Sweden’s Herd Immunity: Success or Failure?

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As SARS-CoV-2 swept across the world in 2020, it left a wave of national lockdowns in its wake. Different countries enforced these lockdowns in different ways. Australia made good use of its status as an island, barring travel into the country except in strict instances followed by a fourteen-day quarantine. Towns in Italy and Spain set curfews and limited the number of times residents could step outside their homes. The United States lacked a cohesive national strategy; instead, their policy was a patchwork of local restrictions and shutdowns. One country that caught the world’s eye by bucking this trend all together was Sweden.

At the very beginning of the COVID-19 pandemic, Sweden’s public health agency, Folkhälsomyndigheten (FHM), opted for a “de-facto herd immunity approach, allowing community transmission to occur relatively unchecked” [5]. While the agency did recommend limiting gatherings to 50 people or less on March 29, 2020, there were no mandatory measures taken to limit crowds on transport, in malls, schools, and other crowded places [5]. The government acknowledged the fatal risk of such a strategy; on April 3, Prime Minister Stefan Löfven said, “[Sweden] will have to count the dead in thousands. It is just as well that we prepare for it” [4]. In early May, the FHM predicted that 40% of Stockholm’s population would have gotten the disease, recovered, and have protective antibodies; but, according to the antibody studies published on Sept. 3 by the agency, based on samples collected through June, that number was only 11.4% [4]. In August, a study by the Journal of the Royal Society of Medicine stated that herd immunity was still “nowhere in sight” [7]. However, even as the death toll in the country climbed, the government reaffirmed its faith in the strategy, despite the fact that herd immunity against an infectious disease has never been achieved without the aid of a vaccine [4].

Sweden stands in contrast to its Nordic neighbors, with COVID-19 deaths in Sweden reaching 787 deaths per million in December 2020, a figure which is four to five times higher than that in other Scandanavian countries [5]. Neighboring Norway, with 632 total COVID-19 deaths, attributes its low mortality rate to its aggressive testing strategy, one which enables rapid identification and isolation of those who are sick in order to control the spread [1]. Indeed, Norway has administered 663 tests per 1,000 population [8]. Meanwhile, Sweden has consistently had among the lowest test rates in Europe. Even when the country increased its testing in the fall, it still only tested about one-fourth of the people Denmark does per capita [4]. 

Those who do test positive in Sweden, however, face very different paths of what comes next as compared with those in other countries in Europe. Family members of those who test positive for the virus must attend school in person, unlike in other European countries, where a 14-day quarantine is mandatory if a member of a household tests positive [4]. Employees are to attend work as usual despite a positive test if they have no symptoms. FHM guidelines issued on May 15 that are still in place state that students and employees who have symptoms are to return to school and work so long as they are “seven days post-onset of symptoms and fever free for 48 hours” [4]. A curated Google map shows all the outbreaks that have been linked to Swedish schools throughout the year [6]. 

Sweden’s COVID-19 strategy took a toll on those needing immediate medical care of any kind. The country’s “National Board of Health and Welfare’s guidelines for intensive care in extraordinary circumstances throughout Sweden state that priority should be given to patients based on biological, not chronological, age” [4]. This meant that regional health agencies used a Clinical Frailty scale to assess a person’s fragility and determine whether or not they should receive hospital care. Dr. Michael Broome, the chief physician at Stockholm’s Karolinska Hospital Intensive Care Unit, said he had “repeatedly been forced to say no to patients we would normally have accepted due to a lack of experienced staff, suitable facilities and equipment” [4].

In December 2020, Sweden made its first recommendation of wearing masks on public transport; prior to this, masks were only worn in healthcare settings despite strong recommendations regarding mask usage given by the World Health Organization [3]. However, there are no legal consequences if citizens do not comply; the country is relying on an “appeal to citizens’ sense of responsibility and civic duty” [3]. Meanwhile, countries such as the Netherlands, Germany and Italy imposed nationwide lockdowns. 

The main reason behind Sweden’s approach to COVID-19 was economic cost. FHM Director Johan Carlsson and General Counsel Bitte Bråstad wrote to the government as early as Jan. 31, 2020 about the costs associated with classifying COVID-19 as a “socially dangerous disease,” bringing up fears of loss of production and progress in society should containment measures be implemented [4]. But Sweden’s lack of containment measures did not help the economy; Sweden’s GDP fell more than any of its fellow Nordic countries, which imposed lockdowns more in line with other nations. Sweden reported an 8.6% drop in the second quarter of the year, as compared to a 7.4% drop in Denmark and only a 3.2% drop in Finland [2]. Writing about the COVID-19 response in their country, molecular biologist Andrew Ewing and activist Kelly Bjorkland wrote in their article for Time, “the Swedish way has yielded little but death and misery” [4].

Edited by: Shamika Bhandarkar

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