Pre-COVID: national level of science advisory processes

Through the Freedom of Information Laws (Supplement 1), we attempted to gather all email conversations, meeting agendas, meeting notes and press-releases from the relevant parties involved in the decision-making on a national level, with a focus on the Government and Public Health Agency-from 2020 (2020–2021a). An extensive search was conducted to collect published public communications from other relevant parties, including open letters, debate articles, petitions-again focusing on national policy, and the interaction between science and policy.

All authors have lived in Sweden at least through part of the 2020–2021 pandemic and form a multi-disciplinary group with a background in epidemiology, medicine, religious studies, history, political science, and human rights. The group was advised by several national and international independent experts. Ethical approval and informed consents were not applicable since this article does not contain any studies with human participants performed by any of the authors.

Relevant official Swedish agencies or actors

The most prominent official actors in the pandemic are described in detail in Supplement 3, as well as how they operate and the Swedish crisis management structure. These include: the Swedish Government (including the Prime Minister) and Parliament; The Public Health Agency; The National Board of Health and Welfare; Statistics Sweden; The Swedish Civil Contingencies Agency; The Swedish National Agency for Education; The Swedish Association of Local Authorities and Regions; The Health and Social Care Inspectorate; The Swedish Work Environment Authority; and The Swedish Institute.

Health advisory processes including epidemic and pandemic preparedness

Sweden has a well-documented track record of prior epidemics, and corresponding mortality data from mid-eighteenth century and onwards is well-documented by Statistics Sweden (SCB) (Ledberg, 2021, 2020m), with four WHO-declared pandemics affecting Sweden since 1900-all with influenza viruses (1918-19 H1N1 “Spanish”; 1957 H2N2 “Asian”; 1969 H3N2 “Hong Kong”; and the 2009 H1N1 so-called “swine flu” influenza) (2019).

The Public Health Agency has published two planning documents in the recent years, one in 2015 to be prepared for pandemic influenza (previous versions in 2009, first version initiated in 2005) (2015) and one in 2019 titled as considering pandemics in general although it also states in the foreword that it is for an influenza pandemic, which is also clear throughout the document, and confirmed by the Public Health Agency in written correspondence (Box 1) (2019).

The purpose of these documents is to serve as background and support for national authorities, the regional infection control physicians, emergency managers and emergency coordinators, and other relevant actors on the regional and municipal levels (2015, 2019). For both plans the central and crucial role of the World Health Organisation (WHO) is highlighted as they will declare the different global phases, disseminate information and to some extent influence the various measures taken (2019, 2015). The International Health Regulations (IHR) are also mentioned, as a legally binding agreement for WHO member countries including “measures for preventing the transnational spread of infectious diseases” (2019).

Box 1: Pandemic preparedness

The Swedish strategy published by the Swedish Public Health Agency for “handling a pandemic” is noted to be based on: (2015).

It is not possible to completely stop the spread of infection and eradicate the pandemic virus, neither in the country of origin nor in Sweden. This means that the efforts will focus on delaying the process and limiting the consequences for individuals and society.

Vaccination is the most effective measure to reduce the risk to the individual and prevent the spread of infection. During the early stages of an influenza pandemic, a vaccine is unlikely to be available. A vaccine takes at least 3-6 months to develop.

Before a vaccine is available, antiviral drugs will play a major role in reducing the risk to the individual and delaying the course of the pandemic.