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CONFRONTING CORONAVIRUS

Some Swedish care homes have had no cases of Covid-19 – what did they do right?

At least 234 of Sweden's 290 municipalities have elderly care homes with confirmed or suspected coronavirus cases. But a handful seem to have been able to protect residents from Covid-19, in some cases despite staff being infected. So what did they do differently, and could their strategies be applies elsewhere?

Published: 30 June 2020 14:49 CEST
Updated: 10 July 2020 08:41 CEST

Some Swedish care homes have had no cases of Covid-19 – what did they do right?

An elderly care home in Nödinge allows distanced family visits. Photo: Thomas Johansson/TT

“I think the debate on the flaws in elderly care has been lacking nuance. I don't think there have been sufficient efforts to try to describe the underlying reasons for why the spread of infection has been great in different regions. There are almost 60 municipalities which have had better success,” Ebba Gierow, head of social affairs in the Ale municipality, told the TT newswire.

This is one of the municipalities which by late June had not recorded any cases of coronavirus in its five municipal care homes.

Ale is located in Västra Götaland, a region where the spread arrived later and more slowly than for example Stockholm – partly due to the timing of spring school holidays in both regions.

Gierow said that this meant care homes in Västra Götaland had the chance to improve their hygiene routines and make sure that all employees who showed symptoms stayed at home, two of the factors that have long been identified by authorities as decisive in limiting the spread.

Equipment

Beyond this proactive attitude, another tangible factor which has helped certain care homes in preventing or slowing down the spread of the coronavirus in their facilities has been the access to protective clothing.

Gierow explained that Ale decided that “they couldn't sit around and wait for national channels to provide us with equipment”.

Instead, they immediately drove to construction warehouses and other stores to stock up on equipment, and continually kept stock to ensure their supplies would not run out and source more protective clothing.

Photo: Fredrik Sandberg/TT

Accessing protective equipment when it was in such high demand not only in Sweden but internationally was one of the major challenges for the care sector.

Greger Bengtsson, head of elderly care at the umbrella association for Sweden's municipalities and regions (SKR), told The Local that “we knew we should protect staff and residents, but we didn't have the necessary materials”, which instead went to Sweden's hospitals in the first instance.

“Not until about a month ago did care homes start to receive adequate supplies,” Bengtsson said.

And in Ale, the investment in protective equipment was not only a way to keep staff and residents safe, but also to boost perceived safety.

“It was a challenge, but protective equipment gives a feeling of security. You can't expect staff to go out and do their job well if they're scared. We put a lot of money into this in Ale. We did an evaluation and decided that was the right thing to do,” she said.

A recent report published by SKR on the situation in care facilities stated that more equipment is not always the best option. For example, certain high grade face masks have valves which mean that, while the wearer is protected, their exhaled air is released unfiltered into their surroundings. Infected but asymptomatic staff wearing this kind of mask could therefore put elderly residents at increased risk.

Another problem was that funds varied between municipalities, so in early April SKR began acting as a purchaser on behalf of all Sweden's municipalities, as a way to ensure it could act on the world market and ensure equipment was distributed where needed.

Photo: Fredrik Sandberg / TT

Early visitor bans

According to Bengtsson, another major obstacle in protecting care home residents was legislation.

It was only on April 1st that the government declared a visitors' ban for all municipal care homes. Some municipalities had prohibited visits days or even weeks earlier. This meant they may have broken the law on accessibility of these facilities, which are intended to be an open part of society, but in doing so they may have saved lives.

One of the quickest to act, Luleå, which banned visits on March 20th, has cited this as a factor behind the municipality reporting only one care home death from Covid-19. And the Skåne region, where 85 percent of homes reported no infection at all, introduced a visitor ban 10-12 days before the national one.

However, this was only one of several measures in Skåne which may have had an effect, with others including more widespread testing of staff and residents in care homes than other regions, multilingual information campaigns about the coronavirus from an early stage, and a deal which means specialised hygiene nurses hired by the region work in care homes.

Signs on a care home entrance warning of a visitor ban. Photo: Anders Wiklund / TT

Fewer hourly staff

Another factor which has repeatedly surfaced in the debate on how the virus spread in Sweden's care homes so quickly is the high proportion of temporary staff, who often work in multiple facilities. On hourly contracts, these workers were not protected by extended sick pay legislation, which may have given them less incentive to follow national guidelines in staying home if showing the slightest cold or flu symptoms.

A relatively low proportion of hourly workers is a factor common to Ale and other municipalities which have not reported any cases of coronavirus, including Stenungssund and Alingsås. However, it's hard to assess the direct impact of this, partly because in the hard hit care homes, it's almost impossible to know how the infection entered the facility and spread.

Speaking to reporters in early May, the Public Health Agency's Head of the Department for Antibiotics and Infection Control Malin Grape said there was no clear common factor that pointed to how the infection got into affected care homes in Stockholm and Sörmland.

Some of the possibilities the Public Health Agency has pointed to after speaking with care homes include new arrivals to the homes or residents returning from hospital stays, family visits, or asymptomatic staff, as well as a high proportion of hourly workers.

It is not possible to pinpoint the exact actions that determined why some municipalities avoided outbreaks in their care homes – and luck will have played some part.

But in order to give staff the necessary support and training, provide the right equipment in sufficient quantities, and take further measures as needed to protect staff and residents, quick reaction and adaptation to a fast-moving and unprecedented situation was essential. That can only come from an engaged leadership.

In Ale, Gierow says the strategy was hands-on from the start.

“Managers have worked with a close leadership. They've spent a lot of time on the ground, answering questions, supporting staff and simply being around,” she said. “This provides support and security, which means a lot for staff being able to manage” with the pressure of protecting the most vulnerable group in society from the virus.

With reporting by Anne Grietje Franssen and TT's Petronella Uebel

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FACT CHECK: Did Sweden have lower pandemic mortality than Denmark and Norway?

At one point in May 2020, Sweden had the highest Covid-19 death rate in the world, spurring newspapers like the New York Times and Time Magazine to present the country as a cautionary tale, a warning of how much more Covid-19 could ravage populations if strict enough measures were not applied.

“Per million people, Sweden has suffered 40 percent more deaths than the United States, 12 times more than Norway, seven times more than Finland and six times more than Denmark,” the New York Times reported in July 2020.

An article in Time in October 2020 declared Sweden’s Covid response “a disaster”, citing figures from Johns Hopkins University ranking Sweden’s per capita death rate as the 12th highest in the world.

So there was undisguised glee among lockdown sceptics when Svenska Dagbladet published data last week showing that in the pandemic years 2020, 2021 and 2022 Sweden’s excess mortality was the lowest, not only in the European Union, but also of all the Nordic countries, beating even global Covid-19 success stories, such as Norway, Denmark and Finland.

Versions of the graph or links to the story were tweeted out by international anti-lockdown figures such as Bjørn Lomborg, a Danish sceptic of climate action, and Fraser Nelson, editor of Britain’s Spectator Magazine, while in Sweden columnists like Dagens Nyheter’s Alex Schulman and Svenska Dagbladet’s opinion editor Peter Wennblad showed that Anders Tegnell, the state epidemiologist who led Sweden’s strategy, had been “right all along”.

Excess mortality — the number of people who die in a year compared to the number expected to die based on previous years — is seen by some statisticians as a better measure for comparing countries’ Covid-19 responses, as it is less vulnerable to differences in how Covid-19 deaths are reported.

But are these figures legitimate, where do they come from, and do they show what they purport to show?

Here are the numbers used by SvD in its chart:

Where do the numbers come from?

Örjan Hemström, a statistician specialising in births and deaths at Sweden’s state statistics agency Statistics Sweden (SCB), put together the figures at the request of Svenska Dagbladet.

He told The Local that the numbers published in the newspaper came from him and had not been doctored in any way by the journalists.

He did, however, point out that he had produced an alternative set of figures for the Nordic countries, which the newspaper chose not to use, in which Sweden had exactly the same excess mortality as Denmark and Norway.

“I think they also could have published the computation I did for the Nordic countries of what was expected from the population predictions,” he said of the way SvD had used his numbers. “It takes into consideration trends in mortality by age and sex. The excess deaths were more similar for Denmark, Sweden, and Norway. Almost the same.”

Here are Hemström’s alternative numbers:

There are two basic ways of measuring excess mortality. The simplest, and the one used by SvD/SCB, is to simply compare the death rates in the relevant period with the mean of previous years, normally five years.

More sophisticated measures attempt to estimate the expected number of deaths by extending mortality trends seen in a certain country, adjusting for the age of the population and other factors. But this can lead to results to vary significantly depending on how mortality trends and expected mortality are calculated.

The issue with the analysis in the SvD graph is that compares deaths in the pandemic years to deaths over just three years, a mean of 2017-2019, and does not properly take into account Sweden’s longstanding declining mortality trend, or the gently rising mortality trend in some other countries where mortality is creeping upwards due to an ageing population, such as Finland.

“It’s very difficult to compare countries and the longer the pandemic goes on for the harder it is, because you need a proper baseline, and that baseline depends on what happened before,” Karin Modig, an epidemiologist at Sweden’s Karolinska Institute whose research focuses on ageing populations, told The Local.

“As soon as you compare between countries, it’s more difficult because countries have different trends of mortality, they have different age structures, and in the pandemic they might have had different seasonal variations.”

She described analyses such as Hemström’s as “quite crude”.

In an interview with SvD to accompany the graph, Tegnell also pushed back against giving the numbers too much weight.

“Mortality doesn’t tell the whole story about what effect a pandemic has had on different countries,” he said. “The excess mortality measure has its weaknesses and depends a lot on the demographic structures of countries, but anyway, when it comes to that measure, it looks like Sweden managed to do quite well.”

Do the numbers match those provided by other international experts and media?

Sweden’s excess mortality over the three years of the pandemic is certainly below average worldwide, but in most other analyses it remains higher than those of Norway and Denmark.

A ranking of excess mortality put together by Our World in Data for the same period as the SvD/SCB table estimates Sweden’s excess mortality between the start of 2020 and the end of 2022 at 5.62 percent, considerably more than the 4.4 percent SvD claims, and above that of Norway on 5.08 percent and Denmark on 2.52 percent.

The Economist newspaper also put together an estimate, using their own method based on projected deaths. In this estimate, Sweden also has a higher rate of excess deaths than Denmark and Norway (but not than Finland).

Our World in Data uses the estimate produced by Ariel Karlinsky and Dmitry Kobak, who manage the World Mortality Dataset (WMD). To produce the estimate, they fit a regression model for each region using historical deaths data from 2015–2019, so a time period of five years rather than the three used by SCB.

What’s clear, is that, whatever method you use, Sweden and the other Nordic countries are among the countries with the lowest excess mortality over the pandemic.

“Most methods seem to put Sweden and the other Nordic countries among the countries in Europe with the lowest cumulative excess deaths for 2020-2022,” Preben Aavitsland, the Director for Surveillance and the Norwegian Institute of Public Health, told The Local.

So if Sweden had similar excess mortality to those of the other Nordics over the period, does that mean it had a similar Covid-19 death rate?

No. Sweden’s per capita death rate from Covid-19 over the period covered by the SvD/SCB figures, at 2,249 per million people, is still more than double Norway’s 959 per million, 60 percent more than the 1,409 per million who died in Denmark, and more than 50 percent more than the 1,612 per million who died in Finland.

Sweden’s death rate is now much closer to those of the other Nordic countries than it was at the end of 2020, however, something Aavitsland put down to the higher number of Covid-19 deaths seen in his country in the later years of the pandemic.

“The most striking difference between Sweden and the other Nordic countries is that only Sweden had large excess mortality in 2020 and the winter of 2020-21,” Aavitsland explained. “In 2022, the field levelled out as the other countries also had excess mortality when most of the population was infected by the omicron variant after all measures had been lifted.”

So why, if the Covid-19 death rates are still so different, are the excess mortality rates so similar?

This largely reflects the fact that many of those who died in Sweden in the first year of the pandemic were elderly people in care homes who would have died anyway by the end of 2022.

About 90 percent of Covid-19 deaths were in people above 70, Aavitsland pointed out, adding that this is the same age group where you find around 80 percent of all deaths, regardless of cause, in a Scandinavian country.

“My interpretation is that in the first year of the pandemic, say March 2020 – February 2021, Sweden had several thousand excess deaths among the elderly, including nursing home residents,” he said. “Most of this was caused by Covid-19. In the other [Nordic] countries, more people like these survived, but they died in 2022. The other countries managed to delay some deaths, but now, three years after, we end up at around the same place.”

So does that mean Sweden’s state epidemiologist Anders Tegnell was right all along?

It depends on how you view the years lost by the several thousand elderly people who caught Covid-19 and died in Sweden in the first wave because Sweden did not follow the example of Denmark, Norway, and Finland and bring in a short three-week lockdown in March and April 2020. Were those two years worth the greater restrictions imposed in Sweden’s neighbours?

Tegnell himself probably said it best in the SvD interview.

“You’ve got to remember that a lot of people died in the pandemic, which is of course terrible in many ways, not least for their many loved ones who were affected, so you need to be a bit humble when presented with these kinds of figures.”

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