looking back, which countries reacted best during the pandemic?

A recent study compares the different strategies to combat the Covid-19 pandemic implemented in 13 Western European countries, and the results they have achieved. Its conclusions indicate in particular that states which restricted social contacts early on managed to save more lives than others, while better preserving their economies.

During the Covid-19 pandemic, the control strategies put in place to contain the spread of the SARS-CoV-2 coronavirus that causes the disease have varied from one state to another, including in countries with similarities in terms of populations, standards of living, healthcare systems, modes of government, seasonality of respiratory diseases, etc.

In September 2023, representatives of 13 Western European countries involved in the management of the Covid-19 pandemic (including the author of these lines) chose to compare the strategies used in each country to counter the pandemic. Five years after the start of the pandemic, here is what this work, published in the journal BMC Global and Public Health.

Choose a relevant indicator

As part of this work, it was decided that the main indicator for evaluating the strategies used would be the excess mortality from all causes during the period from January 27, 2020 to July 3, 2022.

Certainly, the impact of the pandemic on our societies extends far beyond just the mortality associated with the virus. We can for example cite the morbidity due to long forms of Covid-19, the deterioration of the mental health of the population caused by the pandemic, its effects on education, the economy, etc. Each of these aspects deserves an analysis in its own right.

However, this indicator has many advantages for assessing the relevance of the strategies implemented. It allows:

• to use data available in all countries by sex, age group and week (except for Ireland where they were available by month);

• to free ourselves from the discussion: death “from” Covid-19 or death “with” Covid-19;

• not having to worry about the completeness of Covid-19 screening among deceased subjects which could have been different depending on the country;

• to take into account the delayed mortality linked to the after-effects of Covid-19, such as that linked to cardiovascular damage;

• to include indirect mortality linked to the disorganization of the healthcare system during the pandemic;

• to take into account the drop in mortality linked to the absence of a flu epidemic for two years, and the reduction in some other causes of mortality (such as road accidents during confinement);

• to use methods already developed to calculate excess mortality during seasonal influenza epidemics, or influenza pandemics.

We limited our work to the period between January 2020 and July 2022, because the occurrence, during the summer of that same year, of a heatwave episode, then the return of the flu during the winter of 2022-2023, prevent then to attribute the excess mortality observed solely to the effects of Covid-19.

Finally, compared to most previously published articles, we made two methodological changes: we extended the reference period used to calculate the trend from which excess mortality would be estimated (2010-2019 instead of 2015-2019) and we have standardized the excess mortality by age and sex, in order to take into account differences in the age distribution of the populations of the chosen countries, which can be very significant. For example, Italy has the highest proportion of people aged over 80 in Europe (it was 7.5% in 2020), while in Ireland it was twice as low (3.5%). However, we know that the oldest categories of the population have been particularly vulnerable to the SARS-CoV-2 coronavirus.

Actions taken early are more effective

Over the entire study period, i.e. from January 27, 2020 to July 3, 2022, we see that the Scandinavian countries (Norway, Denmark and Sweden) and Ireland are those which have resisted the best: the excess of Cumulative mortality there was 0.5 to 1 per 1000 inhabitants. The next three countries are Germany, Switzerland and France, with a cumulative excess mortality of between 1.4 and 1.5. Next come Spain, Portugal, the Netherlands, the United Kingdom and Belgium (between 1.7 and 2.0). Finally, Italy brings up the rear, with a cumulative excess mortality of 2.7.

The most interesting period is probably that of the first wave (which extended from the end of January to the end of June 2020), because it gives us lessons on the strategy to follow if a new pandemic of magnitude occurred.

To judge the precocity of the measures to restrict social contacts (confinement, curfews, closures, etc.), we looked at what the rate of weekly admission to hospital of patients with Covid-19 was at the time when said measures were taken. had been taken. The lower this rate was, the earlier we considered that the measures had been taken.

We found that excess mortality over this period was lowest in countries that took action earliest. It is even negative for countries like Germany, Denmark and Norway, due to a shortened flu epidemic.

France, which confined while only three regions were affected (Grand Est, Île-de-France and Hauts-de-France), is not doing so badly. In fact, confinement made it possible to “freeze” the emerging epidemic in the west and south of the country.

The countries with the highest excess mortality during the first wave were Spain and the United Kingdom. Both were immediately victims of widespread epidemics throughout the country, and the United Kingdom was the last country in Western Europe to decide to take strong measures to control the epidemic. (March 24, 2020).

Sweden: an initial choice which was not crowned with success

Sweden is the only country to have initially chosen intermediate measures, based on recommendations calling on the good citizenship of its citizens (in particular invited to voluntarily isolate themselves in the event of symptoms, to favor teleworking and to limit their social interactions), without, however, implementing confinement or closing schools, bars, restaurants or businesses. The only ones who were expressly asked to self-isolate were the oldest, due to their vulnerability to serious forms of the disease.

This strategy was explained by the fear of the occurrence of “pandemic fatigue” in the population if the measures were to last, and by the secondary benefit expected from the construction of population immunity if the virus circulated quietly among people. younger.

Retrospectively, it appears that excess mortality was very high in Sweden during the first period, without comparison with its Scandinavian neighbors, and 80% higher than that of France. This is explained by the fact that the virus ended up finding its way to Swedish EHPADs, in which mortality was very high. The authorities recognized the failure of their strategy at the end of 2020, and advocated a strengthening of measures for winter 2020-2021. Sweden will subsequently experience an evolution similar to that of other Scandinavian countries.

Early measures better preserved the economy

The second lesson from our work is that countries that took action early not only better preserved human lives, but also better preserved their economies. The drop in GDP in 2020 was in fact less significant there than in countries that were slow to react. And this, even though one of the reasons given by some of the latter’s leaders for delaying the implementation of restrictive measures was precisely the preservation of the economy.

This can be partly explained by the fact that countries which took measures early were able to ease these measures earlier, due to a controlled health situation. Thus, Denmark, which reacted on March 13, 2020, when there were only ten people hospitalized in the country, was able to ease restrictions on April 15 (in France, it was necessary to wait until May 11 ).

The lesson to be learned is clear: once we know that the epidemic wave is coming and that it will be severe, there is no reason to wait for hospitals to fill up before taking the necessary restrictive measures. On the contrary, they must be put in place as soon as possible. Thus, lives will be saved, and the impact on the economy will be less.

Trust in institutions, key to success

Another benefit associated with early measurements is that it is possible to calibrate them. When a first set of measures is taken early, it is possible to assess their impact on the dynamics of the epidemic.

In the case of respiratory viruses such as influenza virus or coronaviruses, if the measures taken have an effect, it will be noticeable within ten days on hospital admissions. If, after this period of time, the latter do not decrease, this means that the measures are insufficient and that they must be strengthened.

This room for maneuver does not exist if we wait until hospitals are saturated before taking restrictive measures. In such a scenario, there is no other choice than to immediately adopt very strong measures to try to protect hospitals.

However, it must be emphasized that for a population to accept the implementation of restrictive measures even when hospitals are still empty, its confidence in its government and its institutions must be high. This is the third lesson of this work: the countries which were able to take early measures are those where the said levels of public confidence were the highest.

Unfortunately, the intense circulation of “fake news” as well as the massive impact of disinformation on public debate and decision-making do not encourage optimism, in the event that we have to face a new pandemic. Let us hope that we will still be able to remember the lessons learned, sometimes hard, during the Covid-19 pandemic.