cut their waiting times by citing the guarantee. 

“There’s no system for enforcing that guarantee,” says Emma Spak, the primary care doctor who doubles as section chief for SKR’s healthcare division. 

It would make no sense to set up a complaints line for those who have had to wait too long for phone contact with their primary care centre, she points out, when they could instead talk to patients seeking a primary care appointment in the first place. 

“It’s more of an incentive system for the regions,” she explains.

Every primary care unit and every region reports their waiting times to the national waiting time register, and then as part of the access agreement between SKR and the government, the regional health authorities receive a bonus if they meet their waiting times goal, or if they improve their waiting times. “That’s one way of sort of enforcing this guarantee,” she says. 

When it comes to specialist treatment, though, patients do have the right to demand to be examined or treated by an alternative specialist or hospital if they’ve had to wait longer than 90 days.

If your primary care centre issues you a referral to a specialist, and the specialist cannot then offer you an appointment within 90 days, the specialist, at the same time as offering you a later appointment, will often put you in contact with a unit at the regional health authority who will offer to find you an alternative specialist, either within the region or elsewhere in Sweden. 

The regional health authority will then have to reimburse any extra travel or hotel costs incurred by the patient.  

Similarly, if after examining you, a specialist cannot offer you treatment within 90 days, they will normally put you in contact with the same unit. 

Some regions have a phone line for people who have been waiting too long, or else you can contact your specialist or primary care centre and ask for information on seeking an alternative specialist. 

What happens if I don’t want to travel to see a specialist or get treatment? 

If your regional health authority offers you an alternative specialist, either within your region or in another region, so that you can get treated within the 90 day period, and you are unwilling to travel, then you lose your rights under the guarantee. . 

“If you’re in Gothenburg, and they say you have to go to Stockholm to get your treatment, and you say, ‘no, I want to go here, then then you’ve sort of forfeited your right, and you have to take what’s on offer,” Spak says. 

What happens if I agree with my specialist to wait longer? 

If your specialist says that they can treat you in four months, but also offers you treatment elsewhere within the guaranteed 90 days, and you choose to be treated by your specialist, then that counts as a patient choice, which will not then be counted in the statistics. 

“The specialist might say, ‘I don’t think you will get any worse for waiting two months extra, and if you wait five months, then I can make sure that you get your surgery done here, and we can make sure that you get all the aftercare and everything here as well,” Spak says. 

But these patient decisions are also counted in the statistics, and if a region sees a sharp rise in patients choosing to wait, SKR will tend to investigate. 

“If some region all of a sudden has a lot of patients choosing a longer waiting time, then we will call them and ask what’s going on here, because patients don’t tend to want to wait extra,” Spak says.  

Can I get financial compensation if I’ve been waiting too long? 

No. 

What other ways are there of speeding up the wait for treatment? 

Don’t underplay your symptoms

When drawing up their timetable for treatment and assessment, specialists will tend to give different patients different wait times depending on the urgency of their case.

For this reason, it’s important not to underplay your symptoms when visiting a primary care doctor, as they will tend to include a few lines on the urgency of your case when they write their referral. 

Stress your flexibility 

If you are unemployed, a student, retired, or have a very flexible job, it is worth telling your primary care doctor about this, because they may write in your referral that you are able to make appointments at very short notice. The specialist may then put you on their list of people to ring if one of their patients cancels. 

“Sometimes I write in my referrals that this patient could easily come at short notice, so please put the patient on the list for people you can call if there’s a time slot available,” Spak says. 

If you haven’t told your primary care doctor this, it’s not too late. You can ring the specialist yourself and tell their receptionist that you are very flexible, and ask to be put on the back-up list. This is particularly useful if you’re waiting for a scan, but you could also potentially work even if you’re waiting for heart surgery or a hip replacement. 

“If they’ve accepted you as a patient, and they’ve made sure that you fulfil the criteria for having that scan or whatever, then you can call them and say, ‘I have a really flexible job, I can come anytime if you have a gap,'” Spak says.

“A lot of people do that, because they can have [back-up] waiting lists. If you tell them ‘I work around the corner and I only need 15 minutes to be there’, then they might call you if someone doesn’t show up.” 

Ring up your specialist 

The queue system tends to be quite ad hoc, with no strict rules over who should be treated first, so it is often possible to reduce your wait by ringing up your specialist a few times a month, just to bring your case to their attention. Sometimes the receptionist will remember a slot that has just come free and bring forward your treatment while you are still on the telephone. 

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