COVID-19—a very visible pandemic
Authors: David N Durrheim, Michael G Baker
Journal: The Lancet (2020)

The COVID-19 pandemic is exacting a confronting and extraordinarily visible toll in lives and livelihoods globally. The last occasion where humanity fought a similar calamitous infectious disease threat was the 1918–19 influenza pandemic. There are many lessons from that pandemic that are still relevant. The first pandemic wave did not grant adequate herd immunity and was followed by one or more subsequent waves, with those waves being more deadly than the initial wave.1Hatchett RJ Mecher CE Lipsitch M Public health interventions and epidemic intensity during the 1918 influenza pandemic.Proc Natl Acad Sci USA. 2007; 104: 7582-7587Crossref PubMed Scopus (491) Google Scholar Additionally, stringent public health measures flattened the epidemic curve, preserving hospital capacity and saving many lives.1Hatchett RJ Mecher CE Lipsitch M Public health interventions and epidemic intensity during the 1918 influenza pandemic.Proc Natl Acad Sci USA. 2007; 104: 7582-7587Crossref PubMed Scopus (491) Google Scholar Sweden has adopted a mitigation approach to this pandemic, which involves fewer public health measures to slow transmission than are being implemented by other European states and accepting much higher infection rates in the population. According to the Johns Hopkins University Centre for Systems Science and Engineering (CSSE) COVID-19 Dashboard, as of May 24, 2020, Sweden had one of the highest recorded population mortality rates in the world (343 deaths per million people), far higher than in its Scandinavian neighbours (Denmark, 92 deaths per million people, and Norway, 42 deaths per million people), and most other European nations that have implemented more rigorous pandemic containment measures. Thus, Johan Giesecke's provocative defense of the relaxed Swedish experiment as a model pandemic strategy2Giesecke J The invisible pandemic.Lancet. 2020; 395: e98Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar deserves careful scrutiny. CSSE data show that any countries have contained the COVID-19 pandemic and reduced their daily count of cases to zero or near zero, including Australia, Hong Kong, Taiwan, North Korea, and a few small island states. Some countries, such as New Zealand, are successfully pursuing an explicit elimination strategy.3Baker M Kvalsvig A Verrall A Telfar-Barnard L Wilson N New Zealand's elimination strategy for the COVID-19 pandemic and what is required to make it work.N Z Med J. 2020; 133: 10-14PubMed Google Scholar Some low-income and middle-income countries also appear to be successfully applying these approaches, including Vietnam and Mongolia. These countries are epidemiologically benefiting from rigorously implemented border controls, the strict quarantine of all returning international travellers, the mandatory self-isolation of people with COVID-19 and their close contacts, stringently limited gathering sizes, the active promotion of physical distancing during the first COVID-19 pandemic wave and, in many cases, the widespread use of face masks. The experience of these countries discredits Giesecke's claim that "COVID-19 is spreading like wildfire in all countries"2Giesecke J The invisible pandemic.Lancet. 2020; 395: e98Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar and throws doubt on his contention that "when we count the number of deaths from COVID-19 in each country in 1 year from now, the figures will be similar, regardless of measures taken".2Giesecke J The invisible pandemic.Lancet. 2020; 395: e98Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar Furthermore, it is probable that despite the burden of COVID-19 disease that has already occurred, Sweden and other heavily affected countries do not enjoy sufficient robust immunity (50–70%) to reduce the COVID-19 effective reproduction number below 1, as required to avoid a second pandemic wave. Seroprevalence survey estimates in multiple countries fall well below this mark, and empirical data quantifying the degree or duration of immunological protection conferred by infection and appropriate correlates of protection are elusive.4Altmann DM Douek DC Boyton RJ What policy makers need to know about COVID-19 protective immunity.Lancet. 2020; 395: 1527-1529Summary Full Text Full Text PDF PubMed Scopus (155) Google Scholar Indeed, reports from Sweden itself suggest that the rate of immunity in the population is low. Many developed countries made a serious error in not adequately assessing and responding to the COVID-19 pandemic threat at the point when it was containable. This containment approach offers many advantages, including minimising deaths while awaiting the availability of effective vaccines or antivirals, or both, and the potential for a return to near-normal functioning in many parts of their economies, including carefully managed travel between countries that are enacting a similar approach. Unfortunately, for many low-income countries, containment is now impossible. For them, it will be better to concentrate on protecting susceptible populations, while ensuring other vital health and basic human services continue to operate. We declare no competing interests. COVID-19—a very visible pandemicJohan Giesecke's1 many claims lead to two concepts. First, that lockdowns were bad, with the Swedish way being the best approach to the pandemic; and second, that everyone in the world would get COVID-19 in a thinly veiled argument that herd immunity was the only way that the virus would be controlled. Full-Text PDF COVID-19—a very visible pandemicWe read the Correspondence by Johan Giesecke,1 a senior consultant to the Swedish Public Health Agency, with considerable concern. Full-Text PDF COVID-19—a very visible pandemic – Author's replyLet me express thanks to the many colleagues who have provided valuable feedback. I will not address each of these responses individually, but give a collective answer. Full-Text PDF COVID-19—a very visible pandemicMany predictions have been made regarding the slowing spread of COVID-19; it is not my intention to refute the epidemiological position of Johan Giesecke in his Correspondence.1 However, I will respond as a student doctor concerned about the broader implications. Full-Text PDF The invisible pandemicMany countries (and members of their press media) have marvelled at Sweden's relaxed strategy in the face of the coronavirus disease 2019 (COVID-19) pandemic: schools and most workplaces have remained open, and police officers were not checking one's errands in the street. Severe critics have described it as Sweden sacrificing its (elderly) citizens to quickly reach herd immunity.1 The death toll has surpassed our three closest neighbours, Denmark, Norway, and Finland, but the mortality remains lower than in the UK, Spain, and Belgium. Full-Text PDF COVID-19—a very visible pandemicJohan Giesecke1 referred to the COVID-19 pandemic as an invisible pandemic, estimating that 25% of the Stockholm population was infected by the end of April, 2020, of which 98–99% are unaware of being infected. On April 1, 2020, the media reported that half of the Swedish population might be infected by the end of April, 2020.2 More conservative estimates suggested that at least one-third of the Stockholm population may be seropositive by mid-May, and later that Stockholm might reach herd immunity by mid-June. Full-Text PDF COVID-19—a very visible pandemicI read with interest the Correspondence by Johan Giesecke.1 Applauding the Swedish model, Giesecke1 posits a "relaxed strategy" or the development of a herd immunity as the way forward in dealing with the COVID-19 pandemic. He recommends that the crucial task is not to stop the spread, "which is all but futile, but to concentrate on giving the unfortunate victims optimal care". Given the drastic adverse economic consequences of the lockdown globally, the advocacy of herd immunity as a way out appears attractive. Full-Text PDF