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Why did Sweden have more covid deaths than its neighbors?

By Sebastian Rushworth, M.D. | December 6, 2020

One of the arguments that has been used in support of strict lockdown is that Sweden has had significantly more covid deaths than its nordic neighbours. On the 19th of November, Sweden had registered 637 covid deaths per million people. For comparison, Denmark had registered 140, Norway had registered 57, and Finland had registered 69.

But, as I wrote about recently, the studies that have been done have not been able to find any correlation between severity of lockdown and the number of covid deaths. Which must logically mean that Sweden’s higher death rate was not due to the fact that it didn’t institute a severe lockdown. So, if that is the case, why did Sweden have more covid deaths than its closest neighbors?

A paper written by three economists at the end of August sought to answer that question. The research didn’t receive any specific funding, and the authors reported no conflicts of interest. The authors provided 15 different factors that could potentially explain the difference. I’m going to focus on the few that I think are likely the most important.

The first hypothesis is that Sweden, and in particular Stockholm, imported many more cases of covid-19 from abroad before measures were put in place to stop the spread between countries. The main reason for this is that Stockholm has a half-term holiday (“sportlovet”) in late February, when many people go skiing in the alps. The other nordic countries have similar holidays, but they have them earlier. So any Norwegians, Danes, or Finns who went skiing in the alps, would have gone there before the pandemic exploded in that region, while the people from Stockholm were there when infections were spreading at their worst.

The two other large-ish cities in Sweden, Malmö and Gothenburg, provide a useful control for this hypothesis. Both cities have their half-term holiday a week or two before Stockholm, and both were hit far less severely than Stockholm in the first wave. Stockholm experienced 40% of Swedish covid deaths, despite having only 24% of Sweden’s population.

Apart from this, Swedes travel internationally far more than their nordic neighbors (80% more per million people), which would have resulted in significantly more cases of covid being brought in to the country at the beginning of the pandemic.

The second hypothesis concerns the fact that Sweden has a much bigger population of immigrants than its nordic neighbors. 19% of Sweden’s population is foreign born, as opposed to 14% for Denmark and Norway, and only 8% for Finland. What this means in practice is that Sweden has a bigger population of people with darker skin, and it has been clear since early in the pandemic that darker skinned people in western countries are much more likely to develop severe covid than lighter skinned people.

As an aside, Much of the media debate around this phenomenon has centred around the idea that darker skinned people generally have lower status, higher rates of poverty, worse access to health care and so on – basically, that the difference is due to institutional racism.

But there is one big problem with that idea. It doesn’t fit all the facts. An article in the Washington Post on May 20th reported that 27 of 29 doctors who had died of covid in the UK up to that point belonged to ethnic minorities. In other words, 93% of doctors who had died at that point came from ethnic minorities, even though they only constitute 44% of all doctors in the country. Why is this important? Because doctors with darker skin are still doctors, which means that they are members of a high status, well paid, well-off segment of society.

Note, I’m not saying that institutional racism doesn’t exist. I’m just saying that it can’t explain why darker skinned people in western countries are hit much harder by covid than lighter skinned people.

Vitamin D deficiency could though. Darker skinned people in northern Europe are more likely to be vitamin D deficient for the simple reason that their skin isn’t as good at producing vitamin D from the feeble sunlight we get in this part of the world. A number of observational studies have shown that people with low vitamin D levels do worse when infected with covid, and there is even a randomized trial in which patients treated with high dose vitamin D did much better than the control group, which I’ve written about in a separate article (funnily enough, that study gained pretty much zero media attention, while remdesivir, a highly expensive drug that is almost completely useless against covid, has been talked about endlessly).

Anyway, what the authors are saying is that Sweden has a larger ethnic minority population than its nordic neighbours, and people from ethnic minorities do worse when they get covid.

The third hypothesis, and from my perspective the most important, concerns the fact that Sweden had a much larger vulnerable population at the beginning of 2020 than its nordic neighbours. This can be seen in multiple different ways in the statistics.

The first is that Sweden has a large nursing home population. Relative to population size, Sweden’s nursing home population is 50% larger than Denmark’s. And as I’ve mentioned previously, in Sweden, people don’t go to nursing homes until they are near the end of life.

The second way this can be seen in the statistics is by looking at overall mortality for the immediately preceding year, 2019. If unusually few people die in one year, then unusually many will die in the following year, since there is a carry forward effect (due to the fact that humans are not immortal). 2019 was an unusually un-deadly year in Sweden, and the early part of 2020 (pre-covid), was also unusually un-deadly, which means that there was an unusually large number of very frail old people in the country when covid struck. This same effect was not seen in Sweden’s nordic neighbours – for them 2019 was normal in terms of overall mortality.

To clarify exactly how big this difference is, let’s look at the numbers. In Sweden, overall mortality in 2019 was 2,5% lower than the average for the preceding five years. In Norway, mortality was exactly in line with the average. Denmark and Finland both had mortality rates that were 1% above the average. Denmark, Finland, and Norway were in a much better position in relation to covid from the start. Sweden was always going to have more deaths, regardless of the actions it took.

As I think this article shows, there were a number of big differences between Sweden and its nordic neighbors at the beginning of the pandemic, which are altogether certainly sufficient to explain the big difference in covid mortality.

Correlation is not causation. Many people have chosen to see a causative relationship between Sweden’s lack of severe lockdown and relatively high number of deaths, because it supports their prior beliefs about the effectiveness of lockdowns. Those beliefs are, however, not supported by the evidence.

You might also be interested in my article about how deadly covid really is, or my article about how effective lockdowns are.

December 6, 2020 - Posted by | Science and Pseudo-Science | ,

2 Comments »

  1. (1) The Covid 19 deaths are media deaths!
    (2) Hospitals were paid to put Covid on all death certificates!
    (3) Based on the Covid test, the victims of 911 would have had Covid put on their death certificates!

    Coronavirus Cases Plummet When PCR Tests Are Adjusted
    Published on September 30, 2020
    Written by Barbara Cáceres

    Health experts now say that PCR testing for SARS-CoV-2, the virus associated with the illness COVID-19, is too sensitive and needs to be adjusted to rule out people who have insignificant amounts of the virus in their system.1
    The test’s threshold is so high that it detects people with the live virus as well as those with a few genetic fragments left over from a past infection that no longer poses a risk. It’s like finding a hair in a room after a person left it, says Michael Mina, MD, an epidemiologist at the Harvard T.H. Chan School of Public Health.2
    1 Lenthang M. Experts: US CVOID-19 positivity rate high due to ‘too sensitive’ tests. Daily Mail Aug. 30, 2020.
    2 Ibid.

    In three sets of testing data that include cycle thresholds compiled by officials in Massachusetts, New York and Nevada, up to 90% of people testing positive carried barely any virus, a review by The New York Times found.3

    Manufacturers and Labs Set Criteria For Positive COVID-19 Test Results
    The reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) test used to identify those people infected with the SARS-CoV-2 virus uses a nasal swab to collect RNA from deep within the nasal cavity of the individual being tested. The RNA is reverse transcribed into DNA and amplified through 40 or more cycles, or until virus is detected.4 The result is reported as a simple “yes” or “no” answer to the question of whether someone is infected.

    The U.S. Food and Drug Administration (FDA) officials state they do not specify the cycle threshold ranges used to determine who is positive, and that commercial manufacturers and laboratories set their own threshold ranges.5

    PCR Test Threshold For COVID-19 Positivity Is Too Sensitive
    Any test with a cycle threshold (CT) above 35 is too sensitive, says Juliet Morrison, PhD, a virologist at the University of California, Riverside. “I’m shocked that people would think that 40 [cycles] could represent a positive.” A more reasonable cutoff would be 30 to 35, she added. Dr. Mina said he would set the figure at 30, or even less. Those changes would mean the amount of genetic material in a patient’s sample would have to be 100-fold to 1,000-fold that of the current standard for the test to return a positive result worth acting on.6

    The CDC’s own calculations suggest that it is extremely difficult to detect any live virus in a sample above a threshold of 33 cycles.7
    “We’ve been using one type of data for everything, and that is just plus or minus—that’s all,” Dr. Mina said. “We’re using that for clinical diagnostics, for public health, for policy decision-making.” But “yes” or “no” isn’t good enough, he added. It’s the amount of virus that should dictate the infected patient’s next steps. “It’s really irresponsible, I think, to forgo the recognition that this is a quantitative issue,” Dr. Mina said.8
    The number of people with positive results who aren’t infectious is particularly concerning, said Scott Becker, executive director of the Association of Public Health Laboratories. “That worries me a lot, just because it’s so high,” he said.9

    SARS-CoV-2 Positive Case Numbers Drop When Cycle Threshold Is Adjusted, Removing Need For Contact Tracing
    Officials at the Wadsworth Center, New York’s state lab, have access to CT values from tests they have processed, and analyzed their numbers at The Times’s request. In July, the lab identified 872 positive tests, based on a threshold of 40 cycles. With a cutoff of 35 cycles, about 43 percent of those tests would no longer qualify as positive. About 63 percent would no longer be judged positive if the cycles were limited to 30.
    In Massachusetts, from 85 to 90 percent of people who tested positive in July with a cycle threshold of 40 would have been deemed negative if the threshold were 30 cycles, Dr. Mina said. “I would say that none of those people should be contact-traced, not one,” he said.

    “I’m really shocked that it could be that high—the proportion of people with high CT value results,” said Ashish Jha, MD, director of the Harvard Global Health Institute. “Boy, does it really change the way we need to be thinking about testing.”10

    “Gold Standard” PCR Tests Leave Many Unanswered Questions Due To Knowledge Gaps
    A positive PCR test does not tell doctors whether the person is currently ill or will become ill in the future, whether they are infectious or will become infectious, whether they are recovered or recovering from COVID, or whether the PCR test identified a viral fragment from another coronavirus infection in the past. The CDC reports that a person who has recovered from COVID-19 may have low levels of virus in their bodies for up to three months after diagnosis and may test positive, even though they are not spreading COVID-19.11

    CT Value Adds Context To PCR Results, Personalizes Care
    Although the cycle threshold (CT) is not reported on PCR tests, new evidence suggests the CT value could help to better inform clinical decisions, particularly when testing in the absence of symptoms for COVID-19. When SARS-CoV-2 virus is detected after fewer amplification cycles, that indicates a higher viral load and a higher likelihood of being contagious, while virus detected after more amplifications indicates a lower viral load.

    “It’s just kind of mind-blowing to me that people are not recording the CT values from all these tests—that they’re just returning a positive or a negative,” said Angela Rasmussen, PhD, a virologist at Columbia University in New York. “It would be useful information to know if somebody’s positive, whether they have a high viral load or a low viral load,” she added.12

    In a study published in Clinical Infectious Diseases in May, 2020,13 the authors suggested that viral load based on CT cutoff could establish whether inpatients have transmissible disease or need to be retested. This would conserve valuable testing capacity, reagents, and personal protective equipment (PPE), and determine when a patient could discontinue isolation. Taking the CT value into account may also help justify symptom-based strategies recommended by the CDC. CT values may enable contact tracers to focus only on persons most likely to be infectious, which will become increasingly important as asymptomatic screening expands.

    Another study14 found that patients with positive PCR tests at a CT above 33-34 are not contagious and can be discharged from the hospital or strict confinement at home.
    Evidence from both viral isolation and contact tracing studies supports a short, early period of transmissibility. By accounting for the CT value in context, RT-qPCR results can be used in a way that is personalized, highly sensitive, and more specific.15

    FDA Approves Rapid, Less Sensitive Coronavirus Antigen Test
    Highly sensitive PCR tests seemed like the best option for tracking the coronavirus at the start of the pandemic. But for the outbreaks raging now, Dr. Mina said, what’s needed are coronavirus tests that are fast, cheap and abundant enough to frequently test everyone who needs it—even if the tests are less sensitive. “It might not catch every last one of the transmitting people, but it sure will catch the most transmissible people, including the super spreaders.”

    The FDA noted that people may have a low viral load when they are newly infected. A test with less sensitivity would miss these infections. That problem is easily solved, Dr. Mina said: “Test them again, six hours later or 15 hours later or whatever,” he said. A rapid test would find these patients quickly, even if it were less sensitive, because their viral loads would quickly rise. People infected with the virus are most infectious from a day or two before symptoms appear till about five days after. But at the current testing rates, “you’re not going to be doing it frequently enough to have any chance of really capturing somebody in that window,” Dr. Mina added.16

    When a patient is tested for the coronavirus, doctors typically tell them to stay home until the results come in. If a patient tests positive and faces a two-week quarantine, that means they could spend a total of three weeks in isolation. That’s a long time for anybody who has bills to pay or kids to care for, and it’s understandable that some people will continue working until the results come in. The problem is that anybody who does this with a serious infection is putting others at risk.17 Rapid tests can be helpful in these situations.

    In late August, the U.S. Food and Drug Administration (FDA) approved the first rapid coronavirus test that doesn’t need any special computer equipment. Made by Abbot Laboratories, the 15-minute test will sell for U.S. $5 but still requires a nasal swab to be taken by a health worker.18 The Abbot test is the fourth rapid point-of-care test that looks for the presence of antigens rather than the virus’s genetic code as the PCR molecular tests do. 19
    ________________________________________
    References:
    References:
    1 Lenthang M. Experts: US CVOID-19 positivity rate high due to ‘too sensitive’ tests. Daily Mail Aug. 30, 2020.
    2 Ibid.
    3 Mandavilli A. Your Coronavirus Test Is Positive. Maybe It Shouldn’t Be. The New York Times Aug. 29, 2020.
    4 SARS CoV2 Molecular Assay Evaluation: Results. FINDDX July 3, 2020.
    5 See Footnote 3.
    6 Ibid.
    7 Ibid.
    8 Ibid.
    9 Ibid.
    10 Ibid.
    11 U.S. Centers for Disease Control and Prevention. Duration of Isolation and Precautions for Adults with COVID-19. Sept 10, 2020.
    12 See Footnote 3.
    13 Tom MR, Mina MJ. To Interpret the SARS-CoV-2 Test, Consider the Cycle Threshold Value Clinical Infectious Diseases May 21, 2020.
    14 Scola BL, Bideau ML, et al. Viral RNA load as determined by cell culture as a management tool for discharge of SARS-CoV-2 patients from infectious disease wards. European Journal of Clinical Microbiology and Infectious Diseases Apr. 27, 2020; 39(6): 1059-1061.
    15 See Footnote 13.
    16 See Footnote 3.
    17 Editorial: Questionable Testing Thresholds. The Northside Sun Sept. 17, 2020.
    18 Foster R, Mundell EJ. FDA Approves New Rapid Coronavirus Test. WebMD Aug. 27, 2020.
    19 Brueck, H. Rapid coronavirus tests can give results in 15 minutes, but they aren’t a pass for partying or seeing your parents. Business Insider Sept. 21, 2020.

    Like

    Comment by goldfinger999666 | December 6, 2020 | Reply

  2. An excellent — to me, unusually so — read! (i.e., the basic; no time to read the preceding comment). And not so long as to make me lose interest at 50 percent.

    Like

    Comment by roberthstiver | December 6, 2020 | Reply


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