COVID-19 pandemic in Sweden
The COVID-19 pandemic in Sweden is part of the pandemic of coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2. The virus was confirmed to have reached Sweden on 31 January 2020, when a woman returning from Wuhan tested positive. On 26 February, following outbreaks in Italy and in Iran, multiple travel-related clusters appeared in Sweden. Community transmission was confirmed on 9 March in the Stockholm region. Since then, individuals in every län have tested positive for COVID-19. The first death was reported on 11 March in Stockholm, a case of community transmission. However, it's believed that the virus could have reached Sweden as early as December 2019, when several individuals sought care for respiratory illness in Falun after contact with an individual with recent travel history to Wuhan.
Sweden has not imposed a lockdown, unlike many other countries, and kept large parts of its society open. The Swedish Constitution legally protects the freedom of movement for the people, thus preventing a lockdown in peace time. The Swedish public is expected to follow a series of non-voluntary recommendations from the government agency responsible for this area, in this case the Public Health Agency of Sweden. The Swedish Constitution prohibits ministerial rule – politicians overruling the advice from its agencies is extremely unusual in Sweden – and mandates that the relevant government body, in this case an expert agency – the Public Health Agency – must initiate all actions to prevent the virus in accordance with Swedish law, rendering state epidemiologist Anders Tegnell a central figure in the crisis. Having an expert agency almost completely in control of the country's COVID-19 response without the involvement of politicians set Sweden apart from other countries.
Following agency advice, the government has passed legislation limiting freedom of assembly by temporarily banning gatherings of over 50 individuals, banning people from visiting nursing homes, and physically closing secondary schools and universities. Primary schools have remained open, in part to avoid healthcare workers staying home with their children.
The Public Health Agency issued recommendations to: if possible, work from home; avoid unnecessary travel within the country; engage in social distancing; and for people above 70 to stay at home, as much as possible. Those with even minimal symptoms that could be caused by COVID-19 are recommended to stay home. The karensdag, or initial day without paid sick-leave, has been removed by the government and the length of time one can stay home with pay without a doctor's note has been raised from 7 to 21 days.
The pandemic has put the Swedish healthcare system under severe strain, with tens of thousands of operations having been postponed. Initially, Swedish hospitals and other facilities reported a shortage of personal protective equipment. At the start of the pandemic, concerns were made that Swedish hospitals wouldn't have enough capacity to treat all who could become ill with the disease, especially in regard to those needing intensive care. Swedish hospitals were eventually able to double the number of intensive care beds in a few weeks, and the maximum capacity was never exceeded.
Sweden began testing for the virus in January, and, approximately 820,606 samples had been analysed., there have been 79,404 confirmed cases and 5,702 confirmed deaths related to COVID-19 in Sweden, with Stockholm County being the most affected. Similar to other European countries, close to half of those who died had been living at nursing homes.
Many outside Sweden considered the Swedish response to the pandemic to be strikingly different to that of other countries. This resulted in an unprecedented increase of international news coverage on Sweden.
Background
Outbreak of a novel coronavirus disease
On 12 January, the World Health Organization confirmed that a novel coronavirus was the cause of a respiratory illness in a cluster of people in Wuhan, in Hubei, China, who had initially come to the WHO's attention on 31 December 2019. This cluster was initially linked to the Huanan Seafood Wholesale Market in Wuhan City. A few days later, on 16 January, the Swedish Public Health Agency issued a press release highlighting the discovery of the novel coronavirus, and the agency monitoring the situation. The risk of spread to Sweden was described as "very low" as there was yet no evidence that the virus could spread between humans, but they recommended that individuals developing cough or fever after visiting Wuhan should seek medical care, and asked for healthcare professionals to be observant.After the World Health Organization classified the novel Coronavirus as a Public Health Emergency of International Concern on 30 January and demanded that all member states should cooperate to prevent further spread of the virus, the Agency requested for the Swedish government to classify the novel disease as a notifiable infectious disease in the Swedish Communicable Diseases Act as both dangerous to public health and dangerous to society, where contact tracing is required, giving the disease the same legislative status as Ebola, SARS and Smallpox. The agency also announced that they have analysing methods that can diagnose a case of the novel disease ‘within hours’ after testing, and that such tests had already been carried out, but that all had turned out negative.
Background
Following the 2005 outbreak of the H5N1 avian flu, Sweden drafted their first national pandemic plan which since then had undergone several revisions. Since 2008, the plan includes the formation of a National Pandemic Group, which involves several Swedish government agencies and defines each agency's role. Swedish crisis management is built on a principle of responsibility which means that the organisation who is responsible for an area of activity under normal circumstances is also responsible for that area of activity during a crisis. As the Public Health Agency of Sweden is the agency responsible of monitoring and preventing the spread of infectious diseases, the agency had a central role in the Swedish response to the pandemic.In risk and impact assessments, the risk of Sweden in the future being affected by a severe pandemic was assessed as "high" with a "catastrophic" impact on human health and economics, and that such a scenario would be inevitable within 5–50 years. In the 2019 Global Health Security Index, which ranked the countries most prepared for an epidemic or a pandemic, Sweden was ranked 7th overall. However, the Swedish healthcare system received a lower score, questioning if it was sufficient and robust enough to treat the sick and protect health workers.
In 2013, the Swedish Civil Contingencies Agency investigated Sweden's ability to cope with a pandemic through a simulation where a severe avian influenza infects a third of the population, out of which 190,000 gets severely ill, and up to 10,000 die from the disease. They concluded that Sweden was generally well prepared, with pandemic plans on both national and regional level, but that the healthcare system would be the weak link. They noted that Swedish hospitals were already under heavy burden, and wouldn't have the capacity to treat everyone who become sick. Before the outbreak of the new coronavirus, Sweden had a relatively low number of hospital beds per capita, with 2.2 beds per 1000 people, and intensive care unit beds per capita of 5.8 per 100.000 people. Both numbers were lower than most countries' in the EU. The total number of ICU beds in Swedish hospitals was 526.
Timeline
Early cases (January–February)
On 31 January, the first Swedish case was confirmed in a woman in Jönköping who had travelled to Sweden from Wuhan, China, on 24 January directly from Wuhan. The case was fully isolated and there are no reports of further spread. It's believed that the virus could have reached Sweden as early as December 2019 when several individuals sought care at a primary care clinic in Svärdsjö, Falun with signs of respiratory disease, as all of them had been in contact with an individual with a recent travel history to Wuhan, and later tested positive for antibodies against the disease. There is however no evidence of further spread in connection with those early cases. The second confirmed case was diagnosed at Sahlgrenska University Hospital, Gothenburg on 26 February, after a man who had recently returned from northern Italy following the COVID-19 outbreak in Italy had developed symptoms. With five additional cases confirmed on 27 February, the Public Health Agency put out a statement that these cases were all related to travel to high-risk zones and that there was no evidence of community transmission. Disease control measures, including extensive contact tracing, turned up over 200 travel-related cases in the following weeks, all with connection to confirmed cases or travel to high risk regions. Many of those who tested positive for the virus during this early stage of the outbreak in Sweden had been infected while on vacation in Italy during the one-week spring break in late February. During the four-week period from February to March in which the spring break takes place in different areas of Sweden, around one million Swedes had travelled abroad. Testing were initially primarily done on individuals who had developed symptoms after travelling from the areas hardest hit by the outbreak, such as China, Iran, northern Italy, Tyrol and South Korea, or those with pneumonia of unknown cause. Subsequent whole genome sequencing studies carried out by the Public Health Agency proved that disease control measures including isolation and contact tracing had been largely successful in preventing the infection to spread from Italy. The studies also revealed that early assumptions that Swedes returning from Northern Italy and Tyrol were the main drivers of the outbreak in Sweden was incorrect, as the virus had likely been brought to Sweden by "hundreds" of different people from a range of countries, as the outbreak by that time had "gone under the radar" in many other parts of the world and that other countries already had a large spread. Analyses of early Swedish cases suggested that several early cases had carried the virus from the United Kingdom and the United States, and also from France and the Netherlands. From the start of the outbreak in Sweden, Stockholm County saw a significantly higher number of cases in the Stockholm region compared to other regions of Sweden, including the densely populated regions Skåne and Västra Götaland. According to Johan Carlson, director-general at the Public Health Agency, one reason was believed to be that the Stockholm spring break in took place later than in other regions.On 27 February, Uppsala County confirmed its first case in a woman with a travel history to Germany, where she had met with an Italian colleague, and had been admitted to Uppsala University Hospital after seeking medical attention with flu-like symptoms.
Community spread (March–)
This came as the first cases of community transmission was confirmed among two patients who had sought care at S:t Göran Hospital, Stockholm, on 6 March. They were assumed to have been infected through community transmission. The following day, Jämtland and Västernorrland also confirmed initial cases.Responding to indications of local transmission in the Stockholm area and Västra Götaland, the Public Health Agency on 10 March raised the risk assessment of community spread from moderate to very high, which is the highest level. The first death was reported on 11 March, the same day as the COVID-19 outbreak was declared a pandemic by the WHO, when a person in their 70s from the Stockholm region died in the intensive care unit of Karolinska University Hospital. The person was reported to have acquired the virus through community transmission, believed to have occurred about one week before death. The person also belonged to a risk group. After the first case in Västmanland County was confirmed on 13 March, the disease had reached all of the 21 regions in Sweden.
The Public Health Agency of Sweden declared on 13 March that stopping the spread of COVID-19 had entered a "new phase" which required "other efforts". The continued focus was now to delay spread among the population and to protect the elderly and most vulnerable against the disease. Contact tracing would no longer be part of the strategy, and testing would instead focus on people already in hospital or those considered to belong to be of a bigger risk of a more severe disease.
The health agency believed that 5–10% of the population in Stockholm County was carrying the virus on 9 April. In mid-April, it was reported that out of the approximately 1,300 people who had died after having caught the virus, one third had been living at nursing homes. The figure differed between the regions. In Stockholm, the city most affected by the pandemic, half of the deaths had been residents in one of its many nursing homes. The situation led to the Health and Social Care Inspectorate to begin carrying out controls at the homes.
According to estimations by the Health Agency in early May, the R value had dropped below 1.0 for the first time on 21 April. In June, the Health Agency declared that several regions had entered a "late pandemic phase" with a decrease in the number of new cases, and called for those regions to return to the strategy of stopping the disease through increased testing and detailed contact tracing.
Response from the authorities
Government
The Swedish government considered its overall objective in the Swedish response to the pandemic was to limit the spread of infection in the country to not exceed the capacity of the Swedish health system. They also aimed to ensure that the municipalities and regions responsible for the health care would have the necessary resources to handle the pandemic.The government has tried to focus efforts on encouraging the right behaviour and creating social norms rather than mandatory restrictions. Government officials including Swedish prime minister Stefan Löfven has encouraged each individual to take responsibility for their own health and the health of others, and to follow the recommendations from the Public Health Agency of Sweden, as the agency responsible for monitoring a pandemic and coordinating the response.
The Swedish Constitution mandates that government agencies should work independently from the government and that the relevant expert agencies must issue advice prior to any government actions within the agency's area, in this case aiming to prevent the spread of the virus, with a strong mandate that the expert agencies should initiate actions, avoiding rule by ministers. Having its public health agency almost completely controlling the strategy without the involvement of politicians set Sweden apart from most, perhaps all, other countries. However, the agencies do not have the power to pass laws. Instead, they give out recommendations on how someone can or should act to meet a binding regulation within the agency's area of activity. Although there is no legal framework for a governmental agency to impose sanctions on someone for going against its recommendations, it isn't optional as the recommendations work as guidelines on how to act to follow a regulation. The independence of Swedish agencies and the choice of 'recommendations' instead of legislation has received much coverage in international media.
Swedish foreign minister, Ann Linde described Sweden as having ‘rather small ministries, but rather big authorities’, and this going back 300–400 years, and Sweden being characterised by a very high level of trust in its authorities from both the people and the politicians, and that Swedes had a very strong urge to following recommendations from authorities, thus making legislation largely unnecessary. When asked if Sweden would consider tougher restrictions, Löfven and Linde both made clear that the Swedish government wouldn't hesitate to do so if deemed necessary and on advice from the expert agencies, but that such measures needed to be taken at the right time, and they believe it's hard to make people adhere to lockdowns for an extended period. Deputy Prime Minister of Sweden Isabella Lövin referred to the pandemic being "not a sprint, but a marathon"
Legislation
Advice against travel abroad
Strategy
According to the Swedish Public Health Agency, the Swedish strategy aimed to protect its senior and/or vulnerable citizens, and to slow down the spread of the virus, to keep the healthcare system from getting overwhelmed. They are also mandated by law to make their response based on scientific evidence. The Swedish state epidemiologist Anders Tegnell has questioned the scientific basis of some of the "stricter" measures taken by other governments, including lockdowns and border closures. While many countries imposed nationwide lockdowns and curfews, such measures were prohibited by the Swedish constitution as it's considered to be a violation of freedom of movement, and the Swedish laws on communicable diseases only allows for quarantining individuals and small areas such as buildings, not for entire geographical areas. Instead, it's mostly based around the individual responsibility. Although the government were later granted more authority for imposing restrictions on transport following a temporary amendment in April, the Swedish authorities considered lockdowns to be unnecessary, as they believed that voluntary measures could be just as effective as bans. Although many considered this to be a 'relaxed' approach, it was defended by the authorities as well as government officials, among them Prime Minister Stefan Löfvén, to be more sustainable, as unlike lockdowns, it could be in place for "months, even years" as it wasn't assumed to be likely that the disease could be stopped until a vaccine was produced, thus de Therefore, the Swedish response only included measures where an exit strategy wasn't needed.Unlike many European countries, including neighbouring Denmark and Norway, Sweden did not close its preschools or elementary schools as a preventive measure. This was met with criticism within Sweden. According to the Health Agency, the main reasons for not closing schools was that as a preventive measure it lacked support by research or scientific literature, and because of its negative effects on society. They argued that many parents, including healthcare professionals, would have no choice but to stay home from work to care for their children if schools were closed. There was also concern for a situation where elderly people babysit their grandchildren, as they are of bigger risk of severe symptoms in case of infection. According to agency's estimations, closures of elementary schools and preschool could result in an absence of up to 43,000 healthcare professionals, including doctors, Nurses and nurse's assistants, equalling 10 per cent of the total workforce in the sector. Additionally, there was concern of school closures having negative consequences for disadvantaged and vulnerable children, and according to the agency yet no evidence of children playing a major role in the spread of the virus, nor of a high infection rate among children or preschool teachers, and that children who become infected showed mild symptoms. In May, Tegnell said that the decision was right, as the healthcare system would not have managed the situation the past months if Swedish authorities had chosen to close elementary schools. He later said that the decision to close secondary schools might have been unnecessary, because it possibly had little effect in slowing the spread of the disease.
After the Danish government went against the advice of the Danish Health Authority and closed their national borders in March, Tegnell remarked that there were currently no scientific studies supporting border closures to be an effective measure against a pandemic, and that "history has proven it to be completely meaningless measure", and argued that it could, at best, delay the outbreak for one week, and also pointed out that border closures went against the recommendations from the WHO. He later said closures would be "ridiculous" in a situation where the disease had spread across all of Europe, saying that movements within the country were of more concern.
, the architect of the Swedish strategyRepresentatives of the Swedish government, as well as its agencies, have repeatedly denied that pursuing herd immunity is part of the Swedish strategy, as claimed by foreign press and scientists in and outside Sweden. According to state epidemiologist Anders Tegnell, herd immunity had not been calculated in the strategy, and if it had been the goal, "we would have done nothing and let coronavirus run rampant". But he believed, in April 2020, that Sweden would benefit from herd immunity in the long run, and reasoned that all countries would eventually have to achieve it to beat the virus. In May 2020 he said that he believed it was unlikely that Sweden, or any other country, would ever reach full herd immunity, and also that it would be a mistake to base a strategy on a hypothetical vaccine, as it would likely be years until there is a vaccine that can be distributed to an entire population. Instead, he believed COVID-19 was something "we’re going to have to live with for a very long time".
As the strategy was built by the health experts at the Public Health Agency without any influence from the government, it was built solely on a public health perspective, without any political considerations to the economy. The agency did however regard the economy as part of its broader public health considerations, due to unemployment and a weakening economy typically leading to a poorer public health.
Although Sweden was regarded to have succeeded with making sure the hospitals would keep at pace, it admitted to have failed with protecting its elderly, as three-fourths of its deaths had occurred among nursing home residents or those receiving home care. The Health Agency saw the spread at the homes as their biggest concern, but "not as a failure of our overall strategy, but as a failure of our way to protect the elderly". In an interview with Sveriges Radio in early June, Tegnell was asked if he would have done things differently if he could ‘back the tape’, to which he replied that Sweden should have done more earlier during the outbreak. This received extensive coverage in national as well as international media and was interpreted as he was distancing himself from the Swedish strategy. Tegnell however denied this being the case, and said they still believed the strategy being good, but that "you can always improve things, especially in hindsight". When asked to give examples, he said that it would have been much better if they had been more prepared at nursing homes, and that it would have been better if the testing capacity had been increased earlier on during the outbreak. He also said that the closure of secondary schools might have been unnecessary.
Measures
On 10 March 2020, responding to indications of community transmission, the Public Health Agency advised everyone with respiratory infections, even mild cases, to refrain from social contacts where there is a risk of spreading the virus, in private as well as working life. They also ask health care staff working with risk groups, including nursing homes, not work if they have any symptoms of respiratory infection. Relatives of elderly should also avoid unnecessary visits at hospitals and in facilities for elderly, and never visit if there are any respiratory symptoms.Social distancing
On 16 March 2020, the agency recommended that people over 70 should limit close contact with other people, and avoid crowded areas such as stores, public transport and public spaces. At the end of March, 93% of those older than 70 said that they were following the recommendations from the health service to some extent, with the majority having decreased their contacts with friends and family. In May, the agency looked at easening the recommendations for the 'young elderly' of good health, but ultimately decided against it. They did however encourage those over 70 not to isolate completely in their homes, but to go outside for walks while still following the recommendations. On 16 March 2020, they also recommended that employers should recommend their employees work from home. One month later, statistics showed that roughly half the Swedish workforce was working from home. The following day, the agency recommended that secondary schools and universities use distance learning, with schools following suit all over the country. The decision to recommend distance education for secondary and tertiary education, but not for elementary schools, was that studies at secondary schools and universities to a higher extent require commuting and travelling, and that students would not depend on parental care while not in schools, and school closings therefore did not risk interrupting society. In May, it was announced that the Health Agency were to lift the recommendations on 15 June, and thereby allowing secondary schools and universities to open up as normal after the summer holidays.In April, many of the organisations running the public transport systems for the Swedish counties had reported a 50% drop in public transport usage, including Kalmar Länstrafik in Kalmar County, Skånetrafiken in Skåne County, Stockholm Public Transit in Stockholm County, and Västtrafik in Västra Götaland County. In Stockholm, the streets grew increasingly emptier, with a 30% drop in the number of cars, and 70% fewer pedestrians.
In mid-May, and on the request of the Public Health Agency, the Swedish Transport Agency temporarily suspended the regulations that allowed for passenger transport on lorries or trailers pulled by tractors, trucks or engineering vehicles at graduations and carnivals. The new rules were to be in place between 15 May and 31 December.
These social distancing recommendations have been effective in part because Swedes tend to have a "disposition to social distancing anyway."
Ban on gatherings
The same day as the first Swedish death to COVID-19, 11 March, the Swedish government passed a new law at the request of the Public Health Agency, limiting freedom of assembly by banning all gatherings larger than 500 people, with threat of fine and prison. The ban would apply until further notice. According to the Health Agency, the reasoning behind drawing the line at 500 was to limit long-distance travel within the nation's borders, as bigger events are more likely to attract visitors from all over the country. Although freedom of assembly is protected by the Swedish constitution in the Fundamental Law on Freedom of Expression, the constitution allows for a government to restrict the freedom, if needed to limit the spread of an epidemic. On 27 March the government announced that the ban on public gatherings would be lowered to include all gatherings of more than 50 people, to further decrease the spread of the infection, again at the request of the Public Health Agency. The ban would apply to arts and entertainment events including theatre, cinema and concerts, religious meetings, demonstrations, lectures, competitive sports, amusement parks, fairs and markets. The ban did not include gatherings in schools, workplaces, public transport, grocery stores or shopping malls, health clubs or private events. The agency also recommended that plans for events and gatherings of fewer than 50 people should be preceded by a risk assessment and, if necessary, followed by mitigation measures. Additionally, they recommend that digital meetings should be considered. The ban on large gatherings had no end-date, and as of late April, the Health Agency was reported as having no plans for when the ban should be lifted.Travel
On 18 March, the Health Agency recommended that everyone should avoid travelling within the country. This came after signs of ongoing community transmission in parts of the country, due to concern that a rapid spread over the country would make redistribution of healthcare resources more difficult. They also called for the public to reconsider any planned holidays during the upcoming Easter weekend. The calls to avoid travelling and social interactions during the Easter weekend were repeated several times by agency and government officials, among them Prime Minister Stefan Löfvén and King, Carl XVI Gustaf. Telia, a Swedish multinational mobile network operator, did an analysis of mobile network data during the week of Easter, and found that most Swedes had followed the agency's recommendations to avoid unnecessary travels during the Easter holidays. Overall, travel from the Stockholm region had decreased by 80–90%, and the number of citizens of Stockholm travelling to popular holiday destinations like Gotland and the ski resorts in Åre had fallen with more than 90%. Travel between other regions in Sweden had fallen as well. Ferry-line operator Destination Gotland, who previously had called on their customers to rethink their planned trips for Easter, reported that 85% of all bookings had been rescheduled.The restrictions on domestic travel were somewhat softened on 13 May, allowing for travels equalling one to two hours from home by car would be allowed under some circumstances to which Löfvén referred to as ‘common sense’, such as not risking to burden healthcare in other regions, keeping contact with others low and not travelling to visit new social contacts, the elderly or those at risk of severe disease. On 4 June, the government announced that the restrictions on domestic travel were to be lifted on 13 June, allowing everyone to freely travel in the country if they were without symptoms and rules on social distancing were followed. However, they cautioned that new restrictions could be introduced if the situation were to worsen, and that the County administrative boards of Sweden were tasked to monitor the situation.
Communication and information
Beginning in March, press conferences were held daily to at 14:00 local time, with representatives from the three government agencies responsible for coordinating Sweden's response to the pandemic; the Public Health Agency, usually represented by state epidemiologist Tegnell or deputy state epidemiologist Anders Wallensten, the National Board of Health and Welfare and the Swedish Civil Contingencies Agency. According to the latter, close to one million people followed each press conference on the TV or the radio. The ratings excluded other types of media.issued a series of infographics in different languages describing how to protect oneself and others from infection.For official information on the disease and the situation in Sweden, the authorities referred the public to the website krisinformation.se, which compiles official emergency information from Swedish authorities. The website is operated by the Civil Contingencies Agency, as the agency responsible for emergency information to the public during emergencies. The agency reported a big increase in the number of people visiting the website during the beginning of the pandemic, with 4.5 million views between January and April 2020, compared to 200,000 during the same period in 2019.
In March, the Civil Contingencies Agency received 75 million SEK from the government for public service announcements to inform the public about the virus, and how to reduce the spread of the disease to slow down the spread of the virus.
Monitoring and modelling
In early March, the Health Agency expanded the sentinel surveillance system in use for monitoring the influenza season, so that samples from patients with flu-like symptoms would also be tested for SARS-CoV-2 along with the influenza viruses. In early May, approximately 1500 samples had been analysed within the sentinel system.Between 27 March and 3 April, the health agency tested approximately 800 randomly selected individuals in Stockholm County, to seek knowledge of the then current infection rate.
As it was estimated that Stockholm County by then had the highest infection rate in Sweden, the agency choose to focus on that region. According to the results, 2.5% of the local population were carrying the virus in the upper respiratory tract during the surveyed period. Based on the study and a doubling time of 6–7 days, the agency concluded that 5–10% of the population in the region were carrying the virus on 9 April.
This was followed by a similar study on national level. In the study, approximately 4000 people would be tested for an active infection. It was followed by a second national study on 4000 individuals in late April, and a similar national study where "thousands" would be tested for antibodies.
In an April study by researchers at the KTH Royal Institute of Technology and the Science for Life Laboratory, home sample kits were mailed to 1,000 randomly selected individuals in Stockholm to be tested for the presence of antibodies against the SARS-CoV-2 virus which causes the COVID-19 disease. After analysing 440 out of the 550 blood samples returned, the scientists concluded that 10% of the donors were infected during or prior to late March. A follow-up study was carried out later that month with an additional 1,000 tests to determine how much the spread has increased during the weeks between the two studies. The same month, a study was carried out by researchers at the KTH Royal Institute of Technology and Danderyd Hospital where staff at the hospitals were tested for antibodies. After analysing 527 samples, the researchers reported that approximately 20% of the staff had developed antibodies against the virus. After testing the entire staff a total of 19.1% of the staff had developed IgG antibodies at the end of May / early June. The researchers intended to continue testing to carry out several follow-up tests during the following 12 months to learn how long the antibodies will stay in the body. In late April, approximately 11,000 out of the staff at Karolinska University Hospital were tested for the virus in either PCR based or serological tests. The tested individuals included both those with clinical medical and non-clinical medical jobs, as well as staff with non-medical jobs. When 5,500 PCR tests and 3,200 serological tests had been analysed, a total of 15% samples came back positive. Only people without symptoms were tested.
Public healthcare system
Testing
The first tests were carried out in January, and according to the Swedish Public Health Agency, ‘around twenty tests’ had already been carried out before the first positive case was confirmed on 30 January. The agency considered that all individuals who developed any symptoms of disease in the respiratory tract after visiting Wuhan should be tested, even those with less severe symptoms. The Public Health Agency expanded testing for COVID-19 on 4 March beyond only those who have been in risk areas abroad, to also test cases of pneumonia without known cause. Initially, all tests were carried out at the agency's high-containment laboratory in Solna. But in mid-February, to increase testing capacity and allow for faster test results, testing also began at the clinical medical laboratories in Göteborg, Halmstad, Lund, Skövde, Stockholm, Umeå and Uppsala. The Public Health agency considered testing and contact tracing to be more important in the early and late pandemic phases, to stop the spread of the disease and find every case, as "it isn't possible to test millions of individuals in the country" during the pandemic phase.At the end of March, the number of tests carried out each week numbered 10,000. In mid-April, the number of weekly tests had doubled to approximately 20,000. In early April, the government instructed for the testing capacity to be vastly increased to be able to analyse 100.000 samples every week. This was mainly to make it possible to test people with jobs considered crucial to society, for instance policemen and those working in rescue service or with electric power supply, while still having enough capacity to handle all tests needed for the health-care sector. In mid-May, the number of tests carried out were still far from the goal, with approximately 30.000 tests carried out weekly, and according to a representative for Swedish municipalities and regions it would likely be 'weeks' until goals were met. On 4 June, the government announced that due to several regions in Sweden having entered a late phase of the pandemic, coronavirus testing and contact tracing were to be broadened so that everyone with suspected COVID-19 symptoms could be tested free of cost. On 31 May, a total of 275,819 samples had been tested since the start of the Swedish outbreak.
Capacity
The Stockholm International Fairs, Stockholmsmässan, are being converted into a field hospital with the help of the Swedish Defence Force. The field hospital will be able to house 600 seriously and critically sick patients. The Swedish Defence Forces will provide equipment for 30 of the 600 beds and the Stockholm Regional Council will provide the remaining 570. The facilities were initially used for treating less severe cases, as opposed to those needing intensive care. In late April, it was reported that the Defence Force had provided 50 intensive care beds as part of the two field hospitals. Field hospitals were also erected in Gothenburg, and Helsingborg. The field hospital in Älvsjö were never needed to be taken into use, and were dismantled in early June. The Gothenburg hospital was used for intensive care during a short time span, but was soon taken out of use following massive criticism from health-care workers who voiced concern for patient safety, increased risks of infection and working conditions.outside Östra Sjukhuset in Gothenburg on 23 March 2020. The tents contain temporary intensive care units for COVID-19 patients.
Hospital, 14 March 2020.
Hospital
The increasing number of cases in March resulted in the cancellation or postponement of close to 50% of planned surgeries, including cancer-related surgeries, in all of Sweden, and up to 90% in large areas such as Stockholm and Uppsala. By May, 44,000 planned surgeries had been postponed in Sweden, increasing the total number of Swedes in line for a surgery to over 150,000. Several regions also chose to cancel many, or all, planned non-acute dentistry as a measure to redistribute healthcare equipment like disposable gloves and masks.
Before the pandemic, the Swedish healthcare system had the capacity to treat approximately 500 persons in Intensive Care Units. The relatively low number of beds had stayed a source of concern as the crisis evolved, and even though the number had increased to 800 at the beginning of April, healthcare professionals continued to express worry that their hospitals would eventually run out of beds. According to the calculations of the Swedish health agency, up to 1300 ICU beds would be needed when Sweden reached the top of the pandemic. Sweden was eventually able to double the number of intensive care beds in a few weeks, and on 13 April, the National Board of Health and Welfare reported that the total number of ICU beds had risen to 1039, with an occupancy of 80%.
Equipment
On 13 March, media reported that there is a shortage in personal protective equipment for health care staff, and hospitals in Stockholm have been forced to reuse disposable PPEs after sanitation. The regional Health Care Director warned about this scenario in early March and government agencies have temporarily waived the public procurement law to hastily procure more supplies. The National Board of Health and Welfare confirmed that there is no preparedness storage and nothing to distribute to the health care sector. In early April, several counties expressed concern that they might run out of some vital drugs used in intensive care. Later that month, Stockholm County reported of an acute shortage of the anaesthetic propofol.As one of the main tasks of the Swedish Defence Force is to support the civil community in case of disasters, their resources were used to lessen equipment shortages in the health-care system. The material supplied by the military included crucial medical equipment; X-ray generators, electrocardiographic machines, 154 ventilators and 154 intensive care monitors. The military also supplied personal protective equipment, including 60,000 gas masks and 40,000 protective suits.
Staffing
On 25 March 2020, Björn Eriksson, the Director of Healthcare in Stockholm, appealed to anyone in the Stockholm region who had experience in healthcare to volunteer. As of the 26 March 2020, 5100 people with healthcare experience had registered as volunteers.The increasing number of cases in large areas such as Stockholm and Uppsala has resulted in the cancellation or postponement of up to 90% of planned surgeries, including cancer related surgeries.
When it became clear that the civil society would face difficulties managing the emergent crisis, the Swedish Defence Force were called in to assist the civilian society with manpower, equipment, and logistics. The preparations began in February and the first servicemen were deployed in March. By early April the total military deployed in civilian society numbered 400 servicemen, among them a number of officers to support the National Board of Health and Welfare with crisis management and laboratory technicians to support the Public Health Agency of Sweden. Tasks for the military personnel also including collecting and transporting samples. A number of military ambulances were also taken in use within the civilian health system.
Social impact
Finance and the economy
In March, Swedish Minister for Finance Magdalena Andersson said that the government believed that the Swedish economy would be hardly hit by the pandemic, with a 4% downturn in gross domestic product, similar to the levels seen following the 2008 financial crisis. Andersson also warned that they also expected unemployment to increase up to 9% during the year. In a forecast by the Swedish National Institute of Economic Research published in late April, the Swedish GDP was expected to fall with 7% during 2020 due to the impact of the ongoing pandemic. The European Commission predicted that the Swedish economy would contract -6.1%, a level similar to that of the eurozone. In June, the Swedish central bank Sveriges Riksbank forecasted a fall of 10%. This was mainly due to the Swedish economy being heavily reliant on exports with the shrinking global economy being predicted to decrease international demand of Swedish goods and services. The Economy were also affected by problems with global supply lines, which had forced some of the biggest manufacturing companies in Sweden, including Scania and Volvo Cars, to halt their production in March, as well as a decrease in consumption. The National Institute of Economic Research also exptected that unemployment in Sweden would rise to 11% during 2020, and the Swedish Pensions Agency calculated a 1.5% drop in pensions for 2021, as Swedish pensions are attached to GDP and income. While some predicted a rebound already in the second half of 2020, Magdalena Andersson warned that things "could get worse before they get better." In mid-June, Andersson said it was possible that Sweden had reached the bottom of the downturnn, as the government had revised their forecast to a -6% GDP downturn in GDP and an unemployment level of 9.3% although they expected unemployment to further increase in 2021 to 10.3%. However, she cautioned that there was still a big uncertainty regarding the numbers. Similarly, the National Institute of Economic Research also revised their forecast downwards, to a -5.5% fall in GDP and for unemployment to increase to 8.5% during 2020, with a further increase up to 10% in 2021.In mid-March, the government proposed a 300 billion SEK emergency package to reduce the economic impact of the crisis. The proposal included a system with a reduction in work hours where the government will pay half to salary, aiming to help businesses stay afloat without having to do layoffs. Further, the government would pay the employer's expenses for any sick leaves, which is normally shared between the employer and the state. The normal costs of employer contributions have also been temporarily discontinued for small business owners. This will save small businesses approximately 5000 SEK per employee each month but will result in a loss of tax revenue of 33 billion SEK. The budget emergency package proposed by the government in mid-March to lessen the economic impact of the crisis was supported across the political spectrum, including all parties in opposition in the Riksdag. It was also welcomed by trade unions as well as the private and business sectors. However, some union representatives stressed that 'it won't be enough', a view shared by the biggest employer's organisation, the Confederation of Swedish Enterprise.
On 2 April, the Financial Supervisory Authority decided that Swedish banks temporarily can allow exemptions for housing mortgage lenders regarding amortising of loans.
Transportation
Air transportation in Sweden is primarily run by public and private companies – principally Scandinavian Airlines System and Norwegian Air Shuttle – and has been severely impacted by the pandemic and greatly reduced. Like airlines around the world, Sweden's carriers have reduced the frequency of their flights, reduced their work force and asked the local government for financial assistance. On 15 March, SAS announced that they would temporarily reduce their workforce by 10,000 people, which constitutes about 90% of their workforce. Soon almost all domestic flights were cancelled. Swedish authorities advised against all non-essential travel inside and out of Sweden. SAS Group decided to fly only four domestic departures and four domestic arrivals from Arlanda from 6 April 2020, plus some international flights, while Norwegian cancelled all domestic flights in Sweden. Several airports closed temporarily.Rail transport in Sweden, which is principally run by the public operator SJ AB, has continued to operate throughout the pandemic, albeit with a slightly reduced schedule so that additional carriages can be added to trains, which in conjunction with fewer tickets being made available for sale, aims to ensure social distancing of those passengers that continue to travel. The decrease in travel had a big impact on the public transport sector due to a loss of revenue in ticket sales, which led to trade association Swedish Public Transport Association asking the government for financial aid.
Politics
In mid-March, the parliamentary leaders from the parties in the Riksdag agreed on usingpairing for the upcoming weeks, to make it possible to decrease the number of members of parliament present during voting sessions, from the usual 349 to 55. This decision was taken both as a measure to lower the risk of spread of the infection, and to make sure the daily work in the parliament could proceed even if a big number of MPs would become sick. Similar decisions were taken in many of Swedish municipal councils. Several regional assemblies also decreased the number of politicians present each session, including Västerbotten County who did it as a measure to decrease long-distance travelling, and Skåne County.
On 25 March, The Swedish Social Democratic Party together with the Swedish Trade Union Confederation decided to cancel their traditional May Day demonstrations. They will instead hold an event on a digital platform, which will include speeches by the Swedish prime minister and leader of the Social Democrats, Stefan Löfven, as well as union confederation leader Karl-Petter Thorwaldsson. The Left Party also cancelled their nationwide demonstrations, and announced that there would instead be a digital celebration, including a speech by party leader Jonas Sjöstedt. The Almedalen Week, considered to be the biggest and most important forum in Sweden for seminars, debates and political speeches on current social issues, held in Visby every summer, was cancelled as a result of the ban on large gatherings. The decision was taken on 1 April by the organiser after consultation with the major political parties. Prime Minister Stefan Löfvén had already announced that he had cancelled his planned participation in the upcoming event. A similar event in Stockholm, 'Järvaveckan', was also cancelled, and won't be held until 2021.
The annual LGBT festival West Pride in Gothenburg was also cancelled as a result of the pandemic. Instead, the organisers proclaimed 25 May to 7 June a 'flag period', encouraging organisations and individuals to hoist the rainbow flag.
Royal family
Following the recommendation from the Swedish authorities that those over the age of 70 should self-isolate, the Swedish King and Queen, Carl XVI Gustaf and Queen Silvia, aged 74 and 76, both chose to leave the palace to work from distance in the estate Stenhammar in Sörmland.On 5 April, at the first day of the Holy week, King Carl XVI Gustaf addressed the nation in a televised speech. In his speech, he stressed that all Swedes had an obligation to the country to "act responsibly and selflessly". He also stressed that many who otherwise would travel, spend time with friends and family or go to church would need to make sacrifices during the upcoming Easter holiday. In his speech, he specifically addressed those working or volunteering in the health-care sector, saying "This is a huge task. It requires courage. And it will require endurance. To all of you involved in this vital work, I offer my heartfelt thanks", as well as other people doing vital work in society, to ensure Swedes "can buy food, that public transport continues to operate, and everything else we so easily take for granted – my warmest thanks to you all". He finished saying that all would embrace the message "The journey is long and arduous. But in the end, light triumphs over darkness, and we will be able to feel hope again", ending his speech wishing everyone a happy Easter.
Education
On 13 March 2020, the spring Swedish Scholastic Aptitude Test was cancelled affecting approximately 70,000 prospective students who had registered themselves. This was the first time the Swedish Scholastic Aptitude Test has been cancelled since it was established in 1977. On 23 March 2020 the Swedish National Agency for Education, cancelled the national tests to give teachers in Sweden more time to prepare for the possibility of distance education.Defence
The Swedish Armed Forces cancelled the international military exercise Aurora 20 which was scheduled to be held between May and June. Austria and Canada had previously announced their cancellation of their planned participation.Arts and entertainment
The ban of public gatherings with more than 500 people, later revised down to 50, led to concerts and other events being cancelled or postponed. Concerts cancelled due to the ban on large crowds included four sold-out concerts with Håkan Hellström at the Nya Ullevi Arena, Gothenburg, scheduled for June and August. As the total number of tickets sold to the concerts numbered 300,000, it was believed to be a significant blow to Gothenburg's tourism industry, with a potential loss of 900 million SEK if all concerts scheduled at the arena were to be cancelled. The organiser of the music festival Summerburst had previously announced cancelling their scheduled event at Nya Ullevi. The rock festival Sweden Rock, held every year since 1992 in Blekinge and scheduled for June, was cancelled due to the ongoing pandemic. Theatre and opera were affected, with major venues such as Gothenburg opera house, Malmö Opera, Royal Dramatic Theatre and Royal Swedish Opera all closing their venues and cancel upcoming events. Cinema were affected as well, and Sweden's largest cinema chain, Filmstaden, decided to close all their cinemas on 17 March until further notice. In April, the Swedish amusement parks Gröna Lund in Stockholm and Liseberg in Gothenburg announced that they were to cancel or reschedule all concerts scheduled before midsummer. The former had already postponed the season opening indefinitely, while the latter were still hoping to open the park as planned in mid-May. As the amusement parks mostly rely on seasonal workers, closures would result in thousands of cancelled employment contracts.Starting 30 March 2020 the public library in Gävle will start with a book delivery service for people aged 70 or older. The library will also start a take-away service where you can pre-loan books and pick them in a take-away bag.
Television
On 6 March, Swedish National Broadcaster SVT held a crisis meeting to consider broadcasting the live finals of Melodifestivalen 2020 on 7 March without an audience, as a response to the growing outbreak. The Danish equivalent had recently decided to broadcast their version of the finals without an audience. Ultimately, SVT decided to allow the audience to enter the arena, although they advised people who felt sick to stay at home.The popular TV show Antikrundan, broadcast by public broadcaster SVT, where a number of antiques appraisers visits different locations in Sweden to appraise antiques brought there by local people, cancelled their planned tour for the recording of the 2020 winter season. According to the producers, they were instead working on an 'alternative' show. The sing-along show Lotta på Liseberg, which is televised live by TV4 from the amusement park Liseberg in Gothenburg, announced that the 2020 season wouldn't be cancelled, but would be recorded without an audience due to the ban of gatherings. SVT had previously announced similar plans for their live sing-along show Allsång på Skansen, which is broadcast live from the amusement park Skansen in Stockholm.
Sports
In athletics, all 2020 Diamond League events scheduled to be held in May were postponed, which included the meet in Stockholm. The world's largest half marathon in Gothenburg, Göteborgsvarvet, was postponed until later in 2020 and then cancelled completely on 27 March. The annual recreational bicycle race Vätternrundan, scheduled to be held in June, was also cancelled as a result of the pandemic. The organisers made the decision public on 2 April. The professional bicycle race Postnord UCI WWT Vårgårda West Sweden, part of the UCI Women's World Tour and scheduled for August, was also cancelled.On 19 March, the governing body for association football in Sweden formally announced that the premiere of the 2020 season for the first and second division leagues, men's Allsvenskan and Superettan as well as women's Damallsvenskan and Elitettan, will be postponed to late May or early June. The decision will not affect the leagues below the second level. Two days later it was announced that the 2020 edition of the association football award ceremony Fotbollsgalan was cancelled. Many of the professional teams in the highest division warned that the loss of income following the postponement of the season would have a severe impact on their economy. After consultations with the Public Health Agency, the organisation behind youth football tournament Gothia Cup, in Gothenburg, decided to cancel the 2020 event. According to the organisers, the tournament will return in 2021. The youth handball tournament Partille Cup was also cancelled. Professional handball was affected as well, with the last rounds and the finals in the highest men's and women's leagues, Handbollsligan and Svensk handbollselit, being cancelled. Similarly, the Swedish Basketball Federation choose to stop all games until May, effectively stopping the highest divisions SBL and SBL Dam mid-season. In Speedway, the start of Elitserien, the highest league in the Swedish league system, was rescheduled to 2 June. To manage a tighter schedule, the sport's governing body Swedish Motorcycle and Snowmobile Federation also decided to cancel the quarterfinals.
Swedish Minister for Sports Amanda Lind announced on 29 May that some recommendations were to be lifted starting from 14 June, when sports events would be allowed under the condition that they're practised outdoors. And as the ban on crowds and the recommendations against travel were still in place, all games had to be played on virtually empty arenas and athletes would not be allowed to travel longer than two miles to participate in sports events. However, professional athletes would be exempt from the recommendations, and allowed to travel nationwide if needed for competitive events.