As we try to extract ourselves from lockdown, one approach to move forward is based on Sweden’s response to the pandemic. For those who haven’t heard of Sweden’s approach, they are not doing universal social distancing, did not close down any businesses, and did not cancel any large events.
Sweden’s plan was crafted by their Head Epidemiologist Anders Tegnell, and it involves a quarantine for people who are infected, isolate and protect those who are at high risk because of pre-existing health problems, but put no restrictions on the rest of the population.
Despite not having universal social distancing, Sweden’s deaths per capita are almost identical to the United States. In addition, there has been no excess hospitalization or medical system trauma compared to the US. Part of this is due to their universal healthcare system, but Sweden’s healthcare is much less centralized other countries like the UK.
So, has Sweden identified an appropriate way forward for the US now that ongoing universal social distancing is becoming impractical? Obviously, there are problems adapting a system from a country the size of Sweden to one as large and complex as the United States. Despite this there are many attractive concepts about Sweden’s approach.
First, normalizing activity is a distinct positive. In Sweden large gatherings are not prohibited it is suggested that most individuals keep 6 feet between each other at most events. In addition, they don’t wear masks because they feel everyone will eventually get infected and the risks are minimal for most people. They want people to get infected and get it over with!
Secondly, they are aggressive in quarantining infected individuals and those who are at high risk for harm from being COVID infected. This is the way a quarantine is usually done; you don’t quarantine everyone but quarantine those who are infected to keep the infection from spreading. This requires substantial virus testing, essentially ongoing testing of the entire population. You’ve probably heard that the US government is trying to scale up testing to a point where they can identify all COVID infected and their contacts. The US must be able to test all people who have a potential infection for this approach to be feasible.
Finally, Sweden believes in herd immunity. They feel that the infections are occurring naturally result in less transmission overall because people who are immune are less likely to shed the virus. This is a concept I agree with, and even if immunity is not absolute, it is likely that individuals that have a secondary infection do not shed virus to the same degree and are not severely ill. Therefore, the concept that ongoing infections serve as a vaccination for most of the population, especially those at low risk for serious injury or death, is a positive one.
We could not have done the Swedish program as a first approach because the infection coupled with disparities in our healthcare system would have destroyed urban hospitals. But now that we have saved the health care infrastructure by social distancing, aggressively identifying those who become infected and protect those who are at high risk may be the best way forward.
Pandemic Pondering 
The following CNN article indicates (in the chart) that large events in Sweden were shut down and some schools.
The article also indicates that Sweden has about 5x the # deaths of neighboring nations with similar population densities.
https://www.cnn.com/2020/04/28/europe/sweden-coronavirus-lockdown-strategy-intl/index.html
Comparing Sweden’s deaths per capita to the United States is not comparing apples to apples, it should be compared to metro areas or states with similar densities. Where can we find that data? Peace
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Legitimate points. Seeing neighbor states there are population differences that make comparisons hard, just like with US. No place in Sweden even approaches NYC, including Stockholm. I agree more data needed, but I think the messages of contact tracing and isolation of infected individuals are important. Thx!
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Thank you Dr. Baker. I agree contact tracing and isolation of those infected away from non-infected is crucial.
“The US must be able to test all people who have a potential infection for this approach to be feasible.”
This seems to not be a goal of the Trump Administration or the pandemic team due to the impracticality of widespread testing at this point.
How would herd immunity begin? Who goes first? Peace
From a science journalist regarding Germany’s and their herd immunity plans – I can’t read German…
Main points:
– reproduction number R has been slightly below 1 in Germany since end of March and that is a consequence of all the measures enacted in March and changes in behavior at a societal level
– The situation is not stable. Even a small uptick in R will lead to renewed exponential spread of #SARSCoV2. Avoiding that will mean stringent contact restrictions.
-Changes in R as a consequence of changing restrictions can only be gauged with 2 to 3 weeks delay
-Reaching herd immunity without overwhelming the health care system would take years based on current data. Some restrictions would have to be in place that whole time.
– From the point of view of modeling a two-phase strategy seems sensible: First reducing the number of new infections further until effective contact tracing is possible. Then in a second phase an adaptive strategy (less restrictions) on the basis of low number of new infections.
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To achieve herd immunity in the US, approximate assumptions:
70% of population infected (~231mm out of 330mm)
CFR of 0.5-1%
= 1.2 – 2.4 million deaths — quite a large amount
In addition, lack of hospital capacity may result in much higher CFR. At a 5-10% hospitalization rate, “herd immunity” path would lead to 12 – 24 million hospitalizations. If we have that, deaths may be well in excess of 2-3 million, unless it’s managed through a rolling series of shutdowns & restarts over months. (And, if managed slowly through rolling shutdowns – if immunity to Covid lasts only a few months, that trajectory may not work at all.)
Seems like herd immunity is a difficult path to pursue?
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A few things. Most people feel there is significant herd immunity at 50-60%. If the death rate is reduced less than 0.5% with remdesivir earlier intervention (1/5 reduction of deaths vs. the 1/3 in the trial today) and we are likely 10% immune at this point, then 330mm X (.5-.1) times 0.1 (instead of 0.5) is 132,000; about double the number of deaths we currently have. This is still horrific, not in the millions.
Also, if there is no vaccine (likely) social distancing will flatten the curve but the area under the curve will remain the same. So rolling shutdown, etc. won’t matter; the same number of people will eventually die. This was demonstrated by the fact that 90% of people put on ventilators never got off; intensive care did not seem to make much of a difference. So the real push should be for medications that reduce mortality. Not sure we are there yet. Thanks for the comments.
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Thank you for your detailed response. Agreed, that scenario would be more acceptable / less disruptive for society. And, hopefully medications are found in the meantime to reduce mortality.
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How can we get the US govt to do this?? Why wont Fauci advise this?? We need to move forward!
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