Should India Consider Sweden’s Unique COVID Model? Experts Answer
Why many experts including Sweden's Public Health Agency officials have been relying on the idea of herd immunity?
Life, largely, remains unaltered for most of Sweden as kids continue to go to the school, people go for walks in the park and bars and pubs continue to host the customers - a parallel universe and perhaps a distinct dream for many other countries affected by COVID-19 in the world right now.
With no restrictive lockdown orders in place, around 10.23 million population of Sweden is hoping that the unconventional and controversial strategy of not enforcing stringent rules and merely suggesting people not gather in large numbers (over 50) with the anticipation that herd immunity can be generated against the coronavirus, works out well for them.
The whole world including India is closely monitoring Sweden's coronavirus model - which some believe is "brave" and others downplay calling it rather "risky".
Irrespective of what opinion one holds, the state’s chief epidemiologist Anders Tegnell, also the architecture of this whole liberal model to contain COVID-19, has captured everyone’s attention and now, the world waits for the results - as and when they come!
Too Early to Call Herd Immunity?
A Reuters report quotes him as saying,
“It is important to have a policy that can be sustained over a longer period, meaning staying home if you are sick, which is our message...Locking people up at home won’t work in the longer term. Sooner or later people are going to go out anyway.”
Sweden's concept of letting young people get exposed to the virus and protecting the elderly by recommending them to isolate is largely derived from the hypothesis that once a large portion of the population is infected with the virus, they will generate some kind of immunity against reinfection.
The biggest caveat in this theory - even though it is being touted by a considerable number of epidemiologists across the world as herd or community immunity - is that we don't yet know whether or not antibodies created by the virus are strong enough to not let the reinfection occur.
Experts are hoping that this new virus would possibly behave like other viruses such as SARS, influenza or measles but there is no conclusive study done so far. Even the World Health Organisation is not convinced.
“As of 24 April 2020, no study has evaluated whether the presence of antibodies to SARS-CoV-2 confers immunity to subsequent infection by this virus in humans.”World Health Organization
More worryingly, a few reports earlier said that recovered COVID-19 patients from China, South Korea and Japan have been testing positive the second time. However, South Korea's infectious disease experts later said that tests must have picked up remnants of the virus - leading to false results.
In addition, the World Health Organization's technical lead, Dr Maria Van Kerkhov too said those positive tests were a result of "false positives caused by dead lung cells."
At this point, the theory about reinfection is not confirmed.
The question, then, is amidst contrary reports and confusion about reinfection, why many experts including Sweden's Public Health Agency officials have been pinning hopes on the idea of herd immunity which, some opposing experts say would work only with the help of a vaccine in a later stage?
To find these answers and to analyze if Sweden's model can be brought to India - which has capital city Delhi alone at slightly less than twice of Sweden's population, starkly different health care systems & culture and high-density populations - at some stage in the long run to fight coronavirus and to recover the economy, FIT spoke to experts. But, first, let's look at how Sweden fairs so far with their model.
A Look at Sweden's Numbers
As of 26 April, Sweden had recorded 18,640 confirmed cases of COVID-19 and 2,194 deaths, as per data collected by Johns Hopkin University. The Nordic country recorded 21.55 deaths per lakh (100k) with a case-fatality of 11.8%.
While deaths per lakh in Sweden is less than other European countries such as Spain, Italy, France and even the UK, the situation here looks grimmer than its neighbours such as Norway, Finland and Denmark which have death/lakh rate at 3.78, 3.44 and 7.28 respectively. These other Nordic countries have some forms of lockdown measures in place.
So, at face value, Sweden may not be doing all that great. More so, because more than half of the deaths here are of older people who lived in elderly care homes.
This is also true that these numbers can be skewed because of the difference in the number of tests done. Sweden is testing around 20,000 people a week, according to the state's officials. So far, the country has not done antibody tests.
However, even when looked with the lens of herd immunity, the requirement of at least half of the population getting exposed to the virus is not yet met.
Authorities in Sweden, though, maintain that the country's capital Stockholm is approaching herd immunity in the coming weeks.
“In a few weeks’ time we might reach herd immunity and we believe that is why we’re seeing a slow decline in cases, in spite of sampling more and more”, Anders Tegnell, the architect of Sweden's policy told the CNBC.
He further added, “Unfortunately the mortality rate is high due to the introduction in elderly care homes and we are investigating the cause of that.”
The state's authorities have also shown confidence that their healthcare system is not burdened and managing the situation well.
Anders Tegnell told Nature,
“We are going into a phase in the epidemic where we will see a lot more cases in the next few weeks - with more people in intensive-care units - but that is just like any other country. Nowhere in Europe has been able to slow down the spread considerably.”
He shows confidence in the country's strategy despite the high death rate and says all countries have to reach herd immunity in one way or another, "and we are going to reach it in a different way".
He agrees that there has been a few cases of reinfection globally "but there is definitely an immune response", he maintains.
In conclusion, it is too soon to say if Sweden's strategy is working or not. The idea of isolating elders and vulnerable people and letting young work, however, looks promising to many keeping in mind the world's crippling economy which understandably can't be compromised for too long.
Herd Immunity, Gamble or Hope? Indian Experts Weigh In
Sweden is not the first country to give the herd immunity a try. Earlier, the UK had shown confidence in the same, however, they moved swiftly to a stricter lockdown, taking into account the number of cases and deaths. The experts in the UK realized that in the absence of a vaccine letting more people get exposed to the coronavirus could put unimaginable pressure on the health care system.
With WHO saying, "People who assume that they are immune to a second infection because they have received a positive test result may ignore public health advice. The use of such certificates may, therefore, increase the risks of continued transmission", many epidemiologists and virologists seem divided on the whole issue.
Between Sweden's unique model and India's current concept of protecting the healthcare system from a heavy burden by imposing a lockdown, which one weighs better for India's future?
In conversation with FIT, Dr Jayaprakash Muliyil, India's leading epidemiologist says, "Prima facie, the approach taken by Sweden looks like the best one to take. I can't think of a better one."
He further tells us,
“A lockdown can reduce the transmission but it will not send the virus away. We can go on locking down - the transmission will remains low. The moment we release the lockdown, it will come up again. This disease is not too dangerous for young people. Sweden’s approach to letting the young go out and work seems like a commonsensical approach.”
On the question of WHO's new warning about reinfection and immunity build-up, Dr Muliyil told us, "Herd immunity is not a strategy, it's a phenomenon associated with the viral infection. WHO can indeed say that there is no proof for immunity but then what is plasma therapy for? Hope is here. We can't keep on saying it's not. We don't have data to say that coronavirus will not work like influenza or measles. This is likely to behave the same way, we can hope this."
Dr Shahid Jameel, Virologist & CEO of Wellcome Trust DBT India Alliance is of a different opinion. He tells FIT, "We don't know about antibodies and whether and not they will protect us from reinfection so to propagate this idea now is ridiculous."
He adds, "Herd immunity will protect us in the long run but how we do it is important. It's a crazy model. You can't get herd immunity as you do in chickenpox."
Dr Sumit Ray, Critical Care Expert tells us that a large number of antibody tests need to be done first to gauge the kind of infection spread and level of immunity then only it is possible to say if we are headed towards herd immunity or not.
He adds, "The fact that there is about 80 percent of asymptomatic or mildly symptomatic cases, indicate that herd immunity is a possibility."
Should India Take a Cue From Sweden?
For India, a country with over 1.35 billion population, the choice, unfortunately, is perhaps between the economy and healthcare system. At this time, with things, the way they are, herd immunity or the idea of letting large population get exposed to COVID-19, may be far fetched, experts believe. But, can the vulnerable alone be put under the lockdown with some young population allowed to work? Can some states take a cue from Sweden?
There are crucial factors to consider such as density population, lifestyle habits, people living in joint families and so on.
Let's remember that 40% of Sweden's households are single-person without children so culturally, it is very different from India where many households are joint and it's challenging to maintain distance even if people wanted it with all their might.
Dr Muliyil hints that it's a risk that needs to be chosen over a heavy impact on the economy and agriculture. He says, "We are deprived of health care facilities unlike Sweden so we have to slow down but it should come from people. The old-age population should also support and put themselves in quarantine. We would pull a miracle if this is done. We can't get a hundred percent compliance considering the nature of things such as density population etc in India but even 50% would reduce mortality."
“Indefinite lockdown is a very poor choice. It will cause more problems than the corona itself. We will run out of resources. We can’t afford our systems to die.”
Dr Shahid Jameel says, "India can't be compared to Sweden which has one of the best healthcare facilities. To achieve herd immunity, you need 55-60 percent of people to be exposed to the virus. With 0.5% population mortality rate, this can be disastrous for India. A huge number of people will die before herd immunity is achieved. Would you want this to be generated in a few months? Because then hospitals would be overloaded. Far more people will die due to that further."
"Such viruses are contained after building up herd immunity which will protect us in the long run but how we do it is important. The other option is to delay this until a vaccine is available. This vaccine can help develop herd immunity.", he adds.
Dr Shahid says no government will allow so many deaths. To put it simply, he cites two key reasons why it can't work for India, healthcare and huge number of deaths.
Some experts also believe that before taking a cue from Sweden, it is important to do more antibody tests and estimate what the spread has been like.
Dr Sumit Ray says, "The conversation about protecting the elderly and developing herd immunity needs to build up. But before that, we need information about how much the spread has been. This is when antibody tests become very important."
He further says,
“At a certain point, the government will have to explain to people that this infection is going to spread but we have to protect the vulnerable. How do we do is, is a difficult question in such a large country with high population density.”
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