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Column: Is it time to evaluate the Swedish strategy?

Johan Brun

What could we have done differently? Would it have changed the outcome? These are questions that will be mulled over again and again over the coming weeks.

In modern times we have not seen a pandemic with such a rapid global spread and high mortality. After almost six months, and with the benefit of some hindsight, it is now easier to map out everything we should have done.

“Lockdown” or not

There are those who are now saying we should have closed down the country immediately and isolated everyone who was confirmed or suspected of having the virus. Initially it was mostly healthy and relatively young ski-tourists or those who had returned home after visiting the Middle East who were infected. The Public Health Agency of Sweden issued clear guidelines that people should self-isolate if they had symptoms, and we were able to follow the progress of the voluntary “house arrest” or isolation in hospital of the first cases reported in the media. Other countries imposed more stringent lockdown measures at an early stage, but even if the information from other countries can’t be directly compared to Sweden, their strategies haven’t always demonstrated better results. However, we will not have full hindsight until this pandemic is over; something that could unfortunately take several years. As time goes by we will continue to speculate on the correct strategy.

Benjamin Born, a German professor in macroeconomics, has written an article that presents a mathematical calculation of what would have happened if Sweden had initially taken a more severe lockdown route. According to his analysis this would not have made a difference to the number infected or the number of deaths. He believes that this is because we in Sweden have voluntarily done what was necessary to minimize the risk of infection spread.

“I can see that there is general skepticism and a good deal misunderstanding about Sweden’s strategy and outcomes in this ongoing pandemic.”

Why European countries would rather open up to residents of countries that have had a total lockdown, and therefore fewer people who have been infected, than to residents of Sweden where there is greater immunity in the population, is a mystery to me. I can see that there is general skepticism and a good deal misunderstanding about Sweden’s strategy and outcomes in this ongoing pandemic.

Testing equals control

Most people agree that greater access to testing would have been beneficial, and a good example of this is South Korea, who with otherwise similar measures to Sweden were able to control the spread of the virus using testing and rigorous follow-ups. The ability to begin testing at an early stage to identify those infected, regardless of the severity of their symptoms, and above all else being able to do this within healthcare and care homes for the elderly, would probably have had an influence on reducing the spread in Sweden. Naturally this also presupposes an ability and sufficient resources to take the necessary action; something that has not always been possible, and unfortunately in certain places is still lacking even now.

“In recent days Denmark has announced a pledge to test the entire population. I hope that this is something Sweden will also do soon.”

In recent days Denmark has announced a pledge to test the entire population. I hope that this is something Sweden will also do soon.

Care of the elderly – a particular challenge

At almost every press conference, the Public Health Agency of Sweden has raised concern about the elderly care situation and the high death rates in the elderly population. With infection reported in 75 percent of Stockholm’s care homes for the elderly, 50 percent of those in the Västra Götaland region and 10 percent in Skåne, there is good reason to wonder what these differences are due to.

“In Skåne, the region with the lowest prevalence of infection within elderly care, there has been no increased mortality during the ongoing pandemic. This is something we should be able to learn from.”

In addition, three-quarters of all deaths in the 70+s age group have been in care homes where 90 percent of residents fulfill the criteria for dementia – a situation that raises the question of whether the measures needed are more complex. Whether banning visitors was an important measure or not, or if it would have been better instead to rapidly improve the conditions for staff paid by the hour to work more safely, using better equipment, and with the right information is a subject for further debate.
In Skåne, the region with the lowest prevalence of infection within elderly care, there has been no increased mortality during the ongoing pandemic. This is something we should be able to learn from.

We are not alone in having problems in the elderly care segment. This week Canada has reported that 80 percent of all corona-related deaths have been within elderly care. They have also cited part-time workers who do not have the right to claim sickness benefits and who work daily at more than one care home as being an underlying cause.

Immunity and T-cells

There is probably no subject that is debated more based on so little data. How widespread is immunity in the community and how does this vary throughout the country? Before we compare studies of large cohorts of representative material to determine the prevalence of antibodies in the population, all percentages cited will only be guesswork. Testing those who work in healthcare or particular cohort groups of people in different studies only provides selective, non-conclusive outcomes.
With figures ranging from between 7.5 percent to 25–50 percent, all of the questions asked become hypothetical and understanding necessitates protracted, complicated explanations.

“The information that only 5 percent of Spain’s population may have been infected is a figure that many are sceptical about, as there were so many reported COVID-19 deaths and the spread of the virus varied greatly throughout the country. At the same time, the information from the same country that 99 percent of all of those confirmed to have had the virus now have antibodies is news that has been readily accepted.”

The information that only 5 percent of Spain’s population may have been infected is a figure that many are sceptical about, as there were so many reported COVID-19 deaths and the spread of the virus varied greatly throughout the country. At the same time, the information from the same country that 99 percent of all of those confirmed to have had the virus now have antibodies is news that has been readily accepted.

Something that has recently emerged as an important factor is our T-cells. These are produced by our immune system as a specific response to foreign intruders, regardless of whether these are microbes or cancer cells. It has now been shown that the T-cells generated to attack the coronavirus can remain in the body to act as an immune defence at a later date if needed, and this is also indirect evidence that a vaccine will be able to work.

Not only the lungs

Our knowledge has increased exponentially, and during the ongoing pandemic around 23 000 scientific articles on SARS-CoV-2 and COVID-19 have already been published, with that number expected to double every twenty days.
Among other things, we have learned that there are ACE2-receptors in more sites in the body than only the airways. This means that the coronavirus has more attachment sites and ways to enter the body.

In addition, the coronavirus has the ability to initially suppress the mechanisms used by cells to defend themselves. This means that the symptoms can be late to develop and that the virus has a window of opportunity to hijack cellular functions and begin the mass production of new virus particles. This is most obvious in the airways, where the nose and lungs are the pathway the virus enters the body.

“This spread explains how very different symptoms can develop late in the progression of the disease.”

What happens afterwards in those who do not quickly recover from their infection is that the immune system loses control, and then does more harm than good. During this stage of the development of the disease the entire cardiovascular system is affected, with elevated risk not only for the formation of blood clots but also of damage to the liver, kidneys, brain and central nervous system, as well as the gastrointestinal tract. This spread explains how very different symptoms can develop late in the progression of the disease.

Proving that treatments work

We have now entered a phase where not many new vaccine or treatment projects are starting up. Instead we are waiting to see the results of current treatment attempts. According to ClinicalTrials.gov, more than a thousand studies have already started, so soon there will not be any shortage of data to analyse. With every passing day it is looking more dubious that hydroxychloroquine will be an effective treatment option and whether or not remdesivir will be an alternative also remains highly uncertain. Interim reports about the use of monoclonal antibody treatments, IL-6 inhibitors and other anti-inflammatory treatments are providing greater hope. But until these have demonstrated what effects they have, the greatest challenges for healthcare are to provide sufficient oxygen supply, nutrition in general, and to prevent the formation of blood clots. Every day healthcare professionals are performing heroic deeds and deserve all our respect and admiration.

“Every day healthcare professionals are performing heroic deeds and deserve all our respect and admiration.”

After a relatively cold spring we are hoping for a warmer summer and that the positive developments continue that the Public Health Agency of Sweden report daily. As daily life increasing returns to normal, albeit with the risk-reduction measures that still apply, we are all naturally eager to return to seeing our social contacts.

Johan Brun is a senior medical advisor for LIF and a doctor with more than 20-years experience in the pharmaceutical research sector.

Read the original column in Swedish here: www.lif.se

Photographer: Gunilla Lundström