The COVID-19 pandemic in Sweden is a part of the pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of 22 March 2023, there have been 2,701,192 confirmed cumulative cases and 23,851 deaths with confirmed COVID-19 in Sweden. Sweden ranks 57th in per capita deaths worldwide, and out of 47 European countries, Sweden places 30th. A 2022 estimate of excess mortality during the pandemic using IHME COVID model estimated 18,300 excess deaths during 2020–2021 The Economist model value estimated 13,670 excess deaths between 16th 2020-Mar 6th 2022.
The virus was confirmed to have reached Sweden on 31 January 2020, although some evidence suggests that the virus could have arrived as early as December 2019. Community transmission was confirmed on 9 March in the Stockholm Metropolitan Area, and the first death was reported two days later. It had spread to all regions of Sweden by 13 March 2020. The authorities declared a "late pandemic phase" was beginning in June, but a surge in cases occurred in the winter of 2020. The Alpha variant, Delta variant and Omicron variant spread to Sweden in 2021.
As the outbreak reached Sweden, authorities responded with limited measures, in contrast with lockdowns and legal restrictions introduced in other countries. The Swedish public were expected to follow a series of non-voluntary recommendations from the Public Health Agency of Sweden (Folkhälsomyndigheten). These included working from home where possible, limiting travel within the country, social distancing, and for people above 70 and those with potential COVID-19 symptoms to self-isolate. Changes were also made to sick leave.
Businesses and organizations were subject to distancing recommendations, regulations (mainly restaurants) and laws (banning public gatherings and events with more than 50 participants, as well as visits to nursing homes). Upper secondary schools and universities were closed until the end of the summer holidays.
From late 2020 amidst a surge in cases, new legislation was passed enacting international travel restrictions and again limiting participation in public events, banning nursing home visits and closing upper secondary schools. Primary schools remained open throughout the pandemic, and face masks were not generally recommended for the public or in healthcare settings. Vaccinations in Sweden began in December 2020. Spring 2021 saw a surge of the Alpha variant of the virus, and further tightening of restrictions and recommendations. In late 2021, vaccine passports and other measures were introduced. On 9 February 2022 almost all regulations and restrictions were abolished, and from 1 April 2022 COVID-19 was no longer classified as dangerous to the general public or society at large (although reporting requirements stayed in place).
The Swedish government's approach has attracted controversy. The impact on the country's healthcare system and its reported death toll have been greater than in other Nordic countries, in part due to its unique strategy. An independent commission that evaluated the response found that Sweden managed to keep excess mortality lower than 31 other European countries, but also said that it failed to protect care home residents due to the overall spread of the virus in society and that the response overall was "slow" and "insufficient". A self-organized group of 40 Swedish scientists and medical professionals had also called for stricter preventative measures throughout the pandemic.
The pandemic put the Swedish healthcare system under severe strain, with tens of thousands of operations being postponed, and only emergency and COVID-related care being available during a surge in the winter of 2020. Initially, Swedish hospitals and other facilities reported a shortage of personal protective equipment. Swedish hospitals were able to increase their intensive care capacity during the earlier stages of the pandemic, but Stockholm's health system still became seriously overwhelmed during the winter surge, with intensive care bed occupancy reaching 99% by 18 December 2020 and the city experiencing healthcare staff shortages. The pandemic and associated restrictions also impacted Sweden's economy, transportation sector, education and arts and entertainment.
The COVID-19 pandemic in Sweden is a part of the pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of 22 March 2023, there have been 2,701,192 confirmed cumulative cases and 23,851 deaths with confirmed COVID-19 in Sweden. Sweden ranks 57th in per capita deaths worldwide, and out of 47 European countries, Sweden places 30th. A 2022 estimate of excess mortality during the pandemic using IHME COVID model estimated 18,300 excess deaths during 2020–2021 The Economist model value estimated 13,670 excess deaths between 16th 2020-Mar 6th 2022.
The virus was confirmed to have reached Sweden on 31 January 2020, although some evidence suggests that the virus could have arrived as early as December 2019. Community transmission was confirmed on 9 March in the Stockholm Metropolitan Area, and the first death was reported two days later. It had spread to all regions of Sweden by 13 March 2020. The authorities declared a "late pandemic phase" was beginning in June, but a surge in cases occurred in the winter of 2020. The Alpha variant, Delta variant and Omicron variant spread to Sweden in 2021.
As the outbreak reached Sweden, authorities responded with limited measures, in contrast with lockdowns and legal restrictions introduced in other countries. The Swedish public were expected to follow a series of non-voluntary recommendations from the Public Health Agency of Sweden (Folkhälsomyndigheten). These included working from home where possible, limiting travel within the country, social distancing, and for people above 70 and those with potential COVID-19 symptoms to self-isolate. Changes were also made to sick leave. Businesses and organizations were subject to distancing recommendations, regulations (mainly restaurants) and laws (banning public gatherings and events with more than 50 participants, as well as visits to nursing homes). Upper secondary schools and universities were closed until the end of the summer holidays.
From late 2020 amidst a surge in cases, new legislation was passed enacting international travel restrictions and again limiting participation in public events, banning nursing home visits and closing upper secondary schools. Primary schools remained open throughout the pandemic, and face masks were not generally recommended for the public or in healthcare settings. Vaccinations in Sweden began in December 2020. Spring 2021 saw a surge of the Alpha variant of the virus, and further tightening of restrictions and recommendations. In late 2021, vaccine passports and other measures were introduced. On 9 February 2022 almost all regulations and restrictions were abolished, and from 1 April 2022 COVID-19 was no longer classified as dangerous to the general public or society at large (although reporting requirements stayed in place).
The Swedish government's approach has attracted controversy. The impact on the country's healthcare system and its reported death toll have been greater than in other Nordic countries, in part due to its unique strategy. An independent commission that evaluated the response found that Sweden managed to keep excess mortality lower than 31 other European countries, but also said that it failed to protect care home residents due to the overall spread of the virus in society and that the response overall was "slow" and "insufficient". A self-organized group of 40 Swedish scientists and medical professionals had also called for stricter preventative measures throughout the pandemic.
The pandemic put the Swedish healthcare system under severe strain, with tens of thousands of operations being postponed, and only emergency and COVID-related care being available during a surge in the winter of 2020. Initially, Swedish hospitals and other facilities reported a shortage of personal protective equipment. Swedish hospitals were able to increase their intensive care capacity during the earlier stages of the pandemic, but Stockholm's health system still became seriously overwhelmed during the winter surge, with intensive care bed occupancy reaching 99% by 18 December 2020 and the city experiencing healthcare staff shortages. The pandemic and associated restrictions also impacted Sweden's economy, transportation sector, education and arts and entertainment.
Background
Outbreak of a novel coronavirus disease
On 12 January, the World Health Organization (WHO) confirmed that a novel coronavirus (nCoV) was the cause of a respiratory illness in a cluster of people in Wuhan, 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 Public Health Agency of Sweden 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.
Following the 2005 outbreak of the H5N1 avian flu, Sweden drafted their first national pandemic plan which since then had undergone several revisions. Since a 2008 revision to prepare for the 2009 swine flu pandemic, the plan includes the formation of a National Pandemic Group (NPG) in the event of a possible pandemic. The group 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, headed by director general Johan Carlson, 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. The Public Health Agency also tasked with having a coordinating role for the national response to a pandemic according to the National Pandemic Plan, together with the Swedish Civil Contingencies Agency headed by Dan Eliasson and the Swedish National Board of Health and Welfare headed by Olivia Wigzell.
Preparedness
In risk and impact assessments by the Swedish Civil Contingencies Agency, the Swedish expert agency on crisis management, 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. They believed that a future pandemic would be inevitable within 5–50 years.
In the 2019 Global Health Security Index of the 'most prepared' countries in the world for an epidemic or a pandemic published by the Johns Hopkins Center for Health Security, Sweden was ranked 7th overall. Sweden received high rankings regarding prevention of the emergence of a new pathogen, early detection and reporting of an epidemic of international concern and having a low risk environment. 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 health-care system would be the weak link. They noted that Swedish hospitals were already under heavy burden, and would not have the capacity to treat everyone who become sick, even when alternative facilities (like schools and sports centres) were used as hospitals. They also pointed out that issues concerning prioritising, including triage, would become central during the crisis, and that they believed this subject needed to be addressed. 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 (2017), and intensive care unit (ICU) beds per capita of 5.8 per 100.000 people (2012). Both numbers were lower than most countries' in the EU. The total number of ICU beds in Swedish hospitals was 526.
By the time of the Fall of the Berlin Wall, the Swedish Defence Forces was equipped with a total of 35 field hospitals, with what some considered to be the most modern battlefield medicine in the world, with the Swedish Navy having an additional 15 hospitals. The field hospitals had a combined capacity of treating 10.000 patients and performing 1000 surgeries every 24 hours, as well as stockpiles with drugs, medical supplies and personal protective equipment to treat 150.000 war casualties. Additionally, the Swedish state had several preparedness hospitals and Swedish schools were constructed to be converted into hospital units in case of a military conflict and with a total capacity of treating 125.000 patients, supported by a network of preparedness storages containing medicine and medical equipment. From 1990 and onwards, the system was gradually dismantled to eventually disappear altogether, with the equipment, including more than 600 new ventilators, being either given away or disposed of. At the start of the 2020 COVID-19 pandemic, the Swedish Defence Forces owned 2 medical units with a total of 96 beds, out of which 16 were ICU beds, and there were no civil preparedness storages for medical equipment left in Sweden.
Until 2009, the Swedish state-run pharmacy chain Apoteket had the responsibility to ensure drug supply in case of emergency. Following a very controversial privatisation, the responsibility was handed over to the private sector, with the intent that these chains would have a profit-based incentive to aid in medicine preparedness. However, a lack of regulations and lack of government action meant that the private companies had no incentive or responsibility to maintain stocks of medication in the event of a crisis, effectively leaving Sweden without an entity responsible for medicine preparedness. At the start of the pandemic, the Swedish healthcare system were instead relying on a "just-in-time" deliveries of medication and medical equipment, and Sweden had no medicine manufacturing of its own, which was considered to make the country's drug supply vulnerable as it relied on global trade and long supply lines. The Swedish healthcare system was already experiencing a growing number of backordered drugs in the years leading up to the pandemic. The lack of medicine preparedness had been strongly criticised in several inquiries and reports since 2013 by a number of Swedish governmental agencies, including the Swedish National Audit Office, the Swedish Defence Research Agency and the Swedish Civil Contingencies Agency. The latter had regarded disturbances in the drug supply as one of their biggest concerns in their annual risk assessments.
Timeline
Early cases (December 2019 – February 2020)
On 31 January 2020, the first Swedish case was confirmed in a woman in Jönköping who had travelled to Sweden directly from Wuhan, China, on 24 January 2020. The case was fully isolated and there are no reports of further spread. It is 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 Municipality, 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 2020, after a man who had recently returned from northern Italy following the outbreak in the country 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 (about one tenth of the total population) had travelled abroad. Testing was 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 were 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.
Analysis of early Swedish cases suggested that several early cases had carried the virus from the United Kingdom and the United States, as well as 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 Metropolitan Area compared to other counties of Sweden, including the densely populated regions Scania 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 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.