Thread by @alvie_barr

THREAD

I believe that many sentiments, which have recently been put forth, regarding Sweden’s approach to #COVID19 overlook a critical metric. I would like to discuss some of my thoughts.

#MedTwitter #IDTwitter

1/

Preface: this thread was not created to favour one country’s response over another’s; nor do I have evidence to substantiate a definitive conclusion

It is merely to suggest other factors which should be considered when evaluating a response's success

Please keep this in mind 2/

A pandemic’s ‘health footprint’ illustrates the summation of direct & indirect implications on a country’s overall health

This concept may be modelled by 4 distinct curves demonstrating each wave’s respective magnitude

Image for context; may not be accurate or to scale

3/

As seen in the figure, the 1st wave refers to direct & initial implications of #COVID19

Dissimilarly, the 2nd, 3rd, & 4th waves represent indirect or prospective implications.

(chart adapted from @VectorSting's figure)

4/

Sweden’s ‘health footprint’ associated with the 1st wave appears to bear a larger burden than, perhaps, many other countries’. This paper attempts to quantify Sweden’s ‘excess mortality’

Link: medrxiv.org/content/10.110…

5/

However, there is a caveat—there are 3 other waves. What can be said about these?

While it is not possible to evaluate future implications, we can use data we currently have to approximate the burden of these 3 waves & compare. 6/

Under lockdown, many countries curtailed elective procedures.

For instance, the U.S. experienced plummeting rates of cancer screening:

Breast & cervical cancer screenings ⬇️ by 94%

Colon cancer screenings ⬇️ by 86%

Link: ehrn.org/wp-content/upl…

7/

Other procedures which have been implicated and/or curtailed in countries under lockdown during the past 2 months:

Cancer care, transplants, mental health services, well-child checkups + immunizations etc.

What impact will this have?

8/

We must also consider the economic burden of lockdown. A shut down disproportionately implicates persons of lower socioeconomic status and further exacerbates health inequalities.

Figures: fightcancer.org/sites/default/… (source for previous tweet’s & this tweet's figures)

9/

So, while I agree that Sweden’s initial health footprint may have been larger than many countries’, it remains to be seen whether these countries’ other 3 waves will summate to a larger overall burden.

10/

I am certainly not against lockdowns nor am I against Sweden’s response.

Ultimately, this discordancy stands as an opportunity for us to learn & appropriately prepare evidence-based plans in the case of a future pandemic

11/

In summary, I ask that, when reporting on the success of a countries’ #COVID19 response, other factors are considered.

The success of a countries’ response should not be solely predicated upon the 1st wave (initial mortality), but rather a summation of all 4 waves.

12/

cc: @InfectiousDz @ABsteward @thehowie @TimLaheyMD @AndreaAdlerPhD @nathanpsmad @drchethansathya @chngin_the_wrld @bethlinas @V2019N