Norway and Sweden re-assess their initial COVID-19 lockdown strategies

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In hindsight, Norway‘s political and health leaders say that they might have achieved the same effects and avoided some of the unfortunate impacts by not locking down, but by instead keeping open but with infection control measures.

No one doubts Norway’s success in bringing the pandemic under control. The Daily Telegraph reports that per capita death toll is now 44 per million people, just over a tenth of that seen in neighbouring Sweden. But, the report says, this success has come at a prohibitive social and economic cost. An expert committee charged with carrying out a cost-benefit analysis into the lockdown measures in April estimated that they had together cost Norway 27bn kroner (£2.3) every month. With only 0.7% of Norwegians infected, according to NIPH estimates, there is almost no immunity in the population.

The report says the expert committee has concluded that the country should avoid lockdown if there is a second wave of infections. “We recommend a much lighter approach,” the committee’s head, Steinar Holden, an Oslo University economics professor. “We should start with measures at an individual level – which is what we have now – and if there’s a second wave, we should have measures in the local area where this occurs, and avoid measures at a national level if that is possible.”

Norway’s current strategy – using testing, contact tracing, and home isolation to keep the level of infections down without heavy restrictions – would be best, the report concluded. But if this ‘keep down’ strategy fails to prevent a surge in cases, a ‘brake strategy’ which aims to suppress the rate of transmission but not bring it below 1, would be preferable to a lockdown.

“If it’s necessary to have very strict restrictions for a long time, then the costs are higher than letting the infection go through the population,” Holden is quoted in the report as saying. “Because that would be immensely costly.”

According to the report, a brake strategy would cost as much as 234bn kroner (£20bn) less than an “unstable keep-down” scenario, if you assume that those infected gain immunity and that no vaccine is developed until 2023. But it would also lead to a little over 3,000 additional deaths.

The Daily Telegraph reports that one measure that no one thinks should be re-imposed is school closures. Holden’s committee estimated in April that the measure had cost 6.7 bn kroner (£520m) a month, while at best having “little impact” on the spread of infection. NIPH has gone further, and suggested that school closures may have even increased the spread.

Margrethe Greve-Isdahl, the doctor who is NIPH’s expert on infections in schools, said that if schools hadn’t been closed, they could have played a role in informing people in immigrant communities – which were hit disproportionately hard by the epidemic – of hygiene and social distancing rules. “They can learn these measures in school and teach their parents and grandparents, so at least for some of these hard-to-reach minorities, there might be a positive effect from keeping kids in school.”

There were also fears in late March and April that adolescents were spreading the virus more out of schools than they would have been in them. “There were large groups of adolescents that were hanging out together and not necessarily following any preventive measures,” Greve-Isdahl said.

But perhaps the main reason Norway is unlikely to close schools again, whatever happens in future waves of infection, is the recognition of the impact on the most vulnerable pupils. “There’s now a lot of information available on how it has impacted negatively on the economy and on vulnerable children. Their whole care system has kind of collapsed,” Greve-Isdahl is quoted in the report as saying. “I think there would be it would be difficult to impose heavy restrictions again.”

Norway, it seems, has already decided a second lockdown is not the way to go, however much the infection flares up again. But that does not mean its prime minister has any regrets. “I think it was the right to do at the time,” she said. “Based on the information we had, we took a precautionary strategy.” The report quotes Greve-Isdahl  as saying it will probably never be possible to know which of the lockdown measures Norway imposed caused the number of infections to drop away so sharply, if any.

 

 

There was a familiar refrain from political commentators on certain corners of the internet in the early days of the pandemic – a three-word slogan that popped up wherever people felt the government’s lockdown plans impinged on their rights: what about Sweden? Wired reports that the Nordic country was used as an example of why closing down society in the way that most other European countries have done was unnecessary. Even now, restaurants and bars in Stockholm remain open, children are still going to school, and people are only advised to stay at home if they feel ill – rather than whole households being put into self-isolation if one person has symptoms.

Life hasn’t exactly carried on as normal – mobility data shows big drops in the number of people moving around, particularly over the Easter weekend when Swedes traditionally travel around the country, and many private companies have their employees working from home. But there’s been more of an emphasis on letting the public use their own judgement rather than enforcing rules from above.

Wired says some argued that Sweden was a unique case because of its demographics, or because of the fact that more people live in single-person households, and multi-generational family units are less common than they are in countries like Italy. In hindsight, however, it’s clear that Sweden is not a special case – and it never was.

More than 4,000 people have died in a country of 10m. For seven of the last 14 days, Sweden has had the highest number of deaths per capita in the world. “Sweden hasn’t changed very much at all,” says Paul Franks, an epidemiologist at Lund University. “But because things have changed in other countries, you’ve noticed the change in the relative death rates.”

The report says the comparison is particularly stark when compared to Sweden’s neighbours, which have similar cultural practices and healthcare systems – it has almost four times as many deaths as Norway, Finland and Denmark combined.

So, Wired asks, what went wrong? How did Sweden go from a poster child for the lockdown sceptics to one of the worst-hit countries in Europe? “For me, it started going wrong at the end of January,” says Lena Einhorn, a virologist and author who has been a vocal critic of Sweden’s approach. She was following research coming out of China, and in early February she emailed state epidemiologist Anders Tegnell – the man who has been leading Sweden’s response to the pandemic – to raise her concerns about some of the projections published in The Lancet. After a while, he just stopped replying. “The public health agency and the government have separated themselves from critics,” she says. “They played down the risk consistently from the beginning of February.”

At the end of February, thousands of Swedes had a week off for the so-called ‘sports vacation’ – with many of them heading skiing in the Alps, just at the time that the situation in northern Italy exploded. But there was no requirement for those returning to self-isolate, and while some private companies shifted to working from home – public workers and school children were told they had to go to school unless they were already feeling ill.

As in the UK, there was a failure to prepare testing capacity and protective equipment – even now, the official advice in Sweden only recommends face masks if you’re working with a sick patient. “They absolutely denied the possibility of pre-symptomatic spread,” Einhorn says.

The way the Swedish response has been structured has made the country more resistant to changing tack during the epidemic. Sweden’s expert agencies are kept quite separate from the government, which is generally a good thing, because it means that scientific issues don’t become politicised. “But if the expert agency is making bad decisions there is nothing to counter it,” Einhorn points out.

So far, both the government and the opposition in Sweden have been happy to sit back and let the public health agency handle the outbreak. “Politicians are happy to go along with that while public opinion is high,” says Franks. “It’s inconvenient to be in a lockdown and people are likely to go along with that.”

Swedes are generally more trusting of authority and science than those in other countries, he adds. Despite recent murmurings of disquiet, the agency remains broadly popular among the public – and Tegnell has become something of a cult figure in Sweden, with toasts on his birthday and people getting tattoos of his face. But that’s been part of the problem. “The biggest problem in Sweden is there is really only one voice – that voice is the public health agency, and in particular Anders Tegnell,” Einhorn says.

So, while the UK and other countries which had initially embarked on a similar path changed tack and instituted national lockdowns, Sweden stuck to its guns. Now, it’s had nine times as many deaths per capita as neighbouring Norway, and it’s facing potential exclusion from a regional travel bubble because of fears Swedes will spread the virus. Tegnell has been criticised by his predecessor for not instituting a lockdown.

“I don’t think there’s any doubt that if we’d taken Norway’s approach, we’d have fewer deaths,” Franks says. The counter-argument is that Sweden is now better prepared for a second wave – that Norway will catch up, and in the end it won’t have made much difference, but the Swedish economy will be in better shape for for not having locked down (although that too is debatable).

Wired reports that in early May, Tegnell was quoted as saying that Sweden would be better prepared for a second wave. “Sweden will have a high level of immunity and the number of cases will probably be quite low,” he said.

A spokesperson for Sweden’s public health agency says that herd immunity was never a deliberate part of the plan – either way, a recent study showed that only 7.3% of people in Stockholm, the epicentre of the epidemic in Sweden, had developed antibodies indicating that they had already been infected with COVID-19. In London, where a lockdown was in effect, that figure is 17% according to one study.

“The virus had not spread as quickly as many people thought it had,” says Franks. “That has thrown a spanner in the works in terms of the Swedish public health strategy.” Instead of 50% to 60% of the population being infected – close to the level required for herd immunity – it was actually not even one in ten, and probably far less than that outside Stockholm. Tegnell told reporters that this probably reflected the situation at the end of April, as it takes a few weeks for antibodies to develop.

In countries that instituted a lockdown, the curve of the epidemic is bell-shaped, with a peak and then a steady decline. Sweden’s looks more like the US, with cases tailing off much more slowly – and the daily death toll stabilising at a higher level relative to the peak. As the rest of Europe begins to tentatively lift lockdown restrictions, Swedes are returning to shopping centres and playgrounds, says Franks – and the approach is likely to remain the same even as the death toll rises.

There are simple measures that could be taken to lessen the effect of a second wave even without a lockdown – face masks for people in crowded spaces and for those working in the elderly (about half of Sweden’s deaths have been in care homes), and more testing and tracing. “It isn’t like influenza,” Einhorn says. “It’s a cluster disease – it digs itself into a spot and it explodes in that spot, and between those clusters it can be very sparse, that’s why the antibodies are so low. It’s a perfect situation for contact tracing and testing.”

But, Wired reports, the researchers fear that the public health agency is “locked in” to its strategy, and are ignoring the data that could help to get a handle on the spread of the disease. “Unless they’re prepared to look at all credible data, they’ll stay on the path they’re on,” says Franks. “And we’ll continue to have high death rates.”

Full report in The Daily Telegraph Full Wired report

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